Presented by: Vakalis Thanos MD
Edited by: Penelope Burle de Politis MD
In a world with an ever-aging population and increased availability of the therapeutic arsenal for the management of chronic conditions and their complications, the ophthalmic surgeon is all the more often faced with complex ocular configurations. On the other hand, as senior patients stay active and become progressively more demanding, surgeons must resolve even the most intricate cases in order to restore visual function and improve quality of life.
When it comes to cataract extraction, certain changes in the eye can pose extra difficulty for an otherwise routine procedure. For example, a previous vitrectomy modifies the hydrodynamics and the depth of the anterior and posterior chambers, thus shifting the lens-iris diaphragm alignment. Likewise, a non-dilating pupil, regardless of the cause, is a primary trigger of complications in phacoemulsification and is now commonly encountered due to the large-scale use of prostate hypertrophy medication. Alone, these variants can turn a “simple” cataract surgery into a challenging procedure. Imagine them together, and furthermore combined with a much harder-than-ideal nucleus. Nevertheless, each and every one of these obstacles can be overcome by means of a compartmentalized surgical approach, in which the altered structures are brought as close as possible to their usual state so as to minimize the strangeness of the operative scenario.
In this video, recorded at the Ophthalmica Eye Institute in Thessaloniki, Greece, Dr. Thanos Vakalis (MD), specialist in vitreoretinal surgery, performs phacoemulsification and IOL implantation on the right eye (RE) of a 91-year-old male patient who had undergone ipsilateral vitrectomy 8 years earlier for vitreous hemorrhage secondary to a macroaneurysm in the setting of diabetic retinopathy. The patient was in regular use of oral tamsulosin. Preoperative visual acuity in his RE was reduced to light perception. His left eye had been pseudophakic for 23 years and had 20/20 best-corrected visual acuity.
The surgical steps and timing in the video are as follows: main incision (00:03); side ports and stretching of the iris in perpendicular meridians a few times (00:18); extra side ports and placement of iris hooks (00:54); capsulorrhexis (02:14); hydrodissection and luxation of the nucleus (03:00); phacoemulsification with settings for a hard nucleus (03:27); injection of the IOL (05:33); iris hook removal (05:57); main incision suturing (06:04); viscoelastic aspiration (06:19); sealing of the incisions (06:26); end of the procedure (06:43).
“Divide each difficulty into as many parts as is feasible and necessary to resolve it.” – René Descartes
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