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ERICK BOTHUN: All right, so as we do in all the pediatric cataract cases, we'll place a super retraction suture, Colibri Elschnig hand over hand. So 4-0 silk traction suture underneath the super erectus insertion provides just a little safety for later in the case and for eye positions.
Trypan blue would be optional in many cases like this where you could probably see it, but it adds that extra confidence in the clarity. Sometimes trypan wants to leak out and I just put a little pressure on that spot. The duration of leaving it in is optional.
My routine is just leaving it for a minute. You get a nice stain. So trypan gets rinsed out. Healon goes in. I always think trying to advance the Healon to the other side of the chamber and fill as you come back is a good routine. So Healon under the eye, across the eye, and filling as you come back. But starting the tear is pretty standard. I would just pull more, try to continue it in a round way from there. It'll round out.
As you go in, you may find the wound Descemet's is somewhat tight. So just rotating that instrument as an anterior vertical, you'll get in much easier, and you won't have that pop as you catch Descemet's.
So pinching close to where the rhexis is is a great control. And I'm always OK if it's a little small. Areas that-- we can always enlarge it easily later. Entering the parencentesis sometimes tight and you're angling posteriorly gets you underneath that tight Descemet's.
So subincisionally removing cortex first, positioning the port and the peripheral cortex, and then holding it steady and using aspiration to break that. You make a cleavage or a cleft in the peripheral cortex to get it to start aspirating, beautiful, and then you work off that position either way.
Notice I don't drag the instrument and pull the cortex away as much as aspiration. So here we can switch bimanually or do what's subincisional. You're always careful not to go in too posteriorly with the port here and just more tucking under. Keep irrigating, irrigating to keep the chamber deep enough.
I tell my fellows to listen to that tone. You will realize what vacuum level you need to create peripheral cortical action and anything less than that won't achieve the results. So position the port and take the vacuum up to that same tone.
Important to make sure at this point that the instruments aren't pointing posteriorly because the poster capsule can come forward quickly using the vacuum. A little burst, like little waves of aspiration, using your second instrument sometimes can help move the cortex around.
So some degree of capsular polish is often needed for these cortical fragments. It's nice to start the vacuum before you go back to the poster capsules. So start aspirating now, and then you go back low level so you see how it's going to move.
So instead of putting your instrument on the poster capsule and the cortex and then aspirating and getting a sudden shift, you start the vacuum mode up above and go back to it. And you can just have a more controlled poster capsule position. See how nicely the rhexis is already becoming round. The capsule rhexis, initially you might wonder if we needed to adjust it and we still can, but it really rounded up beautifully.
So here we're entering in the previous parencentesis site, straight in, straight out for our D cartridge. Sometimes at this point, you double-check again if you need more Healon. But if it looks stable, we're good to go load the lens. All right, these cartridges look like a little airplanes with landing gear, and the landing gear face down to make sure that the lens stays upright. So again, we tap this front edge just like that to get it to come, beautifully, right over the lens.
You slide the lens in, play, get it to bowl, put down like a depression in towards the eye here as a taco. Tuck the back lens in, beautifully done. Now we push the whole lens forward all the way until you get a hard stop. There it is.
And now we're ready for the insertion, dialing the lens in, we're watching that first half-tick unfolding beautifully and horizontally into the capsule. And then leaving the stylet in a little extra longer to push that back posterior shoulder underneath the rhexis before you take it out allows you to relax and let go.
When you take this out, you don't need to be as rushed getting a Sinsky hook in place. I usually close the primary wound at 2.6 millimeter wounds with two sutures. We could do two 10-0 nylon or two 10-0 Vicryl here. We're choosing 10-0 Vicryl. We'll use the same for the parencentesis. These can be removed at a week or left in place.
And here's where you push back on the IOL a couple of times to make sure you got everything coming around a good-- beautiful. And so you can recenter it there, and then we'll take those out. I usually go in on-going first, and beautiful. And then we'll go on Vigamox and give that a swirl as an intracameral protection. It also breaks up the [INAUDIBLE] nicely to make a nice snow globe. Wonderful, thank you, everybody. Successful case.
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