Persistent fetal vasculature cataract surgery
Matthew Weed, MD and Richard J. Olson, MD
Feb 10, 2016
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Hi, this is Matt Weed, and I'm going to show you an interesting case of persistent fetal vasculature cataract surgery that I got to help my mentor Dr. Richard Olson perform recently on this six-week-old child.
Preoperative echography had informed us that this eye was about 1.5 mm smaller than the fellow unaffected eye, which led us to suspect the possibility of persistent fetal vasculature. These suspicions were confirmed as soon as we took a look under the operating microscope and seen what you see here. Now, that echo had also shown that there did not appear to be any stalk or retinal detachment in this eye.
Here, the surgeon is using a 23-gauge MVR blade to make a stab incision superiorly which will then be used to access the anterior chamber. Here, the surgeon is introducing Healon, a cohesive viscoelastic into the anterior chamber, and is gently using viscoelastic and the cannula itself to gently dissect the iridocorneal adhesions present in this eye. This same method is then used to gently break the numerous iridolenticular adhesions that were also present in this very unusual eye.
We thought this central core sitting on top of this white fibrotic plaque posteriorly looked a bit like a sunny-side-up egg. Note also superiorly the numerous, brown, elongated ciliary processed characteristic of PFV.
Here, the surgeon is making a second stab incision and we are going to set up to use the Alcon Centurion cataract surgery system with the bimanual setup, with an irrigation handpiece in one hand and the vitrector in the second hand. This has worked quite well for us in numerous cases thus far.
Now we've got our bimanual setup and we've got the vitrector visible on your right, pointing downward, being used to create a capsulorhexis in the anterior capsule. Of course I realize it's pretty tough to see the edges of the capsulorhexis here in this video. We took several minutes to make a nice, very large capsulorhexis to help prevent postoperative phimosis.
Now we're ready to go after the "yolk" of this "sunny-side-up." We're going to do this with the vitrector, initially on a high cut rate, and we'll do this so that we can open the posterior capsule in a controlled fashion. Again, you can see those elongated ciliary processes and the blood vessels present in the plaque, also very characteristic of persistent fetal vasculature.
Now, for clarity's sake, let's freeze it, and show an arrow pointing to one of these ciliary processes I keep referring to. Those are the pars plicata of the ciliary body, not normally visible during cataract surgery.
This yellow nugget has been separated successfully from the adjacent plaque and is now being vitrectomized. It can be helpful to turn down the cut rate if you're trying to take bites of something that is this big.
All right, so we've got that out of the way. Let's go after the plaque now.
Here you see the vitrector being used on a low cut rate of about 500 to create an opening in this white fibrotic plaque at the back of the lens. You can see we get into a little bit of bleeding from those vessels coursing through there; that stopped on its own without any intervention. Again, taking our time in a very controlled fashion, gradually opening the posterior capsule through that fibrotic plaque. You want to get as close as you can to these ciliary processes to help prevent phimosis postoperatively, but stay away from the processes themselves as they will bleed quite a bit if you hit them.
We've now got that opened up very nicely to within just a small distance of the ciliary processes, and we'll now perform a five-minute vitrectomy to break up the anterior vitreous face.
Now, here the surgeon is inserting MST Duet intraocular scissors to make just a few radial nicks in between the ciliary processes to help prevent postoperative phimosis, which is a known complication of PFV cataracts.
We'll close the wounds with 10-0 Vicryl suture and we are done. Thanks for watching.
