TECHNIQUE

Combined pars plana and limbal approach for removal of congenital cataracts
Xin Liu, MD, Yi Luo, MD, PhD, Xingtao Zhou, MD, PhD, Lin Jiang, Peng Zhou, MD, PhD, Yi Lu, MD, PhD

We describe a combined pars planalimbal approach using a 25-gauge transconjunctival sutureless vitrectomy system for removal of congenital cataracts in a 5-month-old boy. The operated eye had anterior capsulotomy, lensectomy, posterior capsulotomy, and anterior vitrectomy through a pars plana transconjunctival incision created with a 25-gauge trocar. A limbal port incision was used to introduce an infusion micro cannula to maintain the anterior chamber. Incisions did not require suture closure. Following the procedure, inflammation was mild, the pupil was circular and centric, and the intraocular pressure (IOP) was stable. The eyes were left aphakic, and vision was corrected with spectacles. Amblyopia treatment ensued. This surgical technique appears to be safe and effective for the removal of congenital cataracts. Advantages include a more precise capsulotomy and more sufficient lensectomy and anterior vitrectomy, stable intraoperative IOP, and reduced surgical trauma and inflammation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2012; 38:20662070 Q 2012 ASCRS and ESCRS Online Video

Congenital cataract surgery was revolutionized in the late 1970s by the introduction of vitreous suctioncutting devices for the removal of congenital cataracts.1,2 Use of a 20-gauge vitrectomy system dominated congenital cataract surgery for 3 decades until 2002, when Fujii et al.3 introduced the use of transconjunctival sutureless vitrectomy using a 25-gauge system for vitreoretinal procedures. Beginning in 2005, the transconjunctival sutureless vitrectomy 25-gauge system has been adapted for use in the removal of cataracts in children.49 It has been used to perform capsulotomies after phacoemulsification and intraocular lens (IOL) implantation and has also been used exclusively to perform cataract surgery. Some surgeons have advocated using an

anterior approach, inserting the instrument at the limbus; other surgeons have inserted the suction cutting tip through the pars plana. A bimanual technique with 2 incisions, one for the 25-gauge suction cutting tip and another for an infusion cannula, has also been described. The cutting probe has been modified to provide coaxial aspiration, cutting, and irrigation through a single incision.4 We report our bimanual technique that uses a transconjunctival pars plana incision for the transconjunctival sutureless vitrectomy 25-gauge suction-cutting tip combined with insertion of a limbal cannula to remove congenital cataracts. SURGICAL TECHNIQUE A 5-month-old boy with bilateral congenital cataract and amblyopia was referred to our department. Total cataract was noted in both eyes. No other ocular anomalies were observed by biomicroscopy or B-scan ultrasound. Surgery under general anesthesia was considered for removal of the opacified lens. Starting 3 days before surgery, the pupil was dilated with atropine sulfate ophthalmic gel 3 times daily. One hour before surgery, phenylephrine hydrochloride 0.5% and tropicamide 0.5% eyedrops were applied every 15
0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2012.10.001

Submitted: June 20, 2012. Final revision submitted: August 20, 2012. Accepted: August 21, 2012. From the Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China. Corresponding author: Yi Luo, MD, PhD, Department of Ophthalmology, Eye and ENT Hospital, Fudan University, 83 Fenyang Road, Shanghai 200031, China. E-mail: yeeluo116@sina.com.

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minutes to further dilate the pupil. The use of atropine sulfate ophthalmic gel, phenylephrine hydrochloride 0.5%, and tropicamide 0.5% eyedrops are commonly needed to dilate the Asian eye for cataract surgery. Caution is advised because of possible induction of toxic reactions and effects on the blood pressure by these eyedrops. Surgeons should choose their medications and dosage according to their clinical experience. However, it is important to ensure that the pupils are fully dilated. The Millennium Microsurgical System (Bausch & Lomb) was used for the surgical procedure. After written informed consent was obtained from the child's parents, surgery was performed in the left eye (Y. Luo). The operated eye and the surrounding adnexa were cleansed with povidoneiodine 0.5%, and the eye was held open with a lid speculum. A limbal port incision was created using a 25-gauge trocar with a micro cannula. After the trocar was withdrawn, a 25-gauge infusion cannula was inserted through the limbal port incision to maintain the anterior chamber with balanced salt solution (BSS, Alcon Laboratories, Inc.). A pars plana transconjunctival incision was made at the 11 o'clock position 2.0 mm posterior to the limbus using a beveled trocar with a micro cannula. Because the pars plana is not well developed in young children, the options for the sclerotomy sites differ according to each patient's age.10 In our clinical practice, a sclerotomy site 2.0 mm posterior to the limbus is used in patients aged 2 to 12 months and 2.5 mm in those aged 12 to 24 months. The globe was positioned and stabilized with toothed forceps holding the limbus or the edge of the sclerotomy. A 25-gauge trocar was passed in the direction of the optic papilla, just deep enough to ensure that the widest portion of the trocar was past the nonpigmented ciliary epithelium. The trocar was then turned upward to be parallel with the iris plane and was advanced forward to make a stab incision at the lens equator. After the trocar was withdrawn, a 25-gauge vitrectomy cutter was introduced in the direction parallel to the iris plane. The cutter entered the pars plana incision and then cut forward to enter the nucleus through the equator. A central anterior capsulotomy with a 5.0 mm diameter was created with the vitrector (Figure 1, A and B). Lensectomy was performed using the cutter at a rate of 600 cuts per minute and a maximum suction pressure of 400 mm Hg. The nucleus and cortex were cut into very small pieces and carefully aspirated, ensuring that all lens material was removed (Figure 1, C and D). A posterior capsulotomy with a 4.5 mm diameter was created with the vitrectomy cutter. A limited anterior vitrectomy was performed with the same vitrectomy settings (Figure 1, E and F, and Figure 2).

Figure 1. A: Anterior capsulotomy is performed using a 25-gauge vitrectomy cutter via a pars plana incision, which is 2.0 mm posterior to the limbus. A limbal port incision is made for infusion in the anterior chamber. The eye is positioned using a pair of forceps. B: Cross-section diagram shows the anterior capsulotomy procedure. C: Lensectomy is performed after a central anterior capsulotomy of 5.0 mm diameter. D: Cross-section diagram shows the lensectomy procedure. E: Anterior vitrectomy after a posterior capsulotomy of 4.5 mm diameter. F: Cross-section diagram shows the anterior vitrectomy procedure (AV Z anterior vitrectomy; AC Z anterior capsulotomy; PC Z posterior capsulotomy).

After the central capsule and anterior vitreous were removed, the micro cannula of the pars plana incision was removed, without conjunctival or sclera suturing, and the limbal port incision was hydrated with balanced salt solution following removal of the 25gauge infusion cannula (Video, available at http:// jcrsjournal.org). The patient was left aphakic. At the end of the surgery, subconjunctival dexamethasone (2.5 mg) was injected. Ophthalmic ointment containing tobramycin 0.3% and dexamethasone 0.1% and atropine sulfate ointment were applied. The eye was covered with an eye pad and plastic shield. The postoperative course was uneventful. Ophthalmic ointment containing tobramycin 0.3% and dexamethasone 0.1% and atropine sulfate ophthalmic gel were used 3 times daily for 1 month. Two days after surgery in the left eye, the right eye was operated on by the same surgeon (Y. Luo) using the technique described. Postoperative inflammation

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Figure 2. Intraoperative video frame shows the operated eye after anterior capsulotomy, lensectomy, posterior capsulotomy, and during anterior vitrectomy.

was mild. No significant aqueous flare or aqueous cells were observed, nor was any vitreous escape or incarceration in the anterior chamber observed. Five days after the second surgery, the refraction was C19.00 diopters (D) in the right eye and C18.00 D in the left eye. At 2 weeks, biomicroscopy examination revealed that the pupils were circular and centric and the anterior chamber and visual axis were clear and without complications. The aphakia was corrected with spectacles. Amblyopic training was also prescribed to develop binocularity. At 2 months, the refraction was C17.00 D in the right eye and C16.50 D in the left eye. The spectacle lenses were changed. The patient will be examined every 2 months to update the optical correction and amblyopic training items. Secondary IOL implantation will be performed when he is around 2 years of age. DISCUSSION Our initial experience demonstrates the safety and feasibility of using the transconjunctival sutureless vitrectomy 25-gauge system for the management of congenital cataract in infants via a combined pars plana and limbal approach. The 25-gauge system appears to confer several advantages over the conventional 20-gauge system by producing small transconjunctival self-sealing sclerotomies, decreasing operating time, minimizing surgically induced trauma, reducing postoperative inflammation, and hastening postoperative recuperation.3 First, maneuvering room in the anterior chamber is increased due to the small diameter of the cutting probe. We discovered that the smaller instruments, which are more suitable for infant eyes, were easier to manipulate and provided greater flexibility in maneuvering in small eyes. Because it was kept in the anterior chamber, the infusion device allowed the surgeon more space and more precise control of the pars plana manipulations. The cutter was inserted at

the lens equator, which made it easier to reach various parts of the lens nucleus and cortex from within the lens and this facilitated lensectomy. Second, the versatility provided by the suctioncutting instruments enabled the surgeon to perform capsulotomy, lensectomy, and vitrectomy using the same probe, which simplified the surgical procedure. This minimally invasive and simplified surgery diminished surgically induced trauma and disturbance in the eyeball; thus, it decreased the postoperative inflammatory response and accelerated the postoperative recovery. Postoperative inflammation was mild. We did not observe significant aqueous flare or aqueous cells. Third, a more precise capsulotomy and more sufficient lensectomy and anterior vitrectomy were achieved under direct vision. By inserting the 25-gauge vitrectomy cutter at the equator of the lens, the surgeon could turn the cutter upward to perform anterior capsulotomy, forward and around to remove the lens materials, and downward to perform posterior capsulotomy and anterior vitrectomy. The moving distance of the cutter between each step was relatively short, and every step was completed under direct vision. Therefore, cutting was precise and sufficient and the chances of retained lens material or visual axis opacification resulting from insufficient removal of the central posterior capsule and the anterior vitreous were minimized. Fourth, the pupil was circular and centric. The cutter did not have to be manipulated in the relatively small space of the anterior chamber of infants and did not touch the iris. Therefore, irritation to the iris was minimized, meaning that this approach provided a significant safety margin. Finally, surgically induced trauma was minimized. We made only 1 pars plana incision, and no suture closure was required. The self-sealing transconjunctival sclerotomy (0.5 mm in diameter) obviated the need for conjunctival peritomy, minimized surgically induced trauma and hemorrhage, which improved the external appearance of the eye immediately after surgery, and eliminated the need for suturing, which circumvented suture-related discomfort and complications. We did not observe wound leakage in our case; thus, intraoperative IOP fluctuation was reduced. The limbal port incision created by the 25-gauge trocar was only 0.5 mm in diameter, which minimized the development of corneal astigmatism. The patient did not require astigmatic correction. A deep and formed anterior chamber was maintained during the procedure with stable intraoperative IOP. After the infusion cannula was removed, the anterior chamber did not collapse. Therefore, a watertight limbal port incision was easily achieved.

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Aphakia in the 5-month-old boy was corrected with specially designed small, lightweight spectacles. Secondary IOL implantation will be considered when the patient is around 2 years of age. Primary IOL implantation in infants younger than 1 year remains controversial. Fast axial growth and myopic shift increase the difficulty of accurate IOL power calculation.11 Higher rates of postoperative complications, especially visual axis opacification that requires secondary surgery, have been reported.1214 Kim et al.15 demonstrated that the long-term visual outcome following early surgery of bilateral dense congenital cataracts, aphakic correction with glasses, and secondary IOL implantation at around 2 years of age was good in most healthy children. Visual function of our patient was improved. Preoperatively, with dense white cataract, the patient could only sense light perception. Postoperatively, he began to show interest in things surrounding him. He would smile at his parents, look around to follow the movement of his favorite toys in the corner of the room, and stare at the television and become very happy when the cartoons showed up. The patient achieved good compliance with spectacle correction and amblyopia treatment. Evaluation by the CSM method showed that both eyes of the patient were central, steady, and maintained. The 25-gauge instrument has some limitations. It is not suitable for the removal of very hard and calcified lenses, tough capsules, or dense membranes. Therefore, patient selection is important. When the technique is first used, the small bore of the suction cutter and the reduced aperture of the cutting tip will extend the time needed to remove the lens opacity compared with that needed by suctioncutting instruments with larger diameters. However, once the surgeon becomes accustomed to cutting the lens material into smaller pieces at higher speed, efficiency increases. In addition, this technique obviates the need for suture closure and thus saves considerable time. As experience accumulates, the entire surgery can be completed within 15 minutes. In conclusion, using the transconjunctival sutureless vitrectomy 25-gauge system via a pars planalimbal approach to perform anterior capsulotomy, lensectomy, posterior capsulotomy, and anterior vitrectomy conferred several advantages, including a more precise capsulotomy and more sufficient lensectomy and anterior vitrectomy, a stable anterior chamber, minimal surgically induced trauma, decreased postoperative inflammation, and accelerated postoperative recovery. It is ideally suited for the management of congenital cataracts in infants and does not have

a steep learning curve for the anterior segment surgeon. WHAT WAS KNOWN  Management of congenital cataracts in children using a transconjunctival sutureless vitrectomy 25-gauge system has conventionally used an anterior approach. Another technique was to perform posterior capsulotomy and anterior vitrectomy via a pars plana incision after phacoemulsification and IOL implantation. WHAT THIS PAPER ADDS  The combined pars plana and limbal approach using a transconjunctival sutureless vitrectomy 25-gauge system for congenital cataract extraction has several advantages and does not have a steep learning curve for the anterior segment surgeon.

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First author: Xin Liu, MD Department of Ophthalmology, Eye and ENT Hospital of Fudan University, Shanghai, China

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