Lecture: 4th Annual Crandall Cataract Conference

DR. CHANG: Welcome to everyone joining this virtual symposium either live or later on recording. I’m David Chang and I’m proud to welcome everyone to the 4th Annual Cybersight Cataract Conference, dedicated to our dear colleague, Alan Crandall. A prominent cataract and glaucoma surgeon, a past President of ASCRS. But unique to Alan is the fact that he’s the only individual who has won the humanitarian award from AAO, ASCRS and the American Glaucoma Society all to his dedication to global ophthalmology. And in particular, to teaching people around the world to enable them to be better surgeons. This is the fourth time we’ve done this. This was the brain child, the suggestion of Orbis medical director Hunter, and it was to take leading faculty around the world and to have them participate in a case-based discussion. So, we’ll have cases followed by panel discussion and one thing we try to do is leave at least 20 minutes at the end to discuss questions posed by the audience.
You can pose the questions throughout using the Q&A function on Zoom. And please, don’t be shy about posting them and we can sometimes answer some that are quick during the session, but otherwise we’ll leave room for panel discussion at the end.
Now, I’m particularly excited that with the faculty we have this year, each of these individuals is well known not only as a gifted surgeon, but also really for their teaching prowess and they include Dave Crandall from Michigan. Tom Oetting from University of Iowa, the first recipient of the ASCRS Teaching Award. Bonnie Henderson from Massachusetts, the originator of the Harvard residency course program. Bruna Ventura from Brazil who leads the resident education there and has also organized resident courses. And then Kevin Miller from UCLA in Los Angeles who leads the Los Angeles UCLA residency course. So, we have just a dynamite lineup for you today. So, we’re going to start with the first presenter, it will be Dave Crandall. And Dave will also say a few things about his father, Alan.
DR. CRANDALL: Welcome, everyone. First, I want to thank David Chang and Hunter Cherwek for putting this together and Lawrence for keeping everything together and running smoothly. This meeting is really special for me because it really cements dad’s legacy. You know, his big thing that was he not only want the to be a great surgeon, but make everyone around him a great surgeon. And for him, those around him included ophthalmologists all over the world. If you were an ophthalmologist, you were part of his inner circle and he wanted to make you better. And everyone was a better surgeon after being with him. That’s true for me, I have been watching cataracts surgery with him since I was 4 or 5 years old. With that, I will go into my case here. Hopefully this will work. Is my screen showing for everyone? All right.
DR. CRANDALL: Yep. We can go to the next slide. So, this case is a 41-year-old who came with left-sided eye pain to our resident clinic. He had a history of high hyperopia, and it rained plus 12 to plus 13. LPIs performed when he was 12 years old. He was a musician, and for some left-sided pain and halos when lights go down during concerts, BCVA, 20/60 to 20/40. Next slide. Had a sister with similar eyes, and years ago had urgent surgery for high pressure. She had at least eight subsequent surgeries in that eye. Next slide. He had a very shallow anterior chamber spherophakia. And pain improved with medical management and the pressure came down to the mid-30s. His corneas were in the 700 range, there is some overestimation of his pressure. Macular OCT shows some thickening. And two days later, pressure was back up into the 40s with pain and microcystic edema, atropine was added to the interior chamber. Next slide. Measurements, under 16 millimeter length in both eyes. The anterior chamber, definitely said 2.85, the Argos, 1.59. I will show pictures why both are wrong. And steep measurements for a 41-year-old, fairly normal white to white. Next slide. Here is the Argos image. I would argue that’s not 1.5 millimeters anterior chamber depth there. Next slide. So, pre-op plan, obviously we had a long discussion about the risks. We do have the lens limitations in the US, our limit. Our calculations predicted a 54 die on terms of lens to get him to ametropia. We don’t want to block the pressure. Honan-cuff, pre-op and Mannitol. Next slide is the surgery, now is a good chance to get the panelists to see what they would plan going into this and what we want to look out for.
DR. HENDERSON: Sure, quick question, David, really difficult case, even preoperatively. Is there amblyopia.
DR. CRANDALL: Best was 20/40, but also could be from macular issues or any other developmental abnormalities. I don’t know if it truly counts as amblyopia.
DR. HENDERSON: And able to wear contact lenses?
>> Dr. Miller: Sometimes the lens ends up wedged between the iris and the cornea. We had one just last week. They present as emergencies, sometimes the pressure is 70. And you don’t have a lot of space to work in. At least you have some space. That’s great. Lens is not against the cornea. You don’t necessarily have to go straight to a vitrectomy to create space. But that would be one of the early steps of the procedure to create some space. And you have a lot of space to work to get your vitrector in there. It’s a touchy situation.
DR. VENTURA: Dave, in these very, very short eyes, do you go to surgery doing a decompression of the varicose veins or see if you need it?
DR. CRANDALL: I do scleral windows in this case. Not direct decompression of the veins, but I do use scleral windows.
DR. CHANG: Just a couple follow-up questions for the panel. Many of the viewers, general anesthesia may not be so easy to do. And would you feel that a retrobulbar or some type of periocular regional block would be sufficient or adequate? And then Kevin, maybe I’ll have you comment on, you know, the technique of the plan of the vitreous tab. When should you not do that in potentially non-ophthalmic eyes.
DR. MILLER: For the block, these are small eyes and you have a lot of space to get the needle back. I wouldn’t be concerned about doing a block in such an eye. I have found in many of these eyes I’ve not needed to do scleral windows. If you can keep the intraocular pressure elevated, most of the time you don’t have to deal with choroidal effusions. I’ve pretty much never had to do cut downs. I prefer not to go into the vitreous if I can avoid it, if I can get a millimeter of space in the anterior chamber, I will work in that space. As soon as you get the capsulorhexis done and start taking out the cataract, you create space as you’re removing the cataract. You quickly get space where you don’t start off with a lot of space. And, of course, you use a lot of dispersive OVD to make sure you’re protecting the cornea a lot of the time. I’m more thinking what’s the lens gonna look like once I get the cataract out? Can I preserve the capsule, the zonule is gonna be shot. Do I need to plan the capsule — almost always do. Do I need to suture? It I’m gonna do a capsule tension or two of them, pre-plan a Hoffman pocket to secure the rings into it. That’s what I think of ahead of time. If you have to do it because there’s not enough space. In the non-ophthalmic eyes, go to the anterior of the limbus and aim towards the optic nerve. Don’t ding it and make a mess out of it.
DR. CHANG: This is really challenging here because this is not a normal lens and it’s a spherical.
DR. CRANDALL: And also, the pars plana is not where it is in a normal eye. Even at 3, 3.5 millimeters back, you risk going through the retina rather than pars plana.
DR. CRANDALL: Bruna, would you do Mannitol in a situation like this?
DR. VENTURA: Sure, I definitely would do Mannitol. Kevin highlighted the important thoughts. Add to the list too, one of the most important things is intra-operatively would be managing the iris. With such a short eye and a lack of space, it’s going to be really important to create the architecture of the incision very well in order to have a more self-sealing. Oftentimes I prefer not to be in the cornea and will do a limbal or scleral tunnel to give myself space away from the iris. And then also you know that you’re gonna use a gallon of viscoelastic to protect the cornea and you have to manage an iris prolapsing quite a bit. I think mannitol is very, very helpful and useful in many situations, could inning this one.
DR. CRANDALL: We can go to the next slide with the video. So, for me, with his history and his family history of his sister having issues that as we dug down into it more, sounds like she had effusion issues and he had choroidal thickening. I didn’t have enough space between the muscles so I did a 4×6 millimeter window. Basically I’m trying to get down to where I see blue. I have a little spot, you can see I went full thickness, doesn’t bother me because it’s just one more area of decompression. And I did a second one super-temporally. This is a very long tunnel just to give me space. And then using that first gallon of viscoelastic just to deepen things up. Now I can make a more traditional paracentesis. Any complicated case, I always make two or three paracentesis no matter what. I wanted to keep him comfortable, in the young patients, it runs out and I went through the paracentesis. And the micro grafts work well. And even with that, it still wants to run out on me. I won’t say it’s the longest time I’ve ever spent on a capsulorhexis, but usually these are the longest times they spend doing that. And I didn’t show it, but I did stain with vision blue. I like to do that in young patients to help make that capsule a little more brittle. Also, with these tough cases, I can easily see my rectus edge when I see the hooks and everything else. I like the extra visualization. Any time I have a very abnormal eye, I prefer to do that.
And while it does look like there’s a lot of blood on the field, he didn’t exsanguinate through this eye. And then I also did my hydrodissection through my paracentesis. You do have to be a little bit careful doing that, you don’t want to overinflate. I felt he was young enough and the lens felt soft enough that I could use the bimanual INA to use most of the lens. At this case, I haven’t even created my primary incision. As Kevin mentioned, keeping everything pressurized so every time I come out of the eye, I put viscoelastic in before I stop my infusion. And we just sort of visco dissect what’s left of the lens. Slowly removing it. Since he’s under general anesthesia, I feel no pressure to do this case quickly. And I did notice it’s subtle, but when I was removing the nasal cortex, there was a little bit of zonulopathy on that side. And the capsule snaps in and snaps back out. And deepen everything up. I always sweep the capsule even in young patients. It’s amazing how much crud we clear off from the anterior capsule. And then as mentioned, I even without that zonulopathy that I noted, I would have done a capsular ring. I feed it in manually. I feel I have good control and good tactile feedback for where that is. And make sure I’m not putting too much pressure on anything. And just drop that in. Cleaning up whatever remaining cortex. Actually now I’m making my primary incision. Without my main incision, I was able to keep everything nice and deep and keep everything pressurized throughout the case. Since this is a redactor lens, we had to use the B cartridge and make the incision a little bit bigger than I normally like will to. This is one reason to do that. I was worried about post-operative aqueous misdirection. And doing the hyaloidotomy with the vitrector. And then some –. It was a little larger than I normally like to make it. But I wasn’t too worried about that. And thankfully, he did not go into aqueous misdirection. I actually saw him about a month ago. He’s 20/30 best corrected. Actually even with only a 40 diopter lens, plus 6. Which is the best he’s seen, and an improvement where he started. He has had intermittent choroidal effusions. He was on the retinal service. His retina stays relatively flat. He’s been on prednisone one drop a day. Cut down to every other day, and gets macular thickening. He’s been tolerating this well. Now about two years out. Thankfully, his other eye has no PAS and the pressure has maintained low 20s in both eyes.
DR. CHANG: Super.
DR. CRANDALL: Go to the next slide. I like doing the scleral windows, since I’m a glaucoma guy, I’m comfortable digging into the Conjunctiva and the sclera. I mentioned keeping it pressurized. I like to do the hyaloidotomy. And go back to the pars plana, we don’t know where it is, so, avoid sticking anything behind the lens posterior. We can’t trust the normal landmarks. In most small eyes, we don’t need all of these techniques, but any one of them can be useful. You mentioned the Hoffman pockets, which is helpful, since I opened his conjunctiva all around for the scleral windows, I wasn’t worried about suturing something if I didn’t need to.
DR. CHANG: David, it’s a great one, can you expand on the audience for IZAH.
DR. CRANDALL: So, malignant glaucoma or misdirection, to break those attachments, you need a unilateral eye, and going in through the hyaloid, you create the intracameral eye. I was worried about that in his case. There was a risk of that post operatively. Later on I did learn that that was both choroidal effusions and aqueous misdirections were both issues that his sister dealt with. I find the apples don’t fall far from each other off the same tree. I was gonna say, in an urgent situation, you know, I like to do these with a vitrector. But in an urgent situation with a MVR blade or even a 30 gauge needle, at the limbus, straight posterior, through iris, through zonule, and into the inter-hyaloid space. And we have done that in the clinic and in other cases inter-operatively.
DR. CHANG: Super. And let me just ask the panelists: How do you diagnose a supra choroidal hemorrhage? And anything you do in advance to prepare for that possibility?
DR. HENDERSON: So, you know, this patient is under general so you can’t really rely on the pain which is oftentimes our telltale sign when we’re doing cataract surgery. So, a couple things I think the hardening of the eye. The unusual movement of, you know, the anterior movement of the iris, diaphragm also. And, you know, if you see a dark shadowing, that’s always also very worrisome and scary sign that you see. I think those would be very vigilant to look for those types of signs. You know, I do think that mannitol is really, really important in this case and many others to really try to soften the eye and hopefully decrease the risk of having issues inter-operatively. But I also think that pressurizing throughout, as David said, and Kevin said as well, is gonna be really very important. And just keeping, you know, being aware of everything that’s going on besides what you’re using in your hands I think is really important in a very complicated case like this.
DR. MILLER: I don’t know that these eyes are at increased risk of suprachoroidal infection, but effusion. But you don’t have the number one sign, which is patient starts to complain of pain and you got a good block. These eyes — the iris is trying to come out of the incision the entire case. you don’t have that as an additional thing to look for, it’s happening anyway. Be super-vigilant. Put on the scope and look. I probably would not do the iridocyclectomy as the primary. I would risk they could have that. There’s a chance you could go into aqueous misdirection post operatively. Your iris against the cornea. If that happens, we have to go in and do that subsequent procedure. But I’ve only had to do it once or twice in my career and I’ve done dozens and dozens of these small eyes. They don’t all automatically go into aqueous misdirection. That’s one thing I would stage rather than do primarily.
DR. CRANDALL: That’s not unreasonable. I talked to him about it beforehand, and it was easy enough to do while I was in there and he was asleep.
DR. CHANG: Great. David, thank you so much. That was an amazing case, there are a number of questions that I think we can circle back to at the end. But at this point, I would like to introduce Thomas Oetting to present his case. And again, for the audience, please just type your questions, comments, and we’ll try to answer them throughout.
DR. OETTING: Well, thank you, David. I’m so excited and so honored to talk about a case that I think would be of interest to Alan. In 1997, the very first thing I did when I came on faculty was I told my chairman, I need to take a spy trip to Utah and I wanted to see this famous guy, Alan Crandall, who was known for teaching. And he was also really known for teaching teachers. And I spent a whole week just watching him. Kind of sat in the corner. And David, your dad was so nice to me and he just tolerated every stupid question I had and every time I went, oh! Wow! Look at that! That’s amazing. All these sort of things I was doing with him. So, it’s an honor for me to be here. And what I want to talk about is a case that I think that Alan would be interested in. And it’s not the typical case and nowhere near as sexy as David’s last case. Let me just — so, here’s the case that I think happens very much in my practice. And it’s these forgotten patients that are sort of in an institution somewhere. They’re in some residential facility. They’ve got cataracts in both eyes. And nobody wants to mess with them. You know? There’s so much trouble. They’re hard to examine. They’re difficult to get to clinic. They often don’t have family with them. They don’t have caretakers. And then somebody will sort of get up the nerve to bring them to the clinic. And I just love taking care of these patients. Because you can do so much for them, you know? You can really take somebody that’s very dysfunctional and make them more functional. And they’re not seeing 2015OU with a multi-focal lens. But they’re able to see their meals or they’re able to see what’s going on in the space around them. And so, that’s what I want to talk about. And when I think of Alan Crandall, this is the kind of person he would fight for, in my opinion. This is the kind of thing he would want to do. That’s the thing that made me think about these cases. This case is typical of that. And it was a relatively young person, he lives in a residential facility. We weren’t able to get any examine at all. Just uncooperative with exam. But the people that were with this person thought that they had less function. They weren’t able to get around as well. They were sort of hugging the wall. They weren’t enjoying the TV. We weren’t able to get any data, really.
And so, in that situation, the thing to do is to quickly say to yourself, okay, we’re gonna have to do an exam under anesthesia. And this is hard, I know, for some people to do. But it’s the key here is just at some point you just punt and you say, you know what? We’re not getting any good data. We’re gonna have to do this under anesthesia. In order to do that, you’ve got to find somebody that has the power to allow that to happen. So, there’s some medical power of attorney somewhere. And this is the sort of persistence and grit that we learned from Alan, right? This is gonna take some muscle. We’re gonna have to find somebody somewhere that’s got the power to allow us to do this.
And so, I wanted to show a picture of our chief residents. Because those of you that know me know that my first course was to tell one of these chief residents, get this job done. And for this particular case, I believe the woman on the left is the — on the top left — is the one that got this job done and was able to find the parents that had the power of attorney and would allow us to do an exam under anesthesia. But more importantly, we also got a consent to do both eyes. And this is important in this situation. I want to talk about the idea of being able to do both eyes once you’re asleep.
And so, we talked about the idea of doing the exam under anesthesia and being able to do both eyes, because we were sure there was a cataract, but we weren’t sure what else was going on. We also knew that putting drops in was going to be really tricky, right? It’s not going to be easy in this patient to get drops in. The patient is gonna fight. It’s gonna be a real traumatic experience getting drops in. We have to figure out a strategy where we don’t have to use drops post operatively. And we don’t want to do general anesthesia more than once. The last time this patient, 10 years ago, had general anesthesia, it was tricky. The airway was tricky. Come up with a strategy to do general anesthesia once, both eyes if we can. Come up with a strategy where we cannot have drops afterwards. That’s the mission. Any comments on that from our panel?
DR. MILLER: Go ahead.
DR. HENDERSON: I love the holistic view of the patient and not just the ophthalmology. I think that’s a really great case to think about how to take care of this patient completely and not just the cataracts. I agree with everything you said, as always, Tom, actually.
DR. MILLER: My biggest concern for these, what I call them head bangers, not just getting the eye drops in, but keeping the hands from doing this and messing up your great work the moment the patches come up or they wake up. You almost have to do a chemical restraint on them for days and have someone around the clock watching them almost restraining them to keep them from injuring their eyes post operatively.
DR. OETTING: That’s a great point and that’s one of the decisions for us, if the patient is going to be a real eye rubber, do typically one at a time. If we feel reasonable confidence that the patient doesn’t at a baseline rub the eyes, but do both eyes and suture. But be careful with the suture because you don’t want to remove that suture. Do it in a clever way. Let me just tell you about the next day we saw the patient, we took him to the operating room and did the EUA under general anesthesia. I know that’s hard for everybody to do, but you have to do. And anterior segment unremarkable. You can place a contact lens of a known power and see if the cornea is flatter or steeper, and that’s another way to do it in the ballpark. And the A scan and the B scan as well because we hadn’t been able to see the back. Both eyes were normal. If one of the eyes had an RD or some pathology, we wouldn’t have done that eye. But we had the consent for both eyes. We weren’t sure which eye we were going to do. Makes the nurses nervous. We don’t know yet. Either do both or one or the other. We’re gonna decide. And it makes everybody really nervous. You do the right thing and you’re consented for everything. In the OR day, do both eyes. Both retinas and optic nerves looked normal with ultrasound. And I’m always telling the residents, minus 1 is a great place to be. Minus 1 is awesome. You’re a little bit nearsighted, you can see yourself fine, you can read, see 20/40 to drive. If your world of make believe is sort of your table and your food, which more and more that’s my world of make believe, that’s what I love the most is my table and my snacks. The minus 1 is a wonderful place to be. That’s where I put folks where we can’t talk to people. You can’t reasonably communicate with people what the goal is, this is where I think is a good place to be. We also need to do a primary posterior capsulotomy. We cannot do it — we don’t want to do a decision or some or the of YAG or crazy thing in the future, we cannot do a YAG on the patient. We have to plan on a primary posterior capsulotomy. One of the points is just to get good at that. I want you to get good at that. And have a hair trigger in the right situation to do a primary posterior capsulotomy. Micro suture to get at Kevin’s issue. And then I want to talk about most of us use intercameral moxi, but ST Kenalog gets around drops. I wanted to talk about that.
This is the case, and the actual cataract surgery is so trivial compared to what David just showed us. It’s a relatively soft lens, I don’t know why I’m showing this, just so I can talk a little bit. Suturing the incision, but be reasonably solid, not leaky. One dissolvable suture. We want to make this rhexis right at 5 millimeters because we’re probably going to capture the lens. We don’t want to make this huge, make it exactly 5 millimeters. Whatever tricks you have up your sleeve to make a 5, accessory on your scope or some other technique. But we are able to get it at about 5. This is a very soft lens. And so, the nuclear fract us, hydrodissect, Dellen atypical, prolapse it up and suck it out. We’re beginning to think about what lens we’re gonna place. Use an MA-50 lens, which is a great three-piece lens which has a 6.5 millimeter optic, which is beautiful for capturing. Because we’re planning on doing a primary posterior capsulotomy. The way I like to do that is to first remove the lens material. The whole time you’re doing this, you’re thinking that the primary posterior capsulotomy, we’re going to keep this chamber formed. Put some dispersive viscoelastic here. We have to make it bigger for the MA-50. The thing with this, just get good at putting this in. Most of us are so used to putting single piece acrylics in. But you have to do this in a pinch. Usually technicians don’t know how to do it. Make sure you protect the plunger if you get this device. It’s easy to practice on the side. Get good with the three piece. And use the viscoelastic, and go through and we’re pushing the anterior hyaloid face posterior. But we’re also keeping the posterior capsule from folding over. Because the hard part about doing a primary posterior capsulotomy, it keeps folding over and you can’t grab the capsule. But just use the cohesive viscoelastic, it’s behaving like anterior capsulotomy. But it stops it from folding over into the space, burger space or whatever is behind the posterior capsule. In a perfect world, it’s the same shape as the anterior capsulotomy. If it’s the same size you can capture the lens with both of the capsules. In this case, we just captured it with the anterior capsule. This is the MA-50 going in, sorry, it’s a little bit out of range here.
And we’re placing this MA-50, which again, I love this lens for this situation because the optic is so big. And so, we’re just gonna prolapse it back. You could prolapse it all the way back behind the posterior capsule. I didn’t think we needed to in this case. It was a little small. If it was a younger patient, you have to do that like a 5-year-old or something, you have to go all the way back. But in this patient that’s 45, you don’t get it. The 10-Vicryl suture, they dissolve. And lost the sealant, and moxi, and use it in the inferior conjunctival space. And that’s the technique I use. And let me go and show one more slide. And that is I just want to highlight Neal at Kaiser, Neal Shorstein, so much work on dropless surgery in the United States. I love his website which I cited there. But basically what he recommended with a lot of experimentation is to just put 4 milligrams there, and you can do it by either taking the standard 48 milligram per ml and diluting 4 to 1 and replacing.4ccs. Or do the 10 milligrams of triamcinolone, and put it in the conjunctival space, and less needs for drops. And the patients do well with this. It’s easier for caregivers. And then the same thing on the other eye. Get good at doing bilateral surgery, get comfortable with it. And we do routine bilateral surgery at the VA. And so, we’re used to it. It’s not a big deal for us. But when patients are under general, really consider doing both eyes at the same time. Because, you know, it’s like the risk of being in a plane is mainly the takeoff and the landing. And the risk of general anesthesia is the intubation and reversal. Just being a little bit longer, the increased risk is trivial. Again, that’s my case. I just wanted to say, again, just to highlight how much Alan meant to me, what an inspiration he was to me. And I just feel like Alan would want us to fight for these people. And this is sort of my thinking when I encounter one of these patients. It’s gonna be a lot of work. We’re not gonna make any money. We’re gonna lose money galore on this. We’re going — it’s gonna take a lot of work. There’s gonna be a million phone calls with various lawyers and legal people. The nurses are gonna get all upset about all the different things we’re doing. But it’s worth it. It’s worth it to fight for these folks that are sort of forgotten. Anyway, thanks — any questions from the panel or suggestions?
DR. CHANG: That was a great presentation, Tom. We’re gonna move on pretty quickly. So, maybe just a quick comment from each of the panelists. Bruna, do you want to go first?
DR. VENTURA: Yeah. I love how you solved this case. And I always remember how this cataract surgery will impact not only vision, but the interest in the surrounding and like the life as a whole of this patient. Many of the things that you described in this specific case is our routine. And in the exams under general anesthesia. The only thing to remember is that you have to have the lens that you’re going to place with all diopters available to you in the day of the general anesthesia. With regards triamcinolone, it’s a great way of not needing to use drops, steroid drop in the post operative. The only thing is that I do it intracamerally in kids. And in this case, I would have done it intracamerally. But it’s wonderful also sub-conjunctively. And we need to make sure it’s preservative-free for sure. Be sure if you’re using triamcinolone, if you’re using it in the eye for it to be preservative-free. Congratulations, great case.
DR. CHANG: Bonnie?
DR. HENDERSON: Yes, wonderful case. If you could elaborate, for those in the audience, those who don’t always do a posterior capsulotomy. You said you used cohesive on your needle to start. But to fill your vascular bag, what type of dispersive do you use? And how do you remove your viscoelastic since you have an open posterior capsule?
DR. OETTING: That’s a great question. That scared me. I place it like usual, place dispersive viscoelastic at the wound like usual. And then go in with a syringe of cohesive viscoelastic that has a 27-gauge needle attached to. And then I focus down to the posterior capsule. And then simultaneously after going through the posterior capsule with the needle, I inject the cohesive viscoelastic into the space, maybe it’s the burger space, but the space between the anterior hyaloid and the posterior capsule. Then place the lens as I showed. I was super-worried about that cohesive viscoelastic. The first time I did this, I couldn’t even — didn’t even have the nerve to check the pressure. I told the chief resident, go in and check the pressure, I’m too scared. I sat in the other room. It was an 8-year-old young girl, the pressure is gonna be sky high, I have to explain this to everyone. The pressure is fine. The problem with leaving cohesive viscoelastic is when it’s in front of the lens or the anterior chamber. But when it’s in the posterior chamber, behind the lens, it surprisingly causes no issues with pressure. I assume, and I would be skeptical if I were you, Bonnie, and expect you to be scared the first few times you do it too. But it just doesn’t seem to matter. And I’ve always thought that you should never leave it. I think the difference is because it’s behind the lens. And the cohesive is better at sort of cleanly pushing the hyaloid back and cleanly lifting the posterior capsule up a little bit than would be visco.
DR. CHANG: Kevin, real short comment so we can move on.
DR. MILLER: Beautiful case. I think the only thing I would have done differently is probably put the lens inside the bag rather than the haptics in the sulcus. You can argue both ways. It was beautiful, there’s no reason not to put it in the bag completely.
DR. CHANG: And Tom, we had one audience member asking, what about placing the eye well first and then doing the posterior capsulotomy?
DR. OETTING: I think it’s reasonable to do that. As long as you have the chamber formed, you have a little bit more space with the lens in the way.
DR. CHANG: Thank you, everybody. That was obviously a great panel discussion on a complex patient. Our next presenter will be Bonnie Henderson and she’s going present a very advanced cataract. Bonnie, you’re on mute.
DR. HENDERSON: Okay, thanks. So, once again, thank you, David, thank you, Hunter, and thank you, Lawrence, for organizing all of this. And it’s such a pleasure to be here. I also wanted to share something that I thought would be near and dear to Alan’s heart, which is when we deal with advanced cataracts, whether it’s in our country or around the world, I think we need to have a variety of techniques that we can really rely on and manual responses. Cataract surgery is really something that Alan has really spent his career really teaching and teaching all of us how to do it well. So, I just really wanted to honor Alan by showing a case that was a terrible train wreck for me. So, I wanted to share it because I think it’s also much easier to learn from mistakes than to show a perfect case. So, I have — let me see if I request — great. So, I have no financial interest on this. And I just wanted to share a couple pictures of Alan. As already has been mentioned, he was an amazing mentor and role model for many of us, myself included. And what I loved about him, he was such a wonderful warm person, but also very adventurous and never afraid to really jump in and roll up his sleeves and get dirty. This is for you, Alan. This is already double speed, but in the interest of time, I’m gonna fast forward a little bit. And I had just gone to Aravind and learned under the amazing doctor there how to do M6, manual small incision cataract surgery. And I became interested in this early on because as I was teaching residents, we would run into trouble and they would have to convert. It was great to not only know how to do a large incision extra cap, but a small incision manual surgery. I spent time in Aravind, did cases. She’s amazing. And I’m gonna pause while I’m speaking. An amazing surgeon and teacher, so amazing. And I felt pretty confident that I’m a competent cataract surgeon before this, I learned under her, did some cases with her. I felt pretty good. This is my first case after I came back in the US by myself. So, I have this very dense cataract. And I thought, perfect. This patient will probably do well with manual cataract surgery. I’m going to keep playing the video. The first thing I’ll point out, notice that the pupil is kind of small. And so, I thought, well, it’s okay. I felt it’s not that small. It will be fine. Blow it up with viscoelastic. It’s okay. I will try to make as large of a capsule opening as possible. I’m comfortable doing a continuous curvilinear instead of a can opener or a V-shape. I thought, that’s fine. And I learned that Aravind, a lot of the doctors do ccc. Try to make it as large as possible. I went right along the side of the pupil and trying to find the actual edge of the rhexis to do the hydrodissection. I’m going to highlight all the mistakes that I made. So, first of all, as I was hoping that the pupil was large enough, that’s my first and largest concern. Is that pupil is just too small. And that lens is just too big. So, I am trying to hydrodissect, and now I’m trying to mobilize the lens and prolapse it into the anterior capsule. So, I am trying in vain with viscoelastic. And the cystotome to use the needle to prolapse it up. Put in lots of vials of viscoelastic, get it underneath. Mobilize it around, shift it here and there and I’m really struggling. So, I thought, okay, let me try this one more time. I think it’s gonna work this time. And again, I’m struggling and struggling and struggling. So, keep fast forwarding. So, I thought, well, maybe I don’t need it. Maybe use my irrigating — okay, a second instrument to prolapse it up while using the irrigating — the lens hasn’t gone out of the capsular bag. I’m a phaco surgeon. I’m going to use the phaco vacuum to hold on and prolapse it up. Hold on and prolapse it up and use the spatula in the other hand to try to bring it up. Really trying to rotate this, maybe just de-bulk it. Eat up some of the equator, make it smaller. Hold on with vacuum, try to dial it up and maybe just flip it. Hey, I’m maneuvering and flipping it up. It’s kind of working. I’m hoping, I’m hoping, and I’m struggling and now I’m gonna use more viscoelastic. And you can see, it’s just such a struggle. You know, all the beautiful cases that we see our wonderful colleagues around the world doing this effortlessly. You know, and the first case — it was much more challenging thank I thought. So, here I am. I finally got it up. Wonderful! Yay! I’m so thrilled. I finally have this. You can see, it’s a pretty large lens, now I have my irrigating — it’s not good. I notice iris is prolapsing. Why is the iris prolapsing? Two things, number one, my scleral tunnel, my groove was probably entered in too prematurely. I didn’t use it enough to make a longer groove. I’m really struggling with the iris coming out. Secondly, my incision was just too small. As you saw, I went in with the keratome and widened it further to make it a little bit wider so it’s easier. I’m able to take it out and I struggled and came up as you can see, I really made a mess of the iris. Unfortunately, you know, this is — I’m sitting superiorly, it didn’t matter as much and the patient did well. But I wanted to show some of the things that I struggled with, because I think when you start doing manual cataract surgery, it’s really good to know and be aware of the problems that you can run into. First, it’s really the pupillary dilation. So, so important. In hindsight, probably what I could have done is made sure I made that pupil larger. Whether it’s with iris hooks or the ring. Using a ring is sometimes hard because you cannot prolapse a very large lens into the anterior capsule. Capsule hooks or iris hooks — not capsule hooks — iris hooks are a little bit better. You can do sphincterotomies, and make cuts and dilate it there. Make the scleral incision wide enough to ensure that the lens can prolapse without having to really struggle and without damaging your corneal endothelium. Make sure the capsule opening is large. And be aware if they have a floppy iris. I looked back at the chart, the patient was on Flomax, had a small pupil probably because he already was having some iris issues from the medications. And so, again, in hindsight, lots of lessons learned. So, just wanted to share those. So, thank you.
DR. CHANG: Thank you very much, Bonnie. That’s very generous to share a case like that. I think we learn more from that. And it just shows the manual small incision, like all surgery by good surgeons, looks so easy, but it’s not. So, there are great points there. Who wants to start on our panelists? We have Dave, Tom, Kevin?
DR. OETTING: Well, I just want to say before Bonnie got so famous and became such a, you know, a CEO-kind of person, she — she used to do these great videos where she would ask us for videos just like that and she would sync them to music. And she would also ask for everybody else’s complications, remember that? She would ask me, I would give her like ten of them. Bonnie, you need to put that to music like the old days. Well, the only thing — my reses make fun of me, I do what’s called the world’s most expensive extra cap. Make an incision like a small incision, use a loop and split it in two and pull out the two halfs and then I make another incision and use my IA. And then I put in the fancy lens and the caption tension ring. I take a procedure that David showed us costs like 25 bucks and made it into a 2,000, $2500 procedure. But anyway, I think it’s really hard — I mean, the thing that’s funny about small incision, to me, it’s extremely hard to get the incision right, to get the rhexis right. And it’s funny that in Aravind they teach that before they teach phaco. Because to me, it seems so much harder. Anyway, thanks for sharing that
DR. CRANDALL: I thought that was a great case and I have been through those more times than I like. I think the incision size, almost every time I do one after I haven’t done one, I make the incision too small. We get so used to smaller and smaller incisions. One of my partners is doing 1.8 incisions. That seems huge, making it smooth and seal fine. The comment about the ring, I had a partner convert to an extra cap with the ring in and got the lens cap under the nucleus and was stuck, had to cut the ring to get enough space to pull that lens out. And she was just sitting there and holding it hoping not to drop the lens on to the retina. Capsule hooks are definitely the way to go with those.
DR. MILLER: I agree. I showed a video at Dave’s symposium, made the mistake of the lens through the ring, I couldn’t get anything out of the eye. It was like putting your hand through a fence, grab an apple and you can’t get your hand back because you’re holding the apple. It was terrible. I ended up cutting everything and got it out. Sometimes when the nucleus is so dense, especially out to the capsule, you’re not going to prolapse it through any size capsulorhexis. Figure that early on in the procedure and take a cystoma, and convert your beautiful capsulorhexis into a can opener. Then the question will be was the incision large enough to get it out. I appreciate you, Bonnie. All the classic mistakes.
DR. HENDERSON: I did that for everybody. I just wanted to make all the mistakes in one case to have a good teaching case.
DR. CHANG: I would just say, you know, I think that we — when we learn these cases, you know, this was tough because you had a bad lens, you know, a rock. You had a small pupil. And so, you know, to these in the virtual audience, you know, do these, you know, on more routine cases as you’re learning, and I realize that they aren’t necessary lit ones that will need this, but maybe it’s a traumatic case or something like that. But just to echo Dave Crandall’s comment, I also just am always too small on the incision. I also would do a can opener. I do them all the time. Because these are usually really bad cases. That’s why you’re going to this. And I don’t think there’s any great advantage to the rhexis. Although just as Bonnie said, so many of the Aravind surgeons are doing them because they’re that good. And it’s changed the way we handle pupils. Before that, I think we all regular, do sphincterotomies and stretch the pupil. That wouldn’t have worked here if this was an IFIS small pupil. But that really is what I go to with an extracap. And it just, you know, weakens the sphincter enough that it’s just easier to prolapse things through. But thank you again, Bonnie, for that terrific case. We’re gonna move next to Bruna Ventura. And Bruna is gonna discuss an IOL exchange. Bruna, you’re on mute.
DR. VENTURA: Oh, I’m sorry. I wasn’t on mute. I was just thanking everyone, and you, David, specifically, for the invitation to be here honoring Alan. Every moment we had and chaired throughout the numerous meetings we were together, he always was someone that takes the time to teach in the small and big cases. So, I’m very, very happy to be here. I’m going to be speaking on an IOL exchange technique that I recently used and liked a lot. These are my possible conflicts of interest, but none of which are important for this case specifically. So, in woman, she’s a 52-year-old woman that had undergone refractive lens exchange in her left eye in another clinic six weeks before coming to consultation with me. So she had — her doctor had implanted a trifocal toric IOL. And she said she used to wear glasses and she is — she was completely dependent on glasses. But now she sees well, but without seeing with quality. So, she’s like, it’s driving my nuts. I can’t continue with this lens in my eye. And when I — one of her big things was, it was Christmas here in my city. And in Christmas, all the Christmas lights at night, she said I can’t drive in the city. Like it’s driving me nuts. I can’t do this anymore. And I’m like, well, let’s check your vision. Let’s take one step at a time. I am not a surgeon that I rush into a lens exchange. I am very cautious with it because the patient usually has very expectations with any of our cataract surgeries. And especially patients that had refractive lens exchange. So, she was in the operated eye, we had a 20/20 vision, J1 with great speed. But she’s like, I’m like, look how much you’re seeing. And compare it with your right eye that hasn’t been operated. And she’s like, well, yeah, I can see the small letters near and far. But it’s not with quality. And I am crazy with the lights. Like I can’t go ahead with this and looking at her exams. So, these are exams that I had — I took when she came to me. So, these are post-op. So, it’s pseudophakic. We can have a great idea of her eye. We can see she has a significant, a very significant amount of astigmatism. Almost 4 diopters with the rule corneal astigmatism. Corneal, very small amount of corneal aberrations, and also a great pupil for diffractive lens. However, she did say with a residual astigmatism. And my suspicion was that was the main cause of her big symptoms. I tried lubricating her and improving her ocular surface. And she came back like two weeks later. She’s like, I’m still very unsatisfied. I want to take this lens out of my eye. So, before proceeding into saying which technique I used, I wanted to go through the panel to hear which technique we are going to take this lens out. So, which technique do you prefer for lens exchange?
DR. MILLER: If it’s an acrylic lens, might preference this to refold the lens into the eye. Put a cyclodialysis into the anterior chamber. It’s easy to take all lens insertion forceps and fold it over, turn it 90 degrees and pull it out. If it runs away from you, then, of course, you would cut it out. Almost all the trifocals are acrylic. Usually easy to refold. In a warm, intraocular environment, the lens folds very easily. In a cold environment, difficult, like in the operating room. In a warm environment, super easy to fold them.
DR. CRANDALL: I usually roll them, put the tire, put the cyclodialysis over the top and twist it until it becomes small enough to come out of the wound.
DR. VENTURA: Wonderful.
DR. OETTING: I usually just cut them out. Bonnie, to give her proper credit, was the first one to describe the idea of crimpling up and we might give her credit. I usually cut it, I’m good at it. This is not a thing I do a lot. I just want to not worry about it. I want to do something that I’m slick at. The biggest problem to me is not how do you make the lens smaller, but how do you get the lens out of the bag? That’s the big problem for me. It’s not going to be too bad.
DR. VENTURA: Yeah, that’s true. I did use the twist and out technique which was already inputted by you guys here. And I wanted to show you the video of the patient. Let me just play this just a second. Okay. Here. So, I start by injecting viscoelastic and releasing the lens. It’s very easy to release this lens very gently since it was a — the very recent that the first procedure. Here I’m injecting a mono focal toric lens in the bag. It’s useful to protect the posterior capsule while we’re doing all the maneuvers. And here is how we do the twisting out technique. So, first, we exteriorize one of the haptics through the main incision. And I used the McPherson forceps. And the big one is to have our hand in a supine position. This is key for us to have an amount of — a good amount of rotation during this next step that we’re going to see now. So, we — I hold the lens near this — this haptic that’s out of the eye, and then I use my spatula, my spatula that we all have to hold the lens in the same plane while I’m rotating my right hand and letting the lens fold. And you see how easily, as you mentioned, Kevin, it comes out very gently and with no stress. So, again, here I am positioning my hands in a supine position while my spatula is holding the lens horizontally. I rotate my hand counterclockwise and let the lens fold. While it is folding, you push it gently through — you pull it gently through the main incision. And it comes out beautifully. Here we have the other lens in the bag already at the end of the surgery. We see an aligned monofocal lens. I put in a suture. I always like to put in sutures in these cases that I want to have a complete control in the first hours of post op. And no surprises. So, in the other day she had a transparent cornea already 20/20 uncorrected vision and very, very happy. She’s like, I didn’t even believe that I could not see the — all the lights in a very weird way. And the big point here, besides the one I’m going to speak, in the pre-op, she loses the near vision. That needs to be very, very clear. It’s a give and take. We’ll improve the dysopsia, you will lose the vision. Make it very clear. With the twisting out technique, it’s important to always protect the endothelium throughout the procedure. The incision diameter, although it was described, the original technique was described through a 2.2 millimeter diameter incision, I couldn’t get it out through a 2.4. So, I enlarged it slightly, but I did enlarge it. Especially if you have a high diopter lens in the bag coming out of the eye. You might consider increasing your incision’s diameter a bit. And the main point here is to pay very close attention to the Descemet membrane in the incision. I showed you a video of the surgery. But I had to redo that maneuver I think around four or five times until I — it was my first case also doing this technique, applying this technique. While you’re doing that, pay close attention to the Descemet because you can stress it with this counterclockwise motion. And that was everything I wanted to bring to you. And thank you again for this opportunity.
DR. CHANG: Great, thank you, Bruna. What did you do for the other eye?
DR. VENTURA: So, the other eye, monofocal toric also.
DR. CHANG: And did you do mini monovision? Or she wanted distance in both eyes?
DR. VENTURA: No, distance in both eyes. One thing that a mini monovision could have been done. But her main complaint was I didn’t even want to get rid of my glasses. I just wanted to have good vision and then I was offered getting rid of my glasses. But no one said I had a tradeoff. With her glasses, she was completely dependent on them. She had a great quality of vision which she noticed when she changed to a di-reflective lens. What’s important talking about this whole case is also to manage the expectations and always ask our patients, okay, what do you want to do? What is your expectation with this surgery? Because sometimes they don’t — most of the times they don’t understand there’s a tradeoff. Especially with refractive lens exchange, the patient has wonderful quality of patient, near, far, with glasses for them to understand that it is a tradeoff. You can be glass independent. But quality — you will notice if you’re very picky. Most of the patients today, what I feel is that they’re okay giving into a bit of the quality to improving the independence. But that needs to be said. That needs to be very clear out on the table since before surgery for sure.
DR. OETTING: Hey, Bruna, if you had not needed the toricity of the lens, would you consider a silicon lens to maybe lessen the odds of continued positive dysphotopsia?
DR. VENTURA: Instead of the lens?
DR. OETTING: After the exchange, if you didn’t need the toricity of the single piece acrylic, would you have used a three piece silicon lens to make it less likely to have positive dysphotopsia.
DR. VENTURA: I haven’t used a silicon lens in my life. I wouldn’t think of that solution. I was very confident that the source of her problem was the residual astigmatism, the residual refraction post op. And like all her maps, all her measurements were so on spot that I was very — it was planning the surgery was easy. Like I wasn’t stressed about that part. I was just very confident in telling her that this was another procedure that there is an improvement in risks and all of that needs also to be said. Positioning the monofocal lens before explanting with whichever technique you’re using to — if you’re cutting, if you’re doing another technique — is another great tip for you to protect the posterior capsule while you’re doing your maneuvers.
DR. CRANDALL: You do want to be careful not to damage the lens that you implanted when you’re cutting the new one.
DR. VENTURA: Yeah.
DR. CRANDALL: Because then you’re moving a second lens and putting a third one in. If they do need the toricity I like that to reduce the dysphotopsia. I do couple of these a week, unfortunately.
DR. VENTURA: Really?
DR. CRANDALL: We have a lot of people putting the lenses in patients that really when you meet them, it’s not the appropriate choice for that patient. I found up to the higher diopters, 30, 31, I usually cut those unless I need the lens intact when I remove it. The extra thickness, in the just harder to get out of the wound, but harder to do the twisting because there’s a little bit more resistance. I extend my wound a little bit. It’s about a 2.5 when I remove these lenses. The other thing I will mention, you obviously don’t want to do this with a three piece lens. Because that trailing haptic is going to swing all over the place, and create a iridotomy or a vitrectomy. I think the hand position is easier to go straight out instead of turning to the side as you’re rotating that.
DR. VENTURA: Yeah, that’s a great comment, Dave. I tried my straight tier. The thing is you have to pay attention to get the thinnest instrument you have in the wound.
DR. MILLER: There is a difference when you’re removing these lenses. There are two different sort of methods for manufacturing. One uses constant optic — diameter optic zone. That would be the conference in the United States. And then the constant center thickness approach such as Johnson & Johnson vision. If you have a constant thickness lens like J&J, it’s the same thickness no matter what. The diopter is the same. The higher, the thicker the lens. And different approach. Acrylic is the easiest to get out, silicon is hard to get out. It’s hard to grab them, they want to run away from your scissors. You have to get two forceps in while you’re cutting them. And open them widely. And some of us tried to cut out these thermal plastic lens like the Memory lens from years ago. Don’t try, open up the 6 millimeter incision. You have to have a different approach for each material.
DR. CHANG: Tom, final question on this section, you mentioned trouble getting the lens out. What would you say is the limit of limit, you know, this is a patient that is unhappy. What if she came back to you after a year or two, there a limit that you have?
DR. OETTING: I don’t think that’s limit. But I think you change the consent. I think you have to change the consent if there’s been, you know, a capsulotomy, and you have to change the consent the longer that the patient has had the lens. I don’t know if there’s ever a time you would say, no. But I wonder what happened, you know? Is she, you know, has their attitude changed in some way about life? or why has this gone on so long? That would make my nervous. But I think if the posterior capsule is intact, you know, years later, I’ve taken these out. You have to be very careful. And one little trick just real quickly you can use is you can use the MST capsule retractors to support the capsule while you try to get those haptics free. Because the big problem is the bulb at the end of the Alcon lenses. And then some other parts of other lenses that stick a lot. But just be real careful and it’s shockingly easy if you just place the MST retractor right in the area of that bulb and then use viscodissection, get the lenses in there a long time out. Or cut the haptic out.
DR. CRANDALL: 25 years is the record for me removing one. We had a technician, re-zoomer lens, waited for years until she was comfortable with seeing me do so many exchanges and then she wanted it out.
DR. OETTING: I’m guessing you didn’t give her a bonus for 20 years and she stuck in there, hung in there with you. Is that true?
DR. CHANG: That is the profile. There are people that it just never was offered to them because their surgeon was not comfortable with that. And maybe they did a monofocal in the other eye and still noticed that. I think the lesson is, if you’re gonna do diffractive IOLs, you should be able to or be willing to refer the patient to make it reversible. Well, we have one more presenter and we’re gonna turn it over to Kevin Miller who has a traumatic cataract.
DR. MILLER: All right. Is this visible?
DR. CHANG: We’re good.
DR. MILLER: Okay, good. Again, thank you, David, for organizing this. Everybody said this about Alan. But I’d known Alan for 30 years and conferences all over the world. Amazing person, human being, amazing teacher, great surgeon. I see a lot of his patients. Actually, at UCLA even now. You know? So, it was just a phenomenal experience getting to know Alan.
So, I’m gonna show you a traumatic cataract. I have some financial interest. Not, you know, all that relevant. So, this is a 69-year-old man who had an injury to his right eye from a battery explosion in the 1970s. At the time he was treated with some eye drops, but didn’t undergo surgery. The result of the explosion was as you see on the right side. Pupil sphincter tear, a zonular dialysis, and eventually a traumatic cataract. When she saw me, he was counting fingers at 3 feet. Here’s what he looks like on dilated slit lamp photography. So, you can see the zonulopathy and the sphincter care. Bonnie, would you approach cataract removal in this case? Inter-cap? One of your manual small excision extra caps? Phaco?
DR. HENDERSON: At this point, trying phaco. See how well the lens is sitting. But with a small area of zonular dialysis, manage with phaco.
DR. MILLER: David, would you phaco this?
DR. CRANDALL: I had one on Thursday, 50-year-old injury. But I did attempt to phaco and then converted to a small incision extracap when I could not make any progress. Which is usually by approach, I make the incision and go in centrally and try to phaco it. If I can’t, 10 seconds to convert.
DR. MILLER: And do you think there’s vitreous in the anterior chamber?
DR. CRANDALL: Because it’s traumatic, good chance of it. The one yesterday, I did. And I started with the vitrectomy before I did the rest of it.
DR. MILLER: I agree with Bonnie and you, David. I thought I could probably phaco this. The first step was to fashion a inferotemporal Hoffman pocket to get the greater zonular loss. This is sped up four times. I’m creating a Hoffman pocket down there where the zonular is missing. All right. So, then I performed a vitrectomy using a pars plana and the anterior approaches. I used a diamond knife to do my sclerotomies. A lot of people use an MVR blade. Do the posterior approach first. Try to sever the adhesion between what’s in the anterior chamber and the vitreous cavity. The actual procedure went way longer, I spent several minutes cleaning out the vitreous. Once we’ve amputated the vitreous connection, I removed the vitreous in the anterior chamber. You have to be super-careful not to capture the iris with the vitrector. That went on for minutes, not the few seconds. The dissection and the hydrodissection. I use this diamond blade for everything. You can do everything, including relaxing I think significances. I didn’t think it was a good femto case. Most of the cases are femto. But this was all manual. There’s the hydrodissection. All right. So, Tom, would you attempt rotation of the nucleus at this point given the zonulopathy?
DR. OETTING: I don’t think I would yet, Kevin. It’s a miracle you got that rhexis done so beautifully without hooks and devices. I was surprised. I thought for sure you would have to use an iris hook to support and give you counter. But I would place an MST retractor now if it was me. Because the rotation is such a risky business. It puts so much force on the zonules. And so, I would — I would just go ahead and place probably four MST refractors. You could argue possibly just placing two in the area of the known weakness. But there’s like the known unknowns and the known unknowns, and the known knowns and the known unknowns. But the zonules are weak everywhere. I would probably go ahead and plan on four and just do it. And get it all secure and then I would — then I would very carefully do some hydrodissection and very slowly rotate that nucleus.
DR. MILLER: Okay. So, Tom would put in four capsular retractors, Bruna, what would be your next step?
DR. VENTURA: Also do that and then use two hooks to rotate this nucleus. If we use one instrument, OVD cannula or the hook to rotate the nucleus, we push it down. Routine cases and especially in this case I would do this. I would use two hooks and then your movement is always in the same plane and you stress less the zonules. Bonnie, you see the question, do you agree with Bruna? Retractors and two hooks?
DR. HENDERSON: I would do the retractors, and put a hook in the segment to give more support. Instead of rotating, I would try to prolapse the lens out of the capsular bag so I don’t rotate it at all if it’s possible.
DR. MILLER: Okay. Fair enough.
DR. HENDERSON: And I would do that with one hand behind my back and upside down and doing a hand stand. No.
DR. MILLER: I did put a capsular retractor in. I thought I could get away with just one. I put one. I can always put more. Here I am putting in a single capsule refractor in the area of the zonulopathy. And I thought — I thought at that point I had reasonable, you know, zonules elsewhere to proceed. So, David, would iris hooks have worked just as well here? Maybe put — this is David Crandall, David Chang, you can chime in too. Would a bunch of iris hooks work just as well as a capsular retractor in
DR. CRANDALL: They can work. But the problem is the tips are not polished. They have the risk of ripping through the bag. I prefer capsule hooks. And iris hooks supported the first millimeter or so. So, in a pinch, they can be used. But it’s definitely not as safe. There’s a risk of tearing your capsule. And then the trouble with segments and everything else. You’re more likely to have to take everything out and do some kind of other either scleral or anterior chamber lens situation. They can be used. I have used them. I’ve gotten away with it, I have gotten burned by it. I prefer the MST hooks, but the \ — hooks can work.
DR. MILLER: I think we have all been burned by the iris retractors. Bruna, Bonnie mentioned the iris tension and hooking that with an iris hook. Do you think that’s reasonable?
DR. VENTURA: I think that’s reasonable. You still have unstable lens. We could do that. Another thing that I like is that if you do have an unstable lens that from what we saw, you should — you probably do have — we could place a ring in the capsular bag and also use that to stabilize in addition to the capsular tension significant with the iris hook. I like that strategy also.
DR. MILLER: You would do that before removing the nucleus? You trap a lot of cortex, right?
DR. VENTURA: It really depends on how unstable is the bag. If it was very unstable, yeah, I would do that before. If not, I would probably save that for after cortico cleanup.
DR. MILLER: Tom, voting for four capsular retractors before. You saw just one, think I need three more? Or just proceed?
DR. OETTING: Well, I want to see what happens when you have just one, but I want to put four. To get to Bruna’s point, I think you have to be comfortable placing a capsular tension ring in early. And the key to that is using cohesive viscodissection so you don’t trap cortical material. You get a great dissection way wide of where you’re going to put the capsular tension ring in. And make sure to put the ring just under the capsule. And usually you can avoid capturing that, or trapping that cortical material if you use the viscoelastic before you place it.
DR. MILLER: I decided rather than trying the divide of the nucleus, in situ divide and conquer. I’m gonna blast through this. It’s highly-edited. But I was able to just kind of do a kind of — like an inside to divide and conquer. There’s actually no nucleus rotation whatsoever here. And the capsular bag remained relatively stable. So, there’s the nucleus out and cortex out and so far I don’t have a capsule tension ring in so it should be relatively easy to get the cortex out. But you can see there’s striae in the capsule from where the hook is. A little difficult get some of that stuff out there have. But I was able to get through at least that portion of it without additional hooks. So, Bonnie, this is where we are. What would you do next?
DR. HENDERSON: I still put in a capsule tension ring because long-term you want to make sure it’s stabilized. It looks like how many clock hours. Looks fairly large. Suturing in is pretty good. Under three clock hours I think without suturing would be fine.
DR. MILLER: It was about five clock hours, I would say. David, do you agree with Bonnie? Next step is capsule tension ring?
DR. CRANDALL: I usually do capsule tension ring and segment, you could do another one.
DR. MILLER: That was the next step. Injected a CTR and removed the capsule retractor. One of my pearls, make sure you completely fill the back with OVD. Preferably highly cohesive OVD. I pretty much 100% of the time inject these things. I was involved in the clinical trial years ago. And pretty much inject CTRs. There’s a trick to doing it. You want to kind of inject as far — if you’re right-handed — as far to the right as possible, lay it out and for 180 degrees just lay that thing out. You know, they always say inject into the direction of the zonulopathy. If you have support, you don’t have to — see how I’m angling the thing around as I inject. I pretty much always inject now. Now we have some support there. So, I’ll take out the capsule retractor. And this is my way of removing capsular retractors. I just bring them out through the phaco incision. Pretty easy. Okay. Bruna, now what?
DR. VENTURA: Now from my video here, I think you still have like sub-incisional cortex. If you do have that in this moment, I would get a cannula with BSS and aspirate that very, very gently. Because you’re winning the game. And this is a very tough case. So, as gentle as possible in the next steps, because everything can change very quickly. So, I would aspirate this sub-incisional cortex and then my lens.
DR. MILLER: Okay. So, Tom, is that what you do next? Go after the sub-incisional cortex? Or would you do something differently?
DR. OETTING: I like the idea of cleaning things up. But you don’t have to be too worried about a little bit. I would be super-tempted to place a three piece in the sulcus and capture it and not suture thing. I don’t know if that’s what Bruna meant. But I think you’re —
DR. VENTURA: Yeah.
DR. OETTING: I think you get away with a three piece. David for years deny talking about that technique. I don’t think you suture it, I think you put it in the sulcus and prolapse it back.
DR. MILLER: David, are you in agreement?
DR. CRANDALL: Yeah, I think either approach is reasonable. For getting that last little bit of cortex for the traumatic cases, I use the — or the vitrector.
DR. MILLER: What about using anterior polish to get at the cortex?
DR. CRANDALL: You ask about routinely polish, I always polish. I like it, it has a nice long paddle to it. I do that in every case.
DR. OETTING: Listen, polishing this capsule is gilding the lily. This is beautiful. We are so close to being done.
DR. MILLER: I’m gonna polish the capsule.
DR. OETTING: Don’t do it.
DR. CRANDALL: Gently polish the capsule in these cases.
DR. MILLER: So, I did a little bit of capsule polishing beneath the Hoffman pocket and then implanted anterior. Here I am polishing the capsule. I just can’t help it. I got to get that stuff out there have. And I’m gonna spare you all the suture pass, it’s pretty tedious. But here’s the segment. Make sure the eye let is above the rhexis. Make sure it’s above before we cinch it down. I’m trying it temporarily. Not just gonna stay there. Just temporarily tieing it. So, Bonnie, does it really matter here if now they got a capsule tension segment, a capsule tension ring. Does it matter if the IOL is one piece or three piece?
DR. HENDERSON: Technically no, but I like the three piece because it gives more options later on, if it decenters or dislocates later on, you can try to put in the sulcus, suture it in. For these cases, I think a three piece is the way to go. It’s a little bit more rigid as well. If you are putting the haptics in the capsular bag and uses the buttress and pushes the capsular bag apart too.
DR. MILLER: And Bruna, we know you like to take out multi-focals. Would you put in a multi-focal here?
DR. VENTURA: No. But one comment. I’m not like David that’s taking out lenses every week. Thank god. This is a very rare situation for me. But I would not implant a multi-focal in this patient. I am a conservative. I love multi-focals. But I choose my patients carefully and this wouldn’t be one receiving a multi-focal in my hands.
DR. MILLER: I agree with you. But I disagree with Bonnie, I think you can get away with a single piece of acrylic. Everything starts to go south, I got a capsule tension ring, but I put the junctions at 3 and 9:00 to reduce the negative dysphotopsia. I couldn’t let it sit there on the anterior capsule. I did polish that. Tom is shaking his head. Okay. Here I am putting the single piece acrylic lens in, handshake. So, optic junction 3 and the. And then retrieve the sutures through the Hoffman pocket and tie that down. All right. So, David, do we need to suture the iris sphincter where it ruptured?
DR. CRANDALL: In these cases I’m hesitant to do that. You have the possible damage to the ring and everything else. Pushes if it’s a problem come back and fix it after every fibrosed. It’s a little bit safer.
DR. OETTING: I agree. You’re tired, Ken, you have been scrubbing so much. You must be exhausted.
DR. MILLER: Okay. I agree with both of you. So, I just decided ahead of time, even if the lens edge is exposed by the pupil, I’m not gonna run the risk of dinging the anterior capsule, having everything split open. Now I have to take everything out. So, I’m just gonna put some Miostat in, let the pupil come in, it is what it is. If the patient is not happy, take them back once everything is fibrosed in and suture the pupil sphincter. See what the eye looks like at the end after we get it in the eye.
DR. HENDERSON: And the preop iris was not that bad. It wasn’t like a blown pupil. It’s fine. I agree with you.
DR. MILLER: You can tell this is a J&J lens because it has the peripheral flange region. The lens was visible at end of the case. I still decided I’m not gonna take a hand in the hole and fix it. I want to make sure there’s no vitreous over there. I’m sweeping. I figured I could always go back and the patient wasn’t bothered. There was a notch defect in the end post operatively. Wasn’t bothered. Here’s what the final appearance look like. I chose not to suture. The patient was okay with that. Seeing a lot better than they were seeing. 20/20 uncorrected. I don’t know what the corrected vision was. This is a dilated appearance, two weeks after surgery. Any last thoughts, panelists?
DR. OETTING: Beautiful.
DR. VENTURA: Yeah, beautiful case. Amazing.
DR. HENDERSON: Perfect.
DR. MILLER: David, back to you.
DR. CHANG: Yep, Kevin, that’s a good case to end on. We’re at our time. I want to thank our faculty members for some great cases, but even more so, fantastic panel discussion. For those of you in the audience, you can go back and watch this program, all these programs are archived on the Cybersight website, including the first three. So, best to everyone. Thank you for spending part of your Saturday with us. And again, thank you to Cybersight for hosting this great format in honor of Alan Crandall. Good-bye, everyone.
DR. VENTURA: Thank you, bye, bye.
DR. CRANDALL: Thanks, everyone.