1. VIDEO CONFERENCE
R2 강민지/Pf.주천기

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

3. # 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(-)

4. VIDEO

5. # POD 1 wk
VA OS 1.0

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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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.

14. 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.

15. 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

16. 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