Removal of Pediatric Cataract with Intraocular Lens Implantation Using 23 gauge Incisions and 25 gauge Instrumentation Irena Tsui, M.D. Steven Kane, M.D.,

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Removal of Pediatric Cataract with Intraocular Lens Implantation Using 23 gauge Incisions and 25 gauge Instrumentation Irena Tsui, M.D. Steven Kane, M.D., Ph.D. Edward Harkness Eye Institute New York, NY ASCRS Annual Meeting Saturday - April 5, 2008 Financial Disclosures- none Conflicts of Interest- none

Background Pediatric cataract surgery presents unique challenges because of anterior chamber instability, increased capsule elasticity, and decreased scleral rigidity. Improved anterior chamber stability and less post-operative inflammation is seen when using 25 gauge instrumentation in pediatric anterior segment surgery. Vasavada AR, Nihalani BR. Pediatric cataract surgery. Curr. Opin. Ophthalmol. 2006;17(1): Cacciatori M, Arpa P. Surgical technique for anterior segment surgery in pediatric patients using 25-gauge instruments. J. Cataract Refract. Surg. 2006;32(4):562-4.

Purpose To describe a modified technique of pediatric cataract extraction with intraocular lens implantation by combining 23 gauge incisions with 25 gauge instrumentation

EUA and Preparation The pre-operative examination after general anesthesia is induced includes keratometry and A- scan biometry using handheld automated instruments. The lens implant power is calculated using the SRK II formula. (It is unknown which formula is best suited for pediatric eyes.) Traction sutures of 4-0 silk are placed beneath the vertical recti and the lid speculum is removed to improve exposure by lifting the globe and retracting the lids.

Surgical Steps 1. Superior nasal, superior temporal, and inferior temporal paracenteses are created with a 23 gauge MVR blade. 2. A Heslin 25 gauge chamber maintainer with high flow rate is inserted. Viscoelastic is injected through a 30 gauge cannula. 3. Anterior capsulotomy is initiated with a bent 30 gauge needle. The delicacy of 25 gauge disposable Grieshaber forceps and scissors can be helpful, otherwise...

4. A 25-gauge vitrector can be used to complete the capsulotomy. Alternating between high vacuum aspiration and cutting, lens epithelium is removed. Heslin 25 gauge chamber maintainer 25 gauge vitrector

5. A 3.5 mm wide temporal scleral is created and a folded MA30 lens implant is placed in the capsular bag. Traction suture

6. The sclera is closed with 10-0 nylon on a tapered needle. Posterior capsulotomy and vitrectomy are performed through a paracentesis after elevating the optic with viscoelastic or through a pars plana sclerotomy behind the scleral tunnel.

7. The optic is captured by the posterior capsule to stabilize the implant. Viscoelastic is removed with the vitrector. Note that the infusion port and vitrector can be interchanged as indicated by surgical geometry. The blue arrow points to the posterior capsulotomy. Argento C, Badoza D, Ugrin C. Optic capture of the AcrySof intraocular lens in pediatric cataract surgery. J. Cataract Refract. Surg. 2001;27(10):

8. Miochol is injected to constrict the pupil. 9. Sutures of 10-0 Vicryl on a tapered needle are used to close the paracenteses. Air can help maintain anterior chamber stability after the chamber maintainer is removed. 10. The temporal conjunctiva is pulled tightly across the limbus using buried sutures of 9-0 Vicryl on a tapered needle.

Observations A.Primarily 25 gauge instrumentation is effective for pediatric cataract surgery and its smaller size allows improved mobility over 20 gauge instrumentation. B.23 gauge paracenteses are compatible with 25 gauge instruments and in fact allow more mobility than 25 gauge incisions. C.High levels of infusion and vacuum are needed during anterior segment surgery with 25 gauge instrumentation as they are during posterior segment surgery. D.Sculpting the anterior capsule can be performed with better control using a 25 gauge vitrector than with a 20 gauge vitrector.

Conclusions 23 gauge paracenteses combined with 25 gauge instrumentation permit excellent mobility with minimal incision leakage. Improved anterior chamber stability has been helpful while teaching residents pediatric intraocular surgical techniques.