VIDEO CONFERENCE R2 강민지/Pf.주천기 26597714

CASE M/56 C/C) Dec.VA(OS) onset) 7 months ago VA OD 0.8 / OS 0.1(0.16)

# OR at OP day 10일 전부터 갑작스럽게 좌안 흐리게 보였다고 함. Ocular trauma(-) no other ocular dz(-) DM Dx(-), Vit deficiency UV exposure(-) no medication(-) steroid(-)

VIDEO

# POD 1 wk VA OS 1.0

REVIEW Surgery of white cataract Ref) Cataract Surgery, 3rd ed. Steinert, Roger, 2010 26597714

CLINICAL PRESENTATION Intumescent lens begun to lose structural integrity Mature cataract the cortex extensively hydrated, with white opacification Morgagnian nucleus has sunk off-center in the lens as a result of liquefaction of the cortex Hypermature so advanced, some hydrated and denatured protein has begun to slowly leave the capsular bag, resulting in wrinkles in the no longer distended bag

mature and hypermature cataracts, the anterior capsule may undergo degeneration, with deposition of calcium or development of focal dense plaques if possible, or use another technique, such as a Gills-Vannas scissors, to cut across these densities

ABSENCE OF THE RED REFLEX largest challenge in removal of the intumescent cataract is the absence of a red fundus reflex when the cataract is viewed through the operating microscope Intends to perform phacoemulsification with placement of an intraocular lens (IOL) in the capsular bag, an intact capsulorrhexis is critical in maintaining structural integrity it is nearly impossible to avoid large capsule flaps and the potential for equatorial and posterior tears unless the anterior capsule can be visualized

ABSENCE OF THE RED REFLEX SEVERAL APPROACHES Oblique illumination using such as a fiberoptic light pipe Anterior capsule stain Fluorescein sodium 2% : weakly stains the anterior capsule on the exterior surface and has slightly stronger uptake on the inner (epithelial) surface if it is injected after an initial opening into the capsular bag Cobalt blue illumination methylene blue and gentian violet : toxic to the endothelium patient's own blood

Two dyes : proven safe and effective indocyanine green(ICG) trypan blue (VisionBlue, DORC, Zuidland, Holland)

the dye is applied under an air bubble not to dilute the dye prevents the dye from contacting the anterior capsule -> using cannula air bubble replaced with viscoelastic, and capsulotomy is performed. A, Intraoperative photographs of a mature white cataract with anterior capsule staining by trypan blue. B, Injection of air bubble through paracentesis C, Trypan blue dye is applied under an air bubble filling the anterior chamber, using a blunt-tip cannula to inject and wipe the stain across the anterior capsule. D, Capsulorrhexis proceeds normally, with clear visualization as a result of the staining. E, During phacoemulsification, the surgeon can visualize the stained anterior capsule edge, reducing the potential for inadvertent damage by the phaco tip. F, After intraocular lens (IOL) implantation, the stained anterior capsule can be seen overlying the IOL optic

An alternative to the air bubble technique high concentration cohesive ophthalmic viscoelastic device, most commonly Healon 5 (Advanced Medical Optics) may obscure visualization of the anterior capsule -> require washout and reinstillation of viscoelastic for capsulorrhexis. Healon 5 allows better contact of the dye with the anterior capsule compared with an air bubble no need to air bubble for the viscoelastic agent to perform the anterior capsulotomy corneal endothelium(especially in Fuch's dystrophy) :posterior cornea will take up the dye and impair the surgeon's view of the cataract. Application of trypan blue stain under a dome of Healon 5. A, Cannula is wiped across the anterior capsule while the stain is injected into the space created between the capsule and the Healon 5. B, If the dye does not mix with the solid mass of Healon 5 and the surgeon avoids injecting excess dye, visualization is adequate to proceed with the capsulorrhexis without washing out the Healon 5 and replacing it.

THINNING AND WEAKENING OF THE POSTERIOR CAPSULE Increased risk of posterior capsule complications More prolonged phacoemulsification time manipulation of a large and hard nucleus expanded intumescent lens the posterior capsule is often thinned and stretched, weak & flaccid, with wrinkles and a laxity that makes it prone to come up to the phaco tip and be ruptured. worsened by the absence of any epinucleus that protects the posterior capsule. A useful step is to inject a dispersive, noncohesive viscoelastic behind the nucleus one or more times during the phacoemulsification. This will provide an artificial epinucleus to keep the posterior capsule back from the operative plane and also stabilize the nucleus against tumbling • Epinucleus is the outermost nucleus or innermost cortex. • Adult nucleus is the next innermost layer. • Fetal nucleus corresponds to the cotyledonous areas of light scattering in the clear adult lens. • Embryonal nucleus is the innermost core of nucleus.

WEAK OR ABSENT ZONULES the patient is elderly, when zonules typically weaken as part of the aging process or because the cataract has been induced by trauma Witschell capsular tension ring (Morcher GmbH) trans-scleral sutured posterior chamber IOL anterior chamber IOL

THE NUCLEUS young hydration that opacifies the cortex -> softening of the immature nucleus. The nucleus will then aspirate or require minimal ultrasound for removal elderly nucleus is often quite sclerotic and large. Because the cortex is already hydrated, hydrodissection and hydrodelineation are unnecessary