As we demonstrated recently, cataract surgery in a younger patient (under age 50) can be different than in the typical geriatric patient. This case has even more challenges: the patient was previously very myopic (-10 to -11 range) and had corneal refractive surgery performed (PRK), then many years later developed a retinal detachment which required a pars plana vitrectomy (PPV). He later had a second pars plana vitrectomy to peel a macular membrane to restore normal macular anatomy. And now he has a cataract.
The patient has two issues which can cause chamber instability and an excessively deep anterior segment during cataract surgery: prior vitrectomy and a very long axial length. In the video we show how to address the reverse pupillary block which can occur. The key method is to equalize the pressure between the anterior and posterior chambers via temporary tenting of the iris. We can also help achieve more stable fluidics by switching to a smaller incision. In the picture shown above you can see the smaller diamond keratome with a narrower width.
Finally, the capsulorhexis must be of an appropriate size: about 5.5 mm would be great to overlap the optic but also large enough so that in the future when the capsule contracts, it will not be constricted. We can expect it to come down to about 5.0 and keep in mind that the capsule is more elastic in these younger patients. Here we specifically slow down and take time to ensure that the capsulorhexis is perfect.
Click below to learn from this important challenging case: