Playlist: toughest cases of 2020

After reviewing the surgical cases from 2020, I have chosen four tough cases to present here. Two of the cases are with me operating and two are with a resident ophthalmologist in training as the primary surgeon. Each case is challenging for a different reason and each provides some great teaching points.

The first case is a recent surgery in our private surgery center in Beverly Hills where the patient had severe Parkinson’s disease and was not able to have deep sedation or general anesthesia due to severe general medical conditions. The patient was referred to me by a fellow ophthalmologist who did not feel comfortable doing the case. I understand and I echo his same sentiments — this is quite a challenge. The patient has violent shaking about every 15 seconds and despite taping the head down, having my scrub tech hold the head, and administering significant intra-venous sedation with my anesthesiologist. To further confound things, the eye is hyperopic with astigmatism that requires a toric IOL, and the patient is functionally monocular.

Earlier in 2000, I was fortunate to help a newborn baby with leukocoria. The differential diagnosis of leukocoria is very important since it can be deadly conditions like retinoblastoma. This article goes into the possible causes in much detail and it is required reading. This baby had a dense pupillary membrane which blocked the visual axis. We used intra-operative OCT imaging to help while dissecting off this membrane. Fortunately, the crystalline lens was clear and normal, as was the rest of the eye anatomy. It has been about a year and this baby has done well with no signs of amblyopia.

Another case with a pupillary membrane was performed by one of our senior ophthalmology residents who took a step-wise and methodical approach to successfully completing this very challenging case. You will learn a lot from watching this video and it will give you the confidence to use the same approach for conquering a tough case in your future.

The last challenging case is show in two parts: the first part is the cataract surgery and the second part is the pupilloplasty. This patient sustained ocular trauma and developed a cataract, zonular loss, and permanent mydriasis. This surgery successfully fixed the cataract, secured the IOL, reconstructed the pupil, and restored vision to this grateful patient.

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