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Difficult Cataract Cases Scenario  Made Easy
Dr Sudhir Singh, MS
Sr. Consultant & Head
Department of Ophthalmology
JW Global Hospital Research Centre
Mount Abu India 302019
drsudhirsingh@gmail.com 
 
 
Management of Subluxated Cataract by SICS With CTR and IOL
In this video your are to watch management of subluxated hyper mature cataract by small incision cataract surgery (SICS) using capsular tension ring (CTR)

 

 
Subluxated Cataract Management: Ant Capsulotomy+MSICS+CTR+IOL+Post Capsulotomy
She was an elderly female with hyper mature morganian cataract with fibrosed and wrinkled anterior capsule with poor zonular support with subluxation with ns 4 nucleus with primary posterior capsular. Intraoperative As anterior capsule fibrosed and wrinkled so capsulotomy was very difficult but done with 15 degree blade and vannas scissors. Grade 4 nucleus taken out by vectis. Capsular bag was supported by CTR and then PMMA IOL implanted. Dense primary posterior capsular opacification was there, so posterior capsulotomy done. Vision first post operative day 6/18 PH 6/12.
Viscoelastics HPMC 2 % was used
Irrigation Solution Ringer Lactate was used. Please watch out video below
 

 

 

MSICS In Nuclear Cataract Grade 5: First Post Op Day Clear Cornea with 6/9 Unaided Vision
MSICS In Nuclear Cataract Grade 5: First Post Op Day Clear Cornea with 6/9 Unaided Vision This was a 70 years old gentleman presented with grade 5 nuclear sclerotic cataract with poor zonular support. Many surgeons would go for phacoemulsification but it would prone to phaco ultrasound energy related corneal complications, lens capsule and zonules related complications including lens matter drops or zonular dialysis. In other words standard phaco would be challenging and risky despite of best of the phaco machines, OVD and surgical skills. In such cases the role the femto laser assisted cataract surgery (FLACS) is advocated to minimize ultrasound energy related complications. The FLACS is unaffordable to most of the cataract surgeons and patients in the present scenario. Other par excellence, simple and economical option is manual small incision cataract surgery (MSICS). We decided to do MSICS in this case. The capsulorhexis was done and two relaxing incision were made as nuclear size anticipated large. The nucleus was tried to rotate in the capsular bag bit it could not be due to capsulo-cortical matter adhesions. The cortical matter aspirated by IA canula and then nucleus is rotated and dialed out in the anterior chamber. Then nucleus was taken out by vectis. Irrigation aspiration is done. PMMA IOL implanted. The sclero-corneal tunnel was sutured with 10-0 nylon suture to control surgical induced astigmatism. Post operative day 1 vision was 6/9 unaided with crystal clear cornea. Patient had 6/6 unaided vision on 4th day post operative.
Visco used: HPMC 2 %
Irrigation Solution: Ringers Lactate
Biometry: contact US A Scan
IOL Power Formula: SRK 2
 

 

 
Simple Safe Inexpensive High Quality : Hypermature Morgagnian Cataract Management
Hyper mature morgagnian cataracts with hard nuclear with no or very little cortical support are prone to phacoemulsification related serious complications like complications like further posterior extension of capsular tear, zonulodialysis and nucleus drop. Although some experience phaco surgeon can complete phacoemulsification by exercising special precautions and taking calculated risk.

In my opinion, itís always better to do manual small incision cataract surgery to avoid phaco related complications. As MSICS is an inside out procedure as compared to phaco, which is an outside to inside procedure. In this video I am going to demonstrate 6 mm   intratunnel phacofracture manual small incision cataract surgery. Please watch this video below

 

 

6 mm Intratunnel Phacofracture MSICS in Jet Black Hard Nuclear Cataract

Hard nuclear cataracts along with morbid pupil and capsular support pose problems to the best of phaco surgeons equipped with high end phaco machines and expensive OVDs. They are prone to ultrasound energy related complications; posterior capsule related complication and nucleus drop related complication. In cases manual small incision cataract surgery is the savior. We are going share a case of grade 6 large nuclear cataract, pupil not getting dilated, capsule was fibrosed and zonular support was poor. This was managed by 6 mm intratunnel phacofracture MSICS. HPMC 2% as viscoelastics and Ringerís Lactate as irrigation solutions were used.

 
 

 

SICS In Typical Coloboma and Nuclear Cataract
This was a one eyed case of typical iris coloboma with nuclear cataract grade 4.Manual SiCS was done
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Capsulorhexis In Different Situations
Capsulorhexis In Different Situations In this video I am going to demonstrate Capsulorhexis in
non getting dilated pupil
Capsulorhexis in white intumescent cataract
Capsulorhexis in White morganian Cataract
Capsulorhexis in white morganian cataract with fibrosed Capsule
CCC in post uveitis non getting dilated 1mm pupil
 

 

 
Intra tunnel Phacofracture SICS in Rock Hard Nuclear Cataract
 

 

Intratunnel Phacofracture SICS In Floppy Iris and Non Dilating Pupil
 

 

Intratunnel Phacofracture MSICS With Trabeculectomy With Removable Sutures
One eyed 85 years male presented with left eye nuclear cataract grade 4 with psuedo exfoliation with floppy iris with advanced glaucomatous cupping. The right has total glaucomatous optic atrophy.
Vision OD 6/60 OS PL + PR Inaccurate
IOP OD 37.2 mm Hg OS 37.2 mm Hg
Plan 6mm Intratunnel Phacofracture MSICS With Trabeculectomy With Removable Sutures
 
 
Intratunnel Phacofracture MSICS in Intumescent Cataract
 
This types of the intumescent cataracts are prone to anterior capsular radial tear extension (The Argentinian flag sign ).So the three stage capsulorhexis was done. Three Stage Capsulorhexis Stage 1: Small Central Capsulorhexis: Cohesive viscoelastics is preferable for such cases. Initially a curvilinear nick is given and capsular flap is folded and small capsulorhexis is made by shearing and tearing forces.
Stage 2: Capsular bag is debulked by aspirating cortical matter.
Stage 3: Small capsulorhexis Enlargement This is enlarged by forceps after giving a curvilinear nick in margin of small capsulorhexis
Nucleus Management: by 6 mm Intratunnel Phacofracture
IOL 6 mm PMMA IOL
Power Calculation : Contact USG A Scan
Keretometry : Goldman manual Keratometer
Post Op Day 1 Vision 6/12 PH 6/6 N12

 

 
Argentinian Fag Sign In White Intumescent Cataract and Management

Despite all precautions Argentinian Fag Sign encountered. Itís not end of the world. The capsular tear is converted in a can opener capsulotomy. If case is planned for phacoemulsification then its better to convert in MSCIS (Manual Small Incision Cataract Surgery). Phacoemulsification in extended or non intact capsulorhexis could be risky affair. Conditions like hyper mature morgagnian cataracts or hard nuclear cataract with no or very little cortical support might further increase the risk of the serious complications. Although some experience surgeon can complete phacoemulsification by exercising special precautions. Itís always better to covert to manual small incision cataract surgery to avoid complications like further posterior extension of capsular tear, zonulodialysis and nucleus drop. How to convert to MSICS please watch this (Link given below) "Most Practical Way To Convert After Not Intact Capsulorhexis" https://youtu.be/t-jILM9NUMo

 
 
 
Management of the Intumescent Cataract with Adherent Leucoma
This was a 25 year young lady,who had trauma in her left eye about 15 years back.Clinical features as follows:
Central Adherent Leucoma
White Intumescent Cataract
Vision PL+ PR Accurate
IOP Normal (Digitally)
Right Normal
Plan
Stage 1: MSICS with PC IOL
Stage 2 : Penetrating Keratoplasty

 

 
 

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