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An important advance for enhancing the ease and safety of pediatric cataract surgery is 1.8mm coaxial microincision cataract surgery using a particular phaco platform, according to one expert.
Dupage County, IL-An important advance for enhancing the ease and safety of pediatric cataract surgery is 1.8-mm coaxial microincision cataract surgery (C-MICS) using a particular phaco platform (Stellaris Vision Enhancement System, Bausch + Lomb), said Balaji Gupta, MD.
"A smaller incision reduces incision leakage intraoperatively and postoperatively," said Dr. Gupta, a private practitioner with offices in the Chicago western suburbs. "The platform allows coaxial surgery through the smallest possible incision and offers advanced fluidics features that protect against fluctuations in the anterior chamber."
Another relevant issue is that pediatric cataracts often occur in eyes with microphthalmia. In this situation where the anterior chamber is especially crowded, chamber stability is even more important, Dr. Gupta said.
Anterior chamber instability makes all steps of the surgery more difficult, beginning with the capsulorhexis.
"Anterior capsulorhexis is challenging in pediatric eyes because of the elasticity of the anterior capsule," Dr. Gupta said. "Increased posterior pressure and fluctuations in anterior chamber stability compound a difficult situation and make posterior capsulorhexis challenging as well."
Stabilized anterior chamber
With the 1.8-mm incision and its advanced fluidics features (EQ Fluidics and StableChamber, Bausch + Lomb), the phaco platform helps to maintain a stable, deep anterior chamber that enables controlled capsulorhexis.
Several techniques can be used to open the anterior capsule in pediatric surgery, Dr. Gupta said. His preference is the two-incision, push-pull technique described by Ken Nischal, MD, in which the capsule is opened initially with two horizontal stab incisions. The distal flap is grasped with forceps and pulled toward the surgeon and the promixal flap is pushed.
"This method reliably creates a consistently sized oval opening, and it is much easier and safer when done in the presence of a stable, deep anterior chamber," Dr. Gupta said.
Due to the anterior chamber stability present when performing 1.8-mm C-MICS, Dr. Gupta said he also is more confident about working near the posterior capsule and is able to perform primary posterior capsulorhexis via an anterior versus a pars plana approach.
"After inflating the bag and thanks to the chamber stability, I actually can perform the posterior capsulorhexis without a vitrector and then implant the IOL," he said. "Since the vitreous is well-formed in pediatric eyes and with the IOL acting as a tamponade, vitreous prolapse is prevented.
"The ability to finish the surgery without a vitrectomy represents an important advantage for decreasing postoperative inflammation and macular traction," he added.
Because of the elastic nature of the pediatric cornea, achieving a watertight closure is difficult when operating through a 2.5- to 2.75-mm incision, even with suturing. In this case, the 1.8-mm MICS procedure also is an asset because the architecture of a smaller incision favors better postoperative stability and minimizes the risk of incision gape and endophthalmitis.
Balaji Gupta, MD
Dr. Gupta has no financial interest in the subject matter.