In case phaco will be done in such hard cataract I do not advised to use phaco chop or stop and chop technique since this will result in more stress on the zonules and increase the risk of posterior capsule rupture
I agree with suggestion that ECCE wither large or small incision is better in such hard cataract , because even if no complication happened a lot of ultrasound will be used that effect on the endothelial cell
I have a new criteria for not doing phaco....and this type of cataract is one of them....there seems to be more complications in doing phaco with them than is worth the "small incision"....what I do is MSics...
thanks for a nicely shot video..where ample of things to learn. actually one thing led to other
i will like to make couple of points here.
1. since it was a hard nucleus, a stop n chop would have been tried. i really mean a very deep groove.
2. trying nucleus chasing with wire vectis might save our head next day but its really a bad way doing that as it offer hell lot of vitreous traction. its better to leave it like that and ask VR surgeon to take over for PPV.
Thank you very much for the contribution, I really appreciate the comments& points are well taken.
The only thing that made decide to go after the nucleus was seeing it floating freely which indicates how fluid the vidreous was, leading me to believing that there would be minimal vireous traction. I was getting ready to seal my wound, but it just jumped up to resurface again, I think it was a situational discision that I wouldn't do at any other case.
it's a shame when it happens, I have had also a complication like that, but as I was not sure if I could save the rexis, I prefered to convert it in to an extrcapsular, good job man, and god luck in the fellow eye
Quick thinking, well saved, will there not be quite a lot of epi-nuclear and cortex material in the vitreous in this case leading to floaters? I appreciate that the anterior-vitrectomy section was shortened, was there significant loss? I suppose what I'm asking is - have you managed to avoid total victrectomy in this patient despite a dropped nucleus?
No total vit was needed, she alseady had very lquified vitreous (that why the nucleus resurfaced) I did plenty of anterior vitrectomy though the machine was broken (as far as I remember) and she didn't complain of floaters after ward, as I said, I just saw her a week or so ago, she is very happy with 6/18 vision unaided and will be doing the other eye soon. (hopefully complication free this time).
I just recieved this pateint tonihgt at my office. She is still seeing 6/18 unaided and is schadualed for Phaco of the left eye next week. I hope this video will not happen again. I will try and post it here also.
1. It seems that you're a left handed surgeon.Why do you perform the rhexis through a second paracentesis 90 degrees away from your main incision? What's the advantage? Is it common practice or just a personal preference? Don't you have better control on the cystotome if you don't have to flex your wrist?
2. In such a hard nucleus, don't you prefer ECCE with manual nucleus delivery?
3.After retreiving the nucleus by a loop, was the rhexis edge still intact? Where did you lay the IOL?
1- Yes, I am left handed, rhexis from a stab wound has the advantage of highly stable AC under very high pressure if u need to retrieve an extending capsulotomy. The incidance of argantinian tears is almost totaly eleminated (not significant in this case) but I do use my microrhexis foreceps regularly now which helps me have superior controle on the rhexis egde. And actually if you try it, it is a more comfortable position.
2-I am using the infinity/ozile torsional system which gives much better performance with less phaco power & allows emulsification of very hard nucleai. This was one of my early case &I've pointed out where the post capsule was injured. It was due to the use of high vacum in a perephral area. I did harder cataracts with no complications at all after getting more familiar with the infinity/ozile system.
3- yes the rhexia was intact and a 6.5mm PC-IOL was implanted in the sulcus.
wow... you guys really make me nervous about this surgery... ive been living with a cateract for over a year now... and im really nervous to get this done... and now... this is why...you could mess me up man.... would i feel alot of pain if this ever happened? im talking about what happened in this video.. this doesnt look normal
You shouldn't stress out about it. This patient had grade 4 or more cataract, a very advanced long standing hard cataract, that was accompanied by a very rare complication, the dropped nuleus. Displaying this video is for educational and documentation purpose, it doesn't represent what you normally get during routine cataract surgery. The pateint suffered no pain at all, not during nor after the surgery. She's very happy now as she went form completely blind (hand movement only) to 6/18 vision.
I totaly agree, PPV is the right choice always, But I've meantioned it before, the vitrectomy machine was not aspirating, I did aspiration manual (like with the double way canula) and the nucleus just resurfaced out of no where! I don't remember exactly the astigmatic error, bit she was seeing 6/18 after the surgery (still is) unaided. So it did not have a dramatic effect.
Patient was and remains 6/18 unaided till today. I am gratfull to what ever power that drove the nucleus back to surface up behind the Iris. I wasn't going fishing for it with the double way canula, I just wanted to clear the AC and PC from any lens matter to reduce any uveitis before sealing and reffering to a posterior segment surgion. I did make a post-operative theral examination of the retina to chack for breaks. Age related liquification of the vireous can be a bless sometimes.
Believe it or not, the vitrectomy machine was broken, it had no aspiration power! it was only cutting with no aspiration. How do u see lens matter and vireous being removed?? I connected the aspiration tube to a 10ml syringe and did manual aspiration!! so my hands were really busy I had to ask the assisting nurs to hold the irrigation canula while I perform the vitrectomy. The patient was a relative to the assisting nurs. It was a freaking stressfull surgery.
3- For anterior vity, TA (you can dilutes 1:3 with Bss) makes things easier. Leaving some at aend can also be good to prevent CME ?. Another point is better to do anterior vity through 2 paracentesis as closed sytem limits more vitreous prolapse.
1- do not try to chase dropped nucleus with IA or phaco as cocaxial irrigation pushes nucleus south. if nucleus is accessible, place viscoelatic underneath and lift
2- Problem with using a keratome to enlarge a wound is that the inner chord length of the would is always smaller than outer, so be wary about or using a blade and scissor.
I think , using PHACO in this case was not a wise decision , elective manual SICS would have been a better choice and avoided the stitches as well .
I would like to add that , the way the nucleus was delivered out was a little risky but done cleanly .
Tissue respect is very important in any surgery ...
DRIPSINGH 2 months ago
In case phaco will be done in such hard cataract I do not advised to use phaco chop or stop and chop technique since this will result in more stress on the zonules and increase the risk of posterior capsule rupture
professor9850 5 months ago
@professor9850 thank you for your comments, they are invaluable and totally appreciated
dwgendy 3 months ago
Try to but viscoelastic under the lens , close phaco wound and do a regular scleral tunnel ECCE , this will decrease markedly the astigmatism
professor9850 5 months ago
I agree with suggestion that ECCE wither large or small incision is better in such hard cataract , because even if no complication happened a lot of ultrasound will be used that effect on the endothelial cell
professor9850 5 months ago
I have a new criteria for not doing phaco....and this type of cataract is one of them....there seems to be more complications in doing phaco with them than is worth the "small incision"....what I do is MSics...
migtomsar2008 1 year ago
Really nighmare!
arzucomez 1 year ago
i would like to add some suggestions
1-bigger rhexis
2tumble and chop technique
could have saved this case
i will upload this technique for your opinion
mrsharadeye 1 year ago
hi Dr Gendy
thanks for a nicely shot video..where ample of things to learn. actually one thing led to other
i will like to make couple of points here.
1. since it was a hard nucleus, a stop n chop would have been tried. i really mean a very deep groove.
2. trying nucleus chasing with wire vectis might save our head next day but its really a bad way doing that as it offer hell lot of vitreous traction. its better to leave it like that and ask VR surgeon to take over for PPV.
thanks Dr Gendy
jadeally1 1 year ago
@jadeally1:
Thank you very much for the contribution, I really appreciate the comments& points are well taken.
The only thing that made decide to go after the nucleus was seeing it floating freely which indicates how fluid the vidreous was, leading me to believing that there would be minimal vireous traction. I was getting ready to seal my wound, but it just jumped up to resurface again, I think it was a situational discision that I wouldn't do at any other case.
Thank you again
dwgendy 1 year ago
This has been flagged as spam show
it's a shame when it happens, I have had also a complication like that, but as I was not sure if I could save the rexis, I prefered to convert it in to an extrcapsular, good job man, and god luck in the fellow eye
oftalmocito1 1 year ago
Comment removed
oftalmocito1 1 year ago
Thanks for speedy reply and wish you good outcome and easy surgery on the other eye.
AdamZUTube 2 years ago
Quick thinking, well saved, will there not be quite a lot of epi-nuclear and cortex material in the vitreous in this case leading to floaters? I appreciate that the anterior-vitrectomy section was shortened, was there significant loss? I suppose what I'm asking is - have you managed to avoid total victrectomy in this patient despite a dropped nucleus?
AdamZUTube 2 years ago
No total vit was needed, she alseady had very lquified vitreous (that why the nucleus resurfaced) I did plenty of anterior vitrectomy though the machine was broken (as far as I remember) and she didn't complain of floaters after ward, as I said, I just saw her a week or so ago, she is very happy with 6/18 vision unaided and will be doing the other eye soon. (hopefully complication free this time).
dwgendy 2 years ago
I just recieved this pateint tonihgt at my office. She is still seeing 6/18 unaided and is schadualed for Phaco of the left eye next week. I hope this video will not happen again. I will try and post it here also.
dwgendy 2 years ago
what was her recovery time?
jetsamjetsam 2 years ago
1. It seems that you're a left handed surgeon.Why do you perform the rhexis through a second paracentesis 90 degrees away from your main incision? What's the advantage? Is it common practice or just a personal preference? Don't you have better control on the cystotome if you don't have to flex your wrist?
2. In such a hard nucleus, don't you prefer ECCE with manual nucleus delivery?
3.After retreiving the nucleus by a loop, was the rhexis edge still intact? Where did you lay the IOL?
kazemizand 2 years ago
First I'd like to thank you for interacting.
1- Yes, I am left handed, rhexis from a stab wound has the advantage of highly stable AC under very high pressure if u need to retrieve an extending capsulotomy. The incidance of argantinian tears is almost totaly eleminated (not significant in this case) but I do use my microrhexis foreceps regularly now which helps me have superior controle on the rhexis egde. And actually if you try it, it is a more comfortable position.
dwgendy 2 years ago
2-I am using the infinity/ozile torsional system which gives much better performance with less phaco power & allows emulsification of very hard nucleai. This was one of my early case &I've pointed out where the post capsule was injured. It was due to the use of high vacum in a perephral area. I did harder cataracts with no complications at all after getting more familiar with the infinity/ozile system.
3- yes the rhexia was intact and a 6.5mm PC-IOL was implanted in the sulcus.
dwgendy 2 years ago
Thanks for your kind response. NIce job. I experienced tachycardia while watching!!
Good luck.
kazemizand 2 years ago
wow... you guys really make me nervous about this surgery... ive been living with a cateract for over a year now... and im really nervous to get this done... and now... this is why...you could mess me up man.... would i feel alot of pain if this ever happened? im talking about what happened in this video.. this doesnt look normal
FunnyLooking77 2 years ago
You shouldn't stress out about it. This patient had grade 4 or more cataract, a very advanced long standing hard cataract, that was accompanied by a very rare complication, the dropped nuleus. Displaying this video is for educational and documentation purpose, it doesn't represent what you normally get during routine cataract surgery. The pateint suffered no pain at all, not during nor after the surgery. She's very happy now as she went form completely blind (hand movement only) to 6/18 vision.
dwgendy 2 years ago
I expect a lot of postoperative Astigmatism!!!!!!!!! PPV was better choice.
HyungkyuPark 2 years ago
I totaly agree, PPV is the right choice always, But I've meantioned it before, the vitrectomy machine was not aspirating, I did aspiration manual (like with the double way canula) and the nucleus just resurfaced out of no where! I don't remember exactly the astigmatic error, bit she was seeing 6/18 after the surgery (still is) unaided. So it did not have a dramatic effect.
dwgendy 2 years ago
Patient was and remains 6/18 unaided till today. I am gratfull to what ever power that drove the nucleus back to surface up behind the Iris. I wasn't going fishing for it with the double way canula, I just wanted to clear the AC and PC from any lens matter to reduce any uveitis before sealing and reffering to a posterior segment surgion. I did make a post-operative theral examination of the retina to chack for breaks. Age related liquification of the vireous can be a bless sometimes.
dwgendy 3 years ago
Ok, point of clarification:
Believe it or not, the vitrectomy machine was broken, it had no aspiration power! it was only cutting with no aspiration. How do u see lens matter and vireous being removed?? I connected the aspiration tube to a 10ml syringe and did manual aspiration!! so my hands were really busy I had to ask the assisting nurs to hold the irrigation canula while I perform the vitrectomy. The patient was a relative to the assisting nurs. It was a freaking stressfull surgery.
dwgendy 3 years ago
believe it or not same thing happened twice to me last thursday in the operating theatre.. it was tragic
palacritsgg 3 years ago
Excellent presentaion- comments continue
3- For anterior vity, TA (you can dilutes 1:3 with Bss) makes things easier. Leaving some at aend can also be good to prevent CME ?. Another point is better to do anterior vity through 2 paracentesis as closed sytem limits more vitreous prolapse.
Good luck
Ahmed Sallam
asa20007 3 years ago
Excellent presentatn. Just few suggestions
1- do not try to chase dropped nucleus with IA or phaco as cocaxial irrigation pushes nucleus south. if nucleus is accessible, place viscoelatic underneath and lift
2- Problem with using a keratome to enlarge a wound is that the inner chord length of the would is always smaller than outer, so be wary about or using a blade and scissor.
asa20007 3 years ago