Lecture: 2nd Annual Crandall Cataract Conference

[David Chang] Well, hello, everyone. And welcome to the second annual Cataract Video Symposium in honor of Alan Crandall. Dr. Crandall’s known worldwide as one of the top cataract surgeons, as well as glaucoma surgeons, but if you were lucky enough you also heard him lecture or teach. He was one of the consummate teachers of cataract complications and complex cataracts and that’s really the inspiration for this annual conference. We’re lucky enough to have five faculty members joining me today. David Crandall, DP Dhaliwal, Susan MacDonald, Jeff Pettey, and Vaishali Vasavada. And the format will be that they have each selected a case to present to you and to our panelists. But rather than just show the case straight through, we’re probably going to pause at different points and see what the panelists, who have never seen this case, would do. And so this is hopefully a format that you’ll get involved with, in terms of thinking through this, and it’s a great educational format.

At the very end, we’ve allotted a generous amount of time for you to ask questions of us and so you will use the question and answer function on Zoom to do that and we’ll try to go through as many of your questions as possible in that last half hour.

Our first presenter was a fellow under Alan at Utah, she’s now in Pittsburgh and that’s Dr. DP Dhaliwal.

[DP] Thank you, David, I’m going to share my screen. Thank you so much for the invitation. It is such an incredible honor to be here. I am Deepinder Dhaliwal at the University of Pittsburgh. And I left Moran, Utah, the Moran Eye Center at the University of Utah, after my fellowship and I was guided by Alan and Randy to go back to Pittsburgh, and I listened to them. My first job, my only job that I’ve loved so much and so it’s really such an honor to be here. I’d like to discuss positive pressure during cataract surgery because oftentimes this raises our blood pressure and our heart rate.

Here are my financial disclosures. I want to give a huge shout out to Alan and to really all of my teachers over the years who have really been so instrumental. And I continue to learn so much from each and every one of you. Thank you for helping me and guiding me during my cataract career and I just love to teach and give back. And I still hear Alan’s voice in my head and I hear so many of my teachers. Let’s get started.

First Alan taught me, he said know the anatomy. You can’t do cataract surgery unless you really understand the anatomy at a very fine level. You’re great cataract surgeons, you’re operating, you’re looking down, you see that posterior capsule. But remember there’s things next to the posterior capsule and around the posterior capsule that you have to be very familiar with. This concept of Berger space, which is just behind the posterior capsule and in front of the anterior hyaloid face. There is a potential space there. And fluid can sometimes go around the zonule and into Berger’s space and push that capsule forward. Remember that sometimes you’ll see the capsule bulging a little bit during irrigation/aspiration step and it’s okay that you can just gently decompress that, it brings the fluid back around. And there’s no issue. Just remember this anatomy that the zonule is connected back there.

What we’re going to talk about is when there’s significant positive pressure from either you’re seeing a shallow AC, you’re seeing that bulge of the posterior capsule. And the critical thing here is that you want to recognize this thing early. Because early recognition will keep you out of trouble. I, early in my career, really didn’t have a great concept of these things. And I would just force more fluid into the situation and it really made things worse. If you’re starting to see, you’re doing your phaco, you’re starting to see the AC’s shallow, or the posterior capsule is bulging, remember there could be extrinsic causes. And now really you should know that from the get go. Because it could be a tight orbit, retrobulbar block could be too much, the lid speculum. But when you start your case, one key concept is palpate the globe before you start your first incision. Know how high that pressure is. If it’s a high pressure, adjust before you start.

What we’re going to concentrate on are intrinsic causes. So aqueous misdirection, which is fluid going around the zonule into that vitreous space, or a choroidal effusion or a hemorrhage. And that’s a space-occupying lesion in the vitreous space and it pushes things forward, so that’s positive pressure.

Let’s start with a case. Once upon a time in the city of Pittsburgh, a 92-year-old gentleman was undergoing cataract surgery. Everything seemed to be going well, Alan would have been proud, until positive pressure was noted after irrigation/aspiration. But first, let’s see what transpired in the case.

Here is the gentleman. This is a very dense NS. I’m doing a vertical chop because that’s the best thing for these really dense cataracts. Replenish viscoelastic, Alan always said respect the cornea. And here the final nuclear fragment, protect that capsule so that you don’t have a sudden shallowing and things look pretty good. They look pretty deep. There was very minimal I/A, as you see in these very dense cataracts. And that little piece didn’t quite come out, but that’s okay, I came out, I’m like, all right, no problem. We’re just going to go ahead and put the lens in. After I/A was removed, here is where the posterior capsule started to bulge. And it’s very subtle. If you can see these little tiny pieces, what happened is I came out with the I/A, and the posterior capsule came up. So I thought, all right, no big deal, I’m just going to deepen it. However, I was unable to deepen even with viscoelastic.

How many times have we just come out with the I/A and no big deal, you can deepen everything. But this is not deepening. All right, I’m putting a lot of viscoelastic in there. Panel, help me out. What should I do next?

[Susan] I’m going to jump in here and say that at the moment this is not a dire situation. And the one thing that we can do in this situation is make it worse. So I always like to take my hands off the eye and sit back and give myself a differential diagnosis of what is going on. Because if I start to panic I know I have the opportunity to stop clearly thinking and make the wrong decision. So I would start with that suggestion.

[David Crandall] One of the things that I like to do when I’m refilling, and I have my residents do this all the time, is as much as possible do it through my paracentesis. Because then you’re not gaping the main wound and you get a lot more of that viscoelastic to stay in the eye.

[Vaishali] Yeah, I agree with both of the comments and as an additional thing I would just look at also the patient. I would ask my anesthesiologist or the nurse to see if the patient is hypoxic or not feeling well or not able to breathe well. So I would also loosen the speculum a little bit like Dr. Dhaliwal pointed out to begin with. And look at the patient factors if there’s any discomfort, calm them down and then think how you would proceed. I would also use the paracentesis to do any manual now on, not open that main incision.

[DP] Okay, I love those concepts. But here’s the patient. I can’t get the bag to deepen. His pressure was 170/80, so thank you for mentioning that. Vaishali, you’re absolutely right. This is a very old patient with a high blood pressure. But I asked him, “Do you have any pain?” He said, “No.” And the red reflex was still beautiful. So now what am I going to do? What are you going to do? Here is the patient, I can’t fill the capsule, what should I do right now? I wish I didn’t get into this situation but I’m here now and how do I proceed at this point?

[Susan] Absolutely.

[DP] Go ahead.

[Susan] One of the things I still have in the back of my head is, is there something really serious going on? He’s an older man, he absolutely could have, we could be having a problem with the posterior. I would ask and just take a look at the posterior chamber and make sure the retina’s flat, that there’s no hemorrhage, or effusion there. Because that will give me such confidence to do what I’d like to do next and that’s really to decompress with a little posterior vitrectomy.

[DP] Okay, that sounds very, very good. So the key is here, the pressure, I always touch the eye to feel what the pressure’s doing and the pressure was high. The chamber was shallow so I honestly thought at this point we had aqueous misdirection, there was no pain or anything, and I wanted to get the pressure lower. So what we did is we had a time out. And what I did, I said, “Time out.” I was saying let’s decompress the vitreous, I gave some mannitol, gave some lidocaine, and I also gave some atropine drops to rotate the lens-iris diaphragm posteriorly. Great suggestion from the panel. And I think this is the key here, the pressure’s high, you need to get that pressure lower because the blood supply of the eye depends on having a lower pressure so you can have adequate perfusion.

I love that idea and we did this. Again, the globe still was relatively firm as measured by palpation. And it’s important to look at the optic nerve as Susan MacDonald aptly said, with a lens. I didn’t have the indirect right away, so here is, Bobby Osher taught me this, to look at the posterior segment with this max field lens, which is made by Ocular Instruments. And we just pop that on. And I thought that was the nerve, that little geographic area, that’s a geographic atrophy. And then you can see his nerve is perfusing. So I said, okay, nerve is perfusing, geographic atrophy, we’re okay. And we’ve patiently waited some more until the pressure came down after giving those agents. And then finally the viscoelastic was able to push back the posterior capsule. And I said, all right, let’s just get this case done, we’re okay now, so we go ahead and put the lens in because now I could deepen the chamber. And the patient still is just hunky dory, pressure’s better controlled, no issues. And I had to be bold and we just got to get this lens in.

The AC is not really shallow but the posterior capsule is definitely not super deep, but deep enough. I felt comfortable putting this one piece lens in. I’m just sliding it under the capsulorhexis, I’m not angling down too much because I don’t want to catch the posterior capsule. So I just slide it underneath and I took a deep breath because the lens was in. And here I’m just going to pop it, get that little trailing haptic under the capsule, it was a little bit challenging because there was not a lot of space. So there is still some positive pressure. It was difficult to rotate the IOL so viscoelastic is your friend. And I went ahead and put additional viscoelastic in the capsule and in front. And remember, just maintain spaces, that’s a thing that Alan always taught. Respect the anatomy, maintain spaces, and then we were able to get the lens in the capsular bag. And it’s well-centered, it looks great.

One thing at this point that I definitely wanted to do is really minimize irrigation. I’m removing the small and nuclear fragments with viscoelastic, not going in and just putting a ton of irrigation fluid into the eye. Okay, I’m feeling pretty good again. Here we are, we have the lens in the bag, the beautiful red reflex, now we just have to remove the Malyugin ring, don’t forget to do that, and now just remove the viscoelastic. All right, so I’m in the eye and I’m like, hey, this is a piece of cake. Mannitol worked great and we were just talking with the fellow and resident on how this is aqueous misdirection and basically if you just recognize it early, give those medicines, you can finish a case very nicely.

You can see the posterior capsule’s wrinkling there and Alan Crandall taught me to keep the AC deep, but as I’m coming out with the I/A I just couldn’t do it. I just tried hard, I just couldn’t get the fluid to stay in the eye. I’m like, eh, it’s going to be okay because it’s so deep, I’m going to be just fine. I hydrate the wounds and here I’m deepening the AC. But I cannot deepen the AC. I was thinking, oh my gosh, not again! So I came out with the I/A the second time, the IOL is tilted, positive pressure once again. And here’s where the air bubble comes to the rescue. Here’s another critical pearl. Don’t forget air is a wonderful space occupying agent that is actually better than fluid. When you really want to maintain spaces, air to the rescue.

However, when I touched the eye again, always be cognizant of what that pressure is doing. Pressure was too high and so I couldn’t just leave this gentleman like this. Already had given some mannitol. What we’re going to do now, we gave some atropine, some timolol and again, I did not let him leave, just lights out. We take these timeouts in the operating room, even though there’s other cases, just to assess. And then the pressure came back down, we did the final air bubble adjustment. Again, the very fancy IOP measuring device, your finger. (laughs) And the fellow felt it and we said, okay, this is all right. We put the collagen shield in soaked in moxifloxacin. I learned this at the Moran, for endophthalmitis prophylaxis. And that’s the end of the case.

Again, I thought, all right, the next day everything’s going to be cool, no problem. As we were reconstructing this case, would anyone, Susan mentioned this, would have done a pars plana tap? Should I have just not done so many time outs, should I have just gone ahead and done a vitreous tap like David Chang described early on back in 2001 this technique. Who would have? Any panelist would have done this during this case instead of all these timeouts? Okay, so I see Susan, David, David. Okay, okay, all right. Well, guys? Guess what? What are the contraindications for doing a pars plana tap?

[David Chang] Suprachoroidal hemorrhage or effusion even because then you’re decompressing what is actually tamponading the effusion or the hemorrhage.

[DP] Okay, fantastic. I really appreciate your ideas. So the contraindication is if you had a choroidal effusion or hemorrhage. The next day, we looked at the retina and there was a limited suprachoroidal hemorrhage in the temporal periphery. My fellow and I were both flabbergasted because we were so sure this is aqueous misdirection. But what we did not do in this case, we did not look with an indirect ophthalmoscope. We looked at the fundus, we saw a beautiful red reflex, but we did not look in the periphery. That’s why the timeout, medical management, always remember surprising things can happen. The risk factors were in our patient for the hemorrhage: age, hypertension, blood thinners. Other factors that can cause this: long axial length, glaucoma, prolonged OR time with ocular hypotony.

When you’re thinking of aqueous misdirection versus hemorrhage, you have a high IOP and shallow AC in both cases, you typically have pain with a hemorrhage but our patient, our 92-year-old had none. And you only see that dark shadow if that effusion or hemorrhage is large and coming into your view. The critical thing is do an indirect fundus exam to really look at that periphery. And if you see a hemorrhage, as David mentioned, you want to tamponade and not lower the IOP abruptly.

Lessons. Try to avoid AC shallowing and hypotony during phaco first. That’s the critical thing. Fluid misdirection can occur at any time during cataract surgery but really just try to keep the globe formed. If there’s a shallow AC and the IOP is firm, stop! Don’t try to keep on putting more fluid in there. Again, you’re going to make the situation worse. Examine the posterior segment and medical management and time are very helpful. Air is a friend. And a vitreous tap is a great idea and I have done this. As everybody on the panel knows, they’re assuming that I had looked at the retinal periphery and I kind of left that piece of the history out. But they assumed that it was normal and in this case I had not looked. So that’s why we did not do the tap. Only do it if you’re sure the periphery is clear. And it is a great technique.

Thank you to all of you, thank you to Alan, thank you for changing my life. I really just enjoy this conference and I look forward to the rest of the cases.

[David Chang] That was an amazing case, DP, so many teaching points. And a great job. I think just for the audience, I would just add one more thing because I want to move onto Jeff’s case. But the other thing you can do, if it’s an effusion, there was a paper years ago from Willmer, that if you just wait. And sometimes you have to wait an hour, the effusion will resolve and the eye will soften. I would typically send this patient out to the post op area and do another two cases. And then we’ll bring them back and sometimes you’re lucky, the eye will be soft. And if it’s still firm, just I don’t know that we mentioned, you just cancel the case and assess them in the clinic and bring them back in a day or two and do that safely. There’s a lot of judgment involved but if you’re not comfortable forging ahead, if in doubt no one would fault you for postponing the rest of the case. But thank you again. I think it’s time to introduce our-

[David Crandall] David, before we move on, can I mention something real quick?

[David Chang] Yeah, David.

[David Crandall] If you have to leave the Malyugin ring in, it’s prolene. And I have left it in a patient with a suprachoroidal hemorrhage and you just take it out later. We leave prolene in the eye all the time. And the other thing to remember is that both atropine and mannitol are not completely benign medications, especially when you’re looking at a 90-year-old. I do the same thing David mentioned, I take them out into recovery for an hour and then bring them back again.

[David Chang] Excellent, thanks, those are great points. Again, DP, thank you.

Jeff Pettey has a case and Jeff was Alan’s colleague at Moran as well as did his training there.

[Jeff] Good morning, afternoon, and evening wherever you are. It is a distinct honor to be with you today. I’ll just start by saying most of you won’t have known Alan. And I find named lecturers, named things, to be sometimes challenging because you don’t know the person, you don’t understand the person. If I can impress upon you one single thing, Alan treated every human as if they were the most important person in the room. And if I can impress upon you that one thing, that’s something that will create a lot of joy for you in your lives. Again, I’m deeply honored to be with you today.

We’re going to go on a little journey together. I’m going to ask some questions to our panelists, they’re going to answer, but I’m going to give you just a moment at each point to consider how you would answer the question yourself. This is going to proceed as a fairly straightforward case. We’re going to go through some mental exercises here and discuss how we can be better thinking surgeons.

Lidocaine, epinephrine, a little bit of viscoelastic, fairly straightforward. This is a 2.2, doesn’t really matter, could be 2.8. Iris is a little small, pupil’s small. Just going to put in whatever iris fixation device or dilating device that you have, if available. We have a straightforward capsulorhexis. This is actually me operating with one of my early residents. I’m kind of talking the whole time, telling them what I’m thinking. Just a little bit of hydrodissection, a little hydrodelineation, then pretty straightforward. We’re just going to go ahead and do a groove. Very similar to likely what all the cataract surgeons either do or can do. And I’m just going to pause right here.

Now I’m fairly certain, here in the center, that that red hole is just simply a hole in the epinucleus, that the bag is intact. The question for any of the panelists, go ahead and turn your video on. And the question for you is what does one do here? You’ve got about a 90% certainty that this is just epinucleus, that you haven’t broken the bag itself. Vaishali, would you mind just commenting? What’s going through your head right now?

[Vaishali] I think I do agree with you, it looks like a benign thinning, but I would keep in mind, I would keep reminding myself to go very low on my energy and fluid perimeters and try and avoid this area. Work away from the area, be very slow, don’t do any separating maneuvers and lower your vacuum flow rate and model height so that in case there is a vitreous coming in or a posterior capsular rupture, you can minimize the damage that you’re causing.

At any point if I feel that my vacuum is not working or things are not moving the way that I want them to, I would inject viscoelastic, come out and then stain with the triamcinolone mods.

[Jeff] Beautifully said. And really the takeaway, whatever was going through your head or whatever techniques are going to be your go-to, I like to call this a fire drill. And that’s actually what I told the resident in the case. We’re going to actually assume I just went through the bag and do every single thing I would as if I’ve just broken bag. So let’s proceed, carry on. In this particular case I did the same thing, I lowered the fluid X and I just stayed on a sculpt setting. Very low aspiration, put in viscoelastic just to check, still looks really good. But in this case I don’t want to rotate, I don’t want to stress the bag, I’m just going to do what in some circles is called a bowl and fold. And it’s just sculpting out large amounts of this lens. Thankfully the epinucleus was significant, there wasn’t a lot of density here. But we’re just bowling out, debulking the nucleus so that eventually we can pull in from the sides. I’ve put in a dispersive viscoelastic down deep and actually the viscoelastic is still maintained deep because I’m in low flow settings, I haven’t disturbed that.

And so now I just increase my aspiration slightly, rather, my vacuum, I apologize. My vacuum slightly so I can hold and now I’m doing all of this removal up in the anterior capsule well away, keeping that bolus of that viscoelastic deep. Deep bolus of viscoelastic still isn’t disturbed. I’m just bringing this up and out again, trying not to disturb the capsule just in case. But we’re proceeding as if the capsule is open. And then, Susan, any thoughts, comments? You are muted. You’re muted, Susan.

[Susan] My goodness. I love the way that you are continuing to phaco but you’re bringing this lens up into your iris plane there so that you’re really not creating any pressure on the capsular bag and extending it. I do want to say I think there is, if you start to feel anxious that you have a posterior capsular rupture, my feeling is you have to either address it or you’re going, and answer the question for yourself. Because if you don’t, you end up, I find myself doing things a little out of anxiety. I agree with just stopping, assessing, and then if I’m unable to prove to myself 100%, I love the way you gently remove this without putting pressure.

[Jeff] Yeah, and we get back to pretest probability. How likely is there to be an opening? One thing that I do is I put in viscoelastic and often if you get a really hard nice stop when you put in the viscoelastic, it comes right back out, it’s a nice sign. It’s certainly not entirely predictive, and in this case it seemed like quite a nice, hard stop. We’ll just continue. Again, I’ve kept the flow nice and low. We’re to a point where we’re removed, and there it is. And indeed, and I’ll just repeat this a couple of times, it’s the same thing, just on a loop. And at that point, as soon as that viscoelastic bolus was removed, it became clear, well now I have an opening. The nice thing is, we’ve proceeded to this point as if we had an opening and will proceed with… In fact, actually, now’s our next nice thought experiment. Let’s go ahead, David, would you mind commenting thoughts at this point?

[David Chang] Oh, sorry, David Crandall, please.

[David Crandall] One of the things I was just going to point out is right before you came off there, the way those folds of epinucleus were, you could easily be fooled into thinking you were then safe. Because it looked like everything was completely intact. A good evidence that you can never really let your guard down. I think the next step is, with the way that flow was moving there’s a good chance, it’s not guaranteed, but there’s a good chance there’s vitreous that you’re going to have to deal with. And so I think you need to address that as your next step. If I were to guess it looks to me like there’s some coming out of the paracentesis there. Staining of choice or planning on going ahead with the vitrectomy, but I think the first step is redeepening this with replacing your viscoelastic. Ideally with a dispersive, my rule in this situation is whatever the nurse can get in my hand first.

[Jeff] Indeed, put in viscoelastic and then, of course as noted, proceed to a vitrectomy. I did leave out, at this point we still have this larger piece here. There wasn’t that I could see or identify any vitreous, there was certainly viscoelastic that had come out. But at this point, putting, again, a lot of viscoelastic into push everything back, creating the space. Now I know I have viscoelastic deep and you’ll see all of this motion is up well above the iris plane. In fact as I go and gauge pieces and bring them proximal at this point. I wasn’t feeling comfortable going across. And so did a significant core vitrectomy.

I’m just going to pause here, ask a rhetorical question just for the sake of time. Core vitrectomy, and I just want you all to pause because we don’t often get this moment in surgery. We know we have an open capsule, we haven’t lost any nucleus, we know we have a lot, at least, cortex available. Just consider some of the things that you might do at this point. We’ll go ahead, I’ve skipped the significant core vitrectomy. We do a core vitrectomy, really never identify any vitreous in the anterior chamber coming to any of the wounds. Now I just want to focus on the one technique of removing cortex.

Here we are, we’ve turned the vitrector off in this case. And depending on the machine you have, that can be done a number of different ways. But here we have a bolus of dispersive viscoelastic deep in the bag. And every time that we grab one of these pieces it’s on low vacuum, we bring it back up into the space above the iris. And that’s where we actually do the removal. Again, this viscoelastic that’s deep there remains deep. It’s undisturbed. Every time you come out of the eye, in fact, I think maybe a better mantra to go by is once you start the surgery, never let the anterior chamber shallow. If you can always maintain that anterior chamber you’ll end up with more elegant surgery and safer surgery. Again, a really low, low vacuum state, bring things up anterior.

And now we have a posterior capsule rent, have not identified any vitreous to wounds, there was some wicking I did skip. We’re going to remove our ring. You can consider what you would do at this point, where you would place a lens. Certainly a lens in the bag is not an option. If you have a 3-piece that’s suitable for the sulcus, never put a single piece in the sulcus. That is a single piece acrylic, single piece PMMA is, of course, okay.

[Susan] Can I just jump in here for a second?

[Jeff] Please.

[Susan] I love the way that you opened up your incision a little bit to put the lens in because that’s a time where you can really shallow the chamber if you’re trying to really push something through and gape your incision. Opening it up and keeping it so that you’re not creating a situation where you can drop the pressure in the anterior chamber and allow the vitreous to come out.

[Jeff] Thank you, Susan, that’s such a great point. And, Deep, this is one thing that I thought about on your case as well. From here on out I really don’t want to shallow the chamber at any point. And when you have the viscoelastic in, one thing that was going through my mind is just placing a suture in the main wound and then doing the remainder of the viscoelastic removal through paracentesis which are a little easier to seal off. It is not fool-proof, particularly where you have choroidal effusion.

[Susan] Can I just say one more thing?

[Jeff] Carry on.

[Susan] I also think it’s fabulous the way you removed the Malyugin ring before you put the lens in. Because once the lens is in you really don’t want to, again, manipulate the anterior chamber. And so you’ve removed the Malyugin ring, you know it’s foldable, so you know you can get through a small pupil. And you’re really limiting the amount of pressure fluctuation in the anterior chamber.

[Jeff] Yeah, thank you for that point.

[David Crandall] The other thing with that is the way that you did the vitrectomy which is doing another paracentesis and not using your main wound. Which is something that I think people who are not familiar with doing a lot of vitrectomies do all the time is they try to do the vitrectomy through the main incision and then you just have fluid coming out and vitreous following it and the case will feel like it never ends.

[Jeff] Vaishali?

[Vaishali] I also like the way, and I think I want to highlight that you remove the rest of the cortex using your vitrector. You didn’t go back to the aspiration probe. It’s very important to change the setting to an I/A cut mode. So basically use your vitrector so that in case there is some vitreous you can always aspirate into a cut. So you’re not pulling in any residual vitreous. I think this was a brilliantly managed case.

[Jeff] Thank you. One thing that you can do as well is I get a little anxious sometimes when I have the I/A cut mode that perhaps either myself or an experienced surgeon might go into cut when you’re removing cortex. You can actually go back to a plain aspiration mode, but just keep your anterior vitrectomy handpiece. The final thing, and again I impress upon you one thing from this case, at all costs, keep the anterior chamber formed. At every step, however you do it, and that includes this final step. We have all experienced wonderful surgery and at our final step we bring the infusion out and vitreous comes to the wick and we’ve got to start over and do our anterior vitrectomy again.

Just a very quick, subtle thing. In my left hand I have my BSS on a 27 gauge cannula ready, and right when I come out I infuse. And that is the end of that case. This is a deep honor. Treat everyone as if they’re the most important person on earth when they’re sitting in front of you. And always keep the anterior chamber formed at all costs. Thank you.

[David Chang] Thanks, Jeff. I’m just going to hit a couple questions from the audience. One is, how do you, you’ve got to remove the viscoelastic, how do you avoid vitreous prolapse on that?

[Jeff] Wonderful question. A long core vitrectomy, which I did not show you, but taking that time to remove as much of the vitreous at the beginning, that extra time for me over time, has become the thing that saved me a lot of those issues. Sometimes the vitreous wins and that’s just a reality. And in that case you just have to continue whenever there’s vitreous in the anterior chamber at the end, whether you’re using stain or wicking, you need to address it and go back in and do more vitrectomy until that’s removed.

Now the one situation I’ll just advise you. If you do have vitreoretinal colleagues, you can sometimes call it a day. There are times when you just may not be able to manage what’s happening. Make sure your wounds are sealed and they can go in and do a core posterior vitrectomy and help pull that vitreous back from the front. And that’s a nice, safe way, if you’ve ever reached a point at which you’re at the limit of your skill set, you’re at the limit at how well you can mentally function at that moment, and you can come back another day as well.

[David Chang] David Crandall mentioned before just use whatever viscoelastic you can get when you’re trying to stabilize things. But I do think you want to avoid things like Healon GV, Healon5 from that point on, for the reason that you’re not going to be able to necessarily remove everything and sometimes you’re going to leave viscoelastic there. That’s when a dispersive, I think, is probably the best because it’s going to raise the IOP but not for a week. That’s one pearl there.

How about this one? When the capsule’s open how do I know if I can phaco the fragments just to reduce the risk of a dropped fragment? That’s a tricky one. Susan, do you want to talk about when can you continue phaco in the setting of an open capsule?

[Susan] Well I think that’s a really important issue and I think that there are techniques that you can utilize to reduce that. One, in which we haven’t discussed, is really changing to a non phaco technique such as a small incision cataract. And to bring that lens up into the anterior chamber. The second thing possibly you can do is if you do have a foldable lens, you can use that as a scaffolding. And what I mean by that is you can actually take your lens and put it into the eye before all of the nuclear fragments are removed and you’re actually putting it underneath the nuclear fragments. And that provides an opportunity for you to remove the fragments with the phaco and protecting them from falling. And I guess the third way is a sheets glide. That can help as well.

[David Chang] All right, great. I guess the last question is for Jeff. In hindsight, what caused the posterior capsule tear?

[Jeff] I’m fairly certain that it was just the good old grooving a little too deeply. It was epinucleus, the AP diameter of the lens was actually quite narrow. You wouldn’t be able to really tell, we weren’t very deep. But just in that deepest part, it was just on that lowest portion, that little bit of epinucleus came. And like I say, if you think you have a tear, treat it like you have a tear and you’ll save yourself a lot of headache down the road. And you’ll save your patients a lot of poor vision down the road as well.

[David Chang] And I’ll just add the one thing that you did really well is that you did not rotate the nucleus. If you did have a tear, in my experience it’s actually rotating a nucleus or an IOL which forces you to push that against the capsular bag that actually splits it way out. Great job.

We’re going to move on to Vaishali Vasavada, joining us from Rajasthan live in India, for her case next.

[Vaishali] Thank you, everyone. Good morning, good evening, good afternoon wherever you are. And I cannot describe the honor I feel in being part of this annual conference. Every day of my life, not just professional life, I remember Dr. Alan Crandall. And this was way back, several years back, that he… There are some people that just change your lives and all of you who knew him would agree that he was one of them. What I have learned from Dr. Crandall and which was very aptly brought out, that every person, every eye, every situation can be a learning experience. And you’re always, there’s never an end point to learning.

Here is a case with a dense cataract, almost mature, and a small pupil. The thing I wanted to say is I start off making a small incision. I will make a small paracentesis, I will never make a main incision until I’m ready for the phaco. After this, the first thing that you have is you should be aware of these situations. Even if you didn’t see it in post op, take a moment like Dr. MacDonald pointed out, always take a pause. If you see something unusual, think of what you would do as plan A and then if that doesn’t work, what is it that you can do? This should be clear to you and your team. There may be times when you may not have all the instrumentation, the right devices in your OR, but these are the cases where you want your team to be ready with the sort of PCR kit or an IFS kit, and have all the instrumentation and devices ready for you in case you need them.

As the next step I’m trying to inject the combination of dispersive viscoelastic and then followed by cohesive viscoelastic to try and have as much vitreous as possible but also to protect the endothelium. This is something, again, that I have learned to differentiate between the OVDs and use them very correctly from Dr. Crandall. OVD is your friend, but use it appropriately. I would use a dispersive viscoelastic because the iris is floppy, potentially, and the corneal endothelium is going to take a hit with this dense cataract. I want to line the iris and the endothelium both with dispersive viscoelastics at the appropriate stages of surgery.

Now having done that, this case I chose I’m going to use iris hooks, not the Malyugin ring because in some parts of the world, Malyugin ring is expensive, it is not easy to reuse. A lot of surgeons still use iris hooks. So I thought let us give a different perspective. The point I want to make here is this is a 1.2 mm dual bevel knife, but as you will see I’m only entering a little bit. I’m not going to make a full thickness entry. The point I wanted to drive here is that every incision that you make in the eye, please think about what purpose it is going to serve and only use the width that you want for it. It should be compatible with your sleeve, your tip, your IOL, your instruments, your chopper. But no larger than that. Especially in these eyes.

This is something that I really want to show. You can see that I’m struggling, I’m going very deep, but I’m not able to get that hook inside. This is because in my over enthusiasm I have overinflated the eye. Again, like I said, OVD is your friend but use it very judiciously. And then now what do you do? There are two options at this stage. I have inserted the hooks, but as you can see I am very deep. I’m not able to get a hold on the iris. I have one of two choices. One, through this paracentesis I could go and inject a little bit of dispersive viscoelastic behind the iris so as to make it bulge. But the eye’s already too full, so I don’t want too much fluid or viscoelastic trying to push that iris up. What I do instead is I’ll take a spatula and just lift up the iris and then hook it in the hook. These are small tips, nothing very great, doesn’t require skill, but small learning points that you get now and again, even at any stage of your surgical practice.

The point I wanted to make was do not be overzealous with OVD, do not over inflate the eye at any stage.

Now I’m staining the capsule with Trypan Blue under BSS now. This is not that I may not have been able to do the rhexis, but every time I have a small pupil and particularly when the cataract is either very dense cortical or nuclear, I may end up with a smaller pupil down the line or some problems so I like to stain the capsule for the rhexis. And also to keep seeing it for my fragment removal IOL I want to have an idea of the rhexis margin whenever I’m performing surgery. So that was just to show that use all the devices or things that you think will make you comfortable.

This is just a clip from fragment removal. And what I want to show, let’s go back here and play it again. Sorry. What I’m doing, if you can see it is still attached. Some of these cataracts, even with the highest vacuum settings and you can see here that I’m using a very high vacuum. But yet it will be attached at the center. Even when you’re removing the fragment, you can always stop chop and you can always subdivide but don’t take big chunks of the nucleus. That is what I wanted to show here through this video.

And you will notice that my parameters are pretty modest. I’m going only with a 20 cc flow rate because I don’t want too much of turbulence in the anterior chamber. I’m using torsional ultrasound with an interrupted mode. I don’t like to use continuous energy, even if it’s torsional because any energy is going to impact the eye. And vacuum could be appropriate to your cataract grip.

Like I said, I always like and I’ve learned a lot from Dr. David Chang’s courses, especially the chop courses at several conferences, that you have to chop and chop maybe two rounds, three rounds, but have the central plain separated. And only then start working ahead.

The last point that I wanted to show, I have done an I/A. Everything is fine. This is the state. IOP implantation is sometimes, particularly when you have the rings or hooks in the eye, the iris tends to come a little forward. This is the point where you’re doing a pressurized IOL implantation, the iris could bulge up and block your cartridge. This is where I’m again, either going to inject a little bit of dispersive viscoelastic over here or use my second instrument, the spatula, to mechanically push the iris when I start injecting the IOL to avoid any damage.

The most important lesson, the less you traumatize the iris during surgery, the more you protect it, the better your surgery is. But more importantly, the smoother your postoperative period is going to be with less inflammation, less membrane formations, or even eventual CME formation.

I think this is, in summary, what like I said, every case, every day, I remember Dr. Crandall. Record all of your videos, which before we started the meeting Dr. David Crandall was echoing, and I totally agree. Review all your videos, whether you do it with a pizza or without a pizza. But always particularly take time out and just select randomly the cases that you thought were difficult or where you could learn something. And keep reviewing them. And every day is learning as a person, as a surgeon. And thank you Dr. Crandall for always helping and I’m sure you’re looking at us every day and teaching us all the time, thank you.

[David Chang] Wonderful teaching points. We’ll move on to try to make up some time. But maybe one comment from the audience. The doctor was mentioning a subincisional hook for IOL insertion or for managing the iris. Deep, do you want to comment on a subincisional retractor?

[DP] Absolutely. I believe Tom Oetting described that. And I think it’s a really nice technique because then you can make sure that the iris subincisionally does not get tented up and it actually stays down. There’s so many different ways to expand the pupil. And when you use hooks, again, you can even use multiple, but having one just subincisional can definitely keep that iris out of the way. If you don’t do that, just make sure you don’t place them very anteriorly so I love the way Dr. Vaishali described. She kept everything down so that the iris was not tented up because that’s when you get into trouble. Either way, just make sure you don’t eat the iris.

[David Chang] Jeff, I’m just going to ask you, pearls for capsule staining. Because I think if you’re going to expand the pupil, you have to put viscoelastic in. Do you have any tips on how to stain the capsule when you’ve already put viscoelastic in?

[Jeff] Yeah, great question. The couple of options I’ve seen people take BSS, squirt it on top of the capsule to try and remove it and then put in the stain on top. The majority of the time that will result in an incomplete or at least an inconsistent stain. I really like taking my I/A, removing it, staining the capsule whether it’s under air or the way that you typically would, and then putting the viscoelastic back. That will be your best, consistent stain.

[David Chang] All right, perfect, perfect. Vaishali, thank you so much and I think we’re going to move to our fourth presentation and turn it over to David Crandall.

[David Crandall] I’m going to, just a quick, brief history of this patient and then I’ll go into the case. It’s a 41-year-old who came to our ER with left sided pain. He has a history of high hyperopia in the range of plus 12. He’d had LPIs performed at age 12. He’d been a musician and for some time, it sounded like at least a year, he’d had left sided pain and halos whenever the lights went down during concerts. His best corrected acuity was 20/60 and 20/40 and his pressure was in the upper 40s in both eyes. He said he had a sister with similar eyes and she had urgent surgery several years ago which he said didn’t go well but he didn’t know the details and she’d had eight subsequent surgeries since that time.

Not surprising it was very shallow, he had a spherophakic lens. Pupils at two and four millimeters. B-scan showed a small eye and thick sclera. His pain was initially improved with medical management, we got his pressure down to the mid-30s. Macular OCT did show thickening. Two days later his pressure had got back up into the upper-40s, he had some microcystic edema and pain. I added atropine with the idea of sort of pulling everything posterior, though there is some controversy about that. It did work, he said after that he did not have any pain.

Here’s his measurements. Both eyes under 16 millimeters, the anterior chamber depth the IOL master measured it at 2.8 and the Argos at about 1.6, both of them were wrong. He had steep corneas. Lens thickness of six millimeters, so you can see over a ⅓ of his eye is lens. And a pretty normal white to white.

Here’s the Argos image so you can see there’s definitely not 2.8 or 1.6 millimeters there. His cornea’s about 650. And we know the answer to dealing with this is to get that lens out. I figured I’ll briefly throw out to the panel what their preoperative plan would be, and then we will go to what we did and then our intraoperative approach.

[David Chang] All right, anyone on the panel want to talk about their pre op approach here?

[Jeff] Yeah, really challenging case. First of all, this is a situation where depending on UR, this is an eye that you haven’t had experience with. You do want to consider referring to someone when possible who has experience with these types of eyes. When you do read that the different options available to you, things such as scleral windows, even a pars plana vitrectomy, just a short core vitrectomy ahead of time. I think either of those are reasonable in this particular case.

[David Crandall] Preoperatively we had a very long discussion. Both about the risks, which he was pretty well versed in due to his sister’s history. And also our lens limitations. The lens calculations called for between a 52 and 55 diopter lens. For those of us in the US, 40 is the limit of what we have. He knew he’d still need pretty significant correction afterwards. We planned for general anesthesia, this is more work than normal. And I did not want to do a block because that’s going to increase posterior pressure. I put a Honan-cuff on him for about half an hour in the pre op area. And we have this weird Honan-cuff that doesn’t have an actual dial on it, so the way I explained it to him was that I wanted it to be a little bit uncomfortable but not painful. And we got it dialed into that level. Then we gave him mannitol, he’s about 80 kilograms, so 1 gram per kilogram, but we started just before surgery.

Hopefully we can get this video to play. Here, creating the scleral windows, let’s show a little bit of this. My target had been to get 5×5 millimeter windows. He did not have enough room between his muscles, so I cut him down to about 4.4×5 millimeters.

Digging down to where you get that nice blue flush of the choroid. Spending a lot of time. This is where I actually wish I could have done a retrobulbar block just to push the eye forward a little bit because it was deep set. This first paracentesis is very long and very anteriorly to avoid hitting iris or lens. And it was just to give me a little space to where I could deepen the eye and put in vision blue. I wanted to change the texture of his capsule and I wanted to just make sure. I know this is an abnormal case and I want to have visibility of his capsule at all times. I started with a small shell of dispersive viscoelastic and then I’m putting a very, very cohesive viscoelastic underneath it. As with the previous case, our goal here is to maintain space as much as possible.

I’ve made two paracenteses. I’m doing my capsulorhexis through my paracentesis, again, to maintain space. I have no risk of a lot of viscoelastic burping out of this while I’m working. And you’ll see that I’m coming around even, it’s a steep lens, there’s natural posterior pressure and so I’m doing many little maneuvers the entire way around where I’m pulling centrally and back just to get a reasonable size capsulorhexis.

I always tell my residents that the capsulorhexis is not a race. Your goal is to get a good one, not a fast one. One thing you’ll see as I’m coming around here, there are a few folds in the capsule as I’m coming around. That gets my spidey sense up a little bit because that can be a sign of zonular weakness and that’s not uncommon for these high hyperopes to have zonular issues.

I’m doing a lot of little pulses of hydrodissection, I’m not trying to completely free up the lens, but just loosen the cortex. And then I’m going to do bimanual I/A for this case. He’s 41, I think I can get away without phacoing. And I’m going, I actually have a still shot right here in just a moment. And you can see there’s blue in the port. And we know that the capsule is stained blue, the lens is not, so that’s a sign again that I’ve got a zonular issue in that area. Refill with viscoelastic and actually what I start doing is viscodissecting this lens using the dispersive viscoelastic as a pseudo capsular tension ring, which Bob Cionni taught us.

And this is heavily edited, it took me about 20 minutes of just slowly sucking this out. I wanted to do as much as I could through small incisions just to keep that chamber deep and prevent any effusions, which we know he’s at very high risk for. And then taking extra care in that nasal area where we know that there’s potentially some zonular issues.

And now I’m going to completely expand the bag and just manually dissect some of that remaining cortex. I like to sweep the capsule in all my cases anyway, especially in young patients. And then I’m going to put a capsular tension ring. I’m doing it through my paracentesis so that you can’t use an injector for this, it has to be manually. I usually prefer a manual insertion anyway because I like the tactile feedback I get when putting them in this way.

When I viewed the video in depth in retrospect, I may not have needed it. Because the capsule did tend to snap back in that area. But in the moment I wasn’t sure and I felt safer putting one in than not. There’s really no way to easily fixate an eye in this situation. Now I’m going to finally make my main incision after the lens is out. I had to enlarge it a little bit because these lenses won’t go through D cartridge, so we have to make it big enough for D cartridge. I know a lot of our international folks have the option of getting a higher power lens.

And this eye’s also at risk for aqueous misdirection. So here I’m doing a vitrector, made an iridectomy and I’m just pushing forward and doing a quick vitrectomy, a few small PAS that I wanted to remove. Suturing our wounds and then closing the conjunctiva. He actually, he was about 20/40. I saw him on Tuesday of this week. His pressure’s 18. He’s still on topical pressure lowering medication but not on oral.

Just some surgical keys. I did do scleral windows just because the eye is so small. Capsule staining, I wouldn’t have noticed a zonular issue without it. And just like the previous cases, keeping the anterior chamber pressurized throughout the case. The iridozonulhyloidotomy for malignant glaucoma. And then also if I had to do a pars plana vitrectomy, doing an injection pars plana scleral fixations, you can’t trust the normal landmarks. If you go 3.5-4 millimeters back from the limbus, you’re going to be going through peripheral retina and not through the pars plana. And I wanted to cover all of the techniques we used for small eyes. I did use just about all of them for this case, but any of these can be useful in given situations.

That was a lot for me to go through in a few minutes.

[Susan] That was fabulous, well done.

[David Chang] That was a great case. One of the audience questions is did you use a 40 diopter lens?

[David Crandall] Yes.

[David Chang] And if so, what was the refractive outcome or is it too soon?

[David Crandall] It’s a little bit too soon. Last time we checked him he was measuring about a plus nine. He actually felt it significantly better than what he had preoperatively, which was reassuring. I should also mention people talk about doing piggybacks in this case. I didn’t feel there was anywhere near enough room in this eye to put a second lens in there.

[David Chang] Sure. Let’s take the case that maybe isn’t nanophthalmos, panel. And just a high hyperope with a very crowded anterior segment. What’s your go-to IOL calculation formula for the extremely short eye?

[Jeff] Deep, why don’t you comment?

[DP] Absolutely. I tend to use Barrett for a lot of these eyes and I look at the Hoffer Q as well. They can be very good for short eyes. I like to compare a bunch of different formulas. And then the patient needs to understand that there’s, you just don’t know what that effective lens position’s going to be. So David, this case was expertly handled. You did such a nice job in avoiding disaster left and right. You really nailed it. So thank you for that, for showing all those pearls. And I think, again, keeping the chamber as deep as possible, and using mannitol pre op, really, really key.

[David Chang] And then another audience question is about peripheral iridotomies, which you did do with the vitrector. And David, I know time was limited, just spend a moment and explain exactly how you did the PI.

[David Crandall] I took the vitrector port down as far peripherally into the iris as I could. And my settings actually have a peripheral iridotomy setting. So the cut rate’s as low as possible, aspiration and vacuum are high. I aspirate up just a 1/10th up the iris and then chew away at it. That creates usually a very nice round iridectomy. And then in this case with the zonule hyaloidotomy, I advanced it peripherally. With the capsular tension ring I could feel the edge of that so I just slit the vitrector peripheral to that. Switched back to a cut I/A mode and then did just a half second to second pulse of vitrectomy, and then came back out.

[David Chang] Another question is for nanophthalmos, would you consider a irido zonular hyaloid vitrectomy? And I believe what they’re talking about is doing a vitreous tap but going through a PI.

[David Crandall] And that’s essentially what I did at the end of this. I didn’t want to do it preoperatively because I didn’t want to do anything to decompress the eye at any point because that’s where you’re going to see effusions. And then in a normal eye where I’m worried about aqueous misdirection, I prefer to do it from posterior to anterior. I feel it’s a little easier to hit the landmarks. But in this eye, I have no pars plana so there’s nowhere for me to safely stick an instrument in behind the iris.

[DP] May I ask a simple question, a basic one? I personally have never used scleral windows in these cases. Can you just tell me how did that window help you and if you’re worried about an effusion how do you know it’s going to happen there? When do you use it? What’s the deal with that?

[David Crandall] You don’t know where it’s going to happen but these, I don’t know if you’re able to see in the video, but his sclera was extremely thick. Basically we’re just creating a place where you can get some uveoscleral outflow. And I didn’t show it in this, I made two separate windows. I did both temporally just because it was easiest ergonomically. And it just gave me an area that there was some fluid coming out. And then I edited it out of this video but once I made that window you could actually see fluid percolating through there. I knew then I had created a space. I opened his conjuctiva 360 degrees so I could also do a quick cut down elsewhere if I needed to. But with the hope that I wouldn’t need to. The idea is just getting as deep as you can where you see that blue flush of choroid underneath. And the hope is you get enough room to let some of the fluid egress and prevent the build up underneath the choroid.

[David Chang] And did you close them or how do you close them?

[David Crandall] I just left it open. I figured even postoperatively he’s at risk of effusion and so it was better to just leave them open. That’s what our retina guys do. I know some people do a flap and then they close the flap down over the top of it. Even the ones that are completely open I found that if you go back a year or two later, you can’t find where you made your windows usually. It grows back in.

[David Chang] Super.

[Susan] David, I just want to say the preoperative thought you put into this case really paid off and the patient’s very lucky to have had you as a surgeon.

[David Chang] Agreed.

[David Crandall] We’ll see, I still have to do his other eye. (laughs)

(panel laughs)

[David Chang] All right, thank you, we have one last case then and we’ll turn it over to Susan MacDonald.

[Susan] I just want to thank David Chang and Hunter and Cybersight. This is an enormously successful meeting. I’ve learned so much and reminded me of so much as well. Alan really was my compass in medicine and life in many ways. And I really agreed with what Jeff Pettey said, he treated everyone as an equal and it came naturally. It wasn’t something he had to do and it was extraordinary because he lifted up so many people. This photo here is one of the patients that was treated at Eye Corp in Tanzania. And the two surgeons behind there had the, the first one on the right is Jafed Boniface and he was trained by Alan. And the second doctor over there is Grace, Dr. Grace. And she was trained by me. These two are now training others. What is clear to me is there are, Alan is spread across the world by the amount of teaching he was able to accomplish and how he really lifted people up and gave them a skill set to be extraordinary surgeons.

My talk today is going to be about mature cataracts. These cases for me are extraordinarily exciting. And I think the reason why is because they have such potential and it’s such a dramatic change for these patients to go from not seeing to seeing.

I wanted to start, they’re all so exciting or anxiety-provoking because they do carry with it a higher risk of complications. I’m going to just start out, this is my first ever mature cataract back when I just left the Moran. And I was just such a smarty pants and thought I didn’t need to stain this situation. As you can see here, I just want to show you that I think I’m doing this beautiful capsulorhexis, where in fact you can see if you look really hard, that I’ve got an extension going here. The first thing I want to just stop and ask everyone, oops, I didn’t mean to do that. How can we improve this, my view? And one of the ways to improve it is just using Trypan Blue. And we spoke about this, the idea that Alan taught me is he used to say, “I’m a lazy guy, so I like to make things easy on myself.” And I don’t agree with him being lazy but I certainly think making things easy is an extraordinarily brilliant concept and it’s best for the patient. If we stain the anterior capsule, we can see what we’re doing.

Now here’s the second issue that we come across when we have mature cataracts. The capsule, our famous Argentinian flag. The question is, why is this happening? I’ll tell you. If you look at this study that Arup Chakrabati published in the Journal of Cataract and Refractive Surgery way back at the turn of century in 2000. He looked at 212 cases of consecutive phacoemulsification performed on white cataracts. And what they found is that the highest complication rate was in the capsulorhexis. And in fact, other complications were in the single digits, but this complication rate was almost 30%. And if you look into their data further, you can see that there was a limited learning curve here. If you look at that data, you can see the first hundred and second hundred cases, they’re having the same number of incomplete capsulorhexis.

And why is that? White cataracts have a number of challenges. It’s visibility, number one. And the second thing is we know that the epithelial cells that are sodium-potassium pumps are dysfunctioning. And that we have osmotic pressure developing in the eye and we get this swelling. This second important piece that we need to remember is that there are capsule abnormalities. Unlike a regular capsule, you will actually if you look at the electron microscopy of these particular capsules, you can see that there are some longitudinal splitting and so you have that thinning. Then there’s also these little areas of thickening. You can actually feel when you’re doing a capsulorhexis or see that once you pull in one area you’re going to have some resistance and then it will move very quickly.

Third point I want to make, I love this cartoon. And I think this cartoon will resonate with all of you because this is what we’ve been talking about pressure in the anterior chamber. And I’m going to pause that, ope, I’m going to go, let me see. I want to go back to that cartoon. Let me see if I can do that by getting back to the cartoon. Here we are. Look at this cartoon as we are… And what you see is we have the anterior chamber as it naturally is. And we see that our lens is slightly pushing up. When we put viscoelastic in here, what we are doing is we’re artificially expanding the anterior chamber. And we’re creating some potential energy in the posterior to the iris here and any time we manipulate our wound, we are going to have an exit of that viscoelastic and we’re going to see this lens-iris diaphragm actually moving forward. So that’s something we just need to be very conscientious of.

Here’s my case I want to show you all. What I am doing in here is I’m using a 27 gauge needle and I’m going through my paracentesis and I’m piercing the anterior capsule. And you can see that I’ve actually removed some of the white fluid here. That allows me to go back in through my incision and I can proceed with my capsulorhexis. And what I really believe with these cases is you really have to be committed to your capsulorhexis when you start. Did you see how that was a little bit rough there on my start? And now I make sure I am folding over. And not only folding over, I’m also bringing the tail into the center so I know my vector forces are coming into the center and not heading out. Here I’m hitting a little bit of the white fluff coming out. I’m not going to pause, I’m just going to plow forward because I know this isn’t going to get easier. And the more I move my Utrata forceps in and out of the eye, the more I’m going to change the pressure.

Let’s look at, this is the Little technique and this is courtesy of Dr. Little. And you can see this skill set is huge. To rescue our capsulorhexis, what we do is we flatten down the capsule and then we pull on that. What I’m showing you here is one of my residents. And we actually do the Little technique on our non-mature cataracts. And what this does for the surgeon is it just gets you comfortable in doing this maneuver. We’ll have the resident lay the capsule back down, we’ll give a tug and we’ll see how we can redirect our capsule. And we will do this and we’ll end up with a lovely scalloped capsulorhexis here. But what we’re really giving is this surgeon the confidence and the ability to do the Little technique.

Let’s get back. The final issue, I think, with these cases, is you need a lot of energy to break them up. I’m making absolutely sure that this lens is freely moving and then I’m using my phaco and this is a two-handed technique and I’m going to do it in burst mode. And the reason I’m doing this in burst mode is I want to chop as much as I possibly can in the capsular bag. And so I’m bursting and then I’m holding onto the piece of nucleus with my foot position on two and then I’m cracking. And I’m going to make like a flower, I’m going all the way around and I’m not trying to debulk but really what I’m trying to do is crack. And so you can see when I’m cracking I have to walk my way down the crack to make sure I get the thickness in the back of this nucleus. And then now that I’ve had it broken up into these pieces, I can carefully remove the nucleus and keeping it at the iris plane so I am not going to damage my endothelium.

I have one more video but let me just stop there and ask the panel for their input.

[Jeff] Susan, going back to the fundamentals is so important. Another mantra of Alan’s is you can’t cheat physics, surgery is physics. If you’re seeing things that you can’t explain, really try to go back to just some of the basics. The basics of fluidics with phaco or just the basics of biomechanics. Every time there’s an Argentinian flag sign, that capsule is bulging forward 100% of the time. So you as a surgeon have to start thinking, with my tools that I have, what are ways that I can maintain that anterior chamber and not have viscoelastic come out while I’m doing my capsulorhexis or entering into the capsule. When you start thinking about it that way, you’re going to discover many of the same things that other people are going to teach you. In fact, for everything that Tom Oetting or David Chang has written up, there are surgeons around the world who are figuring the same things out and seeing some of those same patterns occur. So it does all go back to those basic fundamentals of physics.

[David Chang] Great.

[Susan] I absolutely agree. And I also think that one of the really valuable pieces of this that Alan…The thing I’ve learned with traveling with Alan is when we’re doing SICS surgery, we open up the capsule, we don’t make a small incision. I open up my incision completely. I am not creating a really pressurized anterior chamber. And I actually think if we hyper pressurize the chamber we’re going to get ourselves into trouble. Actually I don’t add as much viscoelastic as I have in the past. And I think that’s a great example of how that I learned with Alan but from a surgeon in Tanzania that taught both of us about that.

[David Chang] David?

[David Crandall] I was going to mention something that’s really stupid that I found out the hard way is when you’re puncturing the capsule with a needle to withdraw cortex at the beginning of these cases, you want to do it with your bevel up. If your bevel’s down, when you’re coming back out you can catch the proximal end of the capsule and end up creating the Argentinian flag that you were trying to avoid by removing the cortex. And also this is another time that I like using the Honan balloon preoperatively. Just decompress the vitreous a little bit, remove one of the sources of posterior pressure, and I found that makes a little bit less likely to get the Argentinian flag.

[DP] And just to dovetail on what David just said. As you go in, Susan, beautiful case, really lovely and well-presented. But when you’re decompressing the white cataract, make sure you also push down on the nucleus. Take out the liquified cortex on top and then push down because there’s still some liquified cortex posteriorly so you really want to push down and don’t be scared, don’t be scared to do that. And try to relieve the intralenticular pressure that way.

[David Chang] That’s a great point because I think it was Dr. Marquez from Brazil. You will decompress the liquified cortex anterior to the nucleus but there’s still some behind the nucleus. Of course that can explain why it continues to shallow and the lens moves forward. He recommended just that. But also even rocking the nucleus from side to side, like we do rock the IOL to get the viscoelastic from behind it. Great point.

I think we actually saw, I love the fact that you went over Brian Little’s capsule tear out rescue maneuver because here it was due to the intralenticular pressure but we talked about chamber shallowing, the extreme being that nanophthalmic case. And these are all situations where the lens wants to move forward or the fluid wants to push things out. That and also would you agree, panel, would you start with the rhexis a little bit on the small side and spiral out just so you have a little bit of a rescue margin for error? Any other tips on the really tough capsulotomy that you’re having trouble controlling?

[Susan] Yes, I have another tip. The other tip is capsulorhexis isn’t the only way, that we need to remember we can do a capsulotomy. And it’s a really fabulous technique and it works beautifully. And if you feel like you’re starting to be in trouble, that is a very brilliant way to accomplish the task.

[David Chang] Perfect. Perfect.

[Vaishali] If I can add one thing which is very likely pointed out by Dr. MacDonald, if you don’t want to, especially when you’re using Healon5, Healon GV, heavy cohesives, all these viscoelastics, it can be your friend but it can also turn the other way round. Do not over inflate but at the same time see where you are injecting. It’s not like you just inject in the same terrain to inflate the whole chamber. I would inject in the mid periphery, that is the area where I’m actually going to pull the capsule, perform the rhexis. I would do small boluses there and then a little bit in the center. When using these heavy viscoelastics, we need to be a little mindful that it’s not like using a solution or 1% sodium hyaluronic where you just inject as a bolus.

[Susan] And I just want to articulate what I was trying to say about your incision size. Just how we saw with Jeff Pettey how he opened up his incision a little bit more so that when he injected the lens he did not distort the incision. I found that my incision for my capsulorhexis, if I open it up a little bit more, I’m actually going to lose less viscoelastic because I’m not torquing my wound. And so I think that’s a really clever piece of just opening up a little more so you have a little room to maneuver.

[David Chang] Let me ask the panel, Susan showed this very well that you’re chopping this nucleus but with the mature, white lens there’s often no epinucleus. As you’re getting down to those last fragments, anybody on the panel, what do you do differently in these cases where it’s a dense lens but no epinucleus?

[DP] I put a dispersive viscoelastic to make a pseudo epinuclear shell and that has saved me many times. Always viscoelastic is your friend. And using your left hand to put viscoelastic in, to put air, BSS, really getting used to using your left hand by itself is a really important task. Like Jeff showed in his case, you want to do these fire drills when you don’t necessarily have to use them. Really get your left hand used to putting viscoelastic in the eye, lifting up the pieces, and save yourself some hassle.

[Susan] Left handed surgeons, remember the right hand.

[DP] Oh yes, your non-dominant hand. Thank you, Susan. Thank you.

[Jeff] One way you can do that practice, putting viscoelastic in elegantly takes a lot of practice. Every time you’re done with your I/A, if you’re going to take your I out and put in viscoelastic, just take that time on your next 25 cases and every single time before you come out, put your viscoelastic through your paracentesis. And viscoelastics feel a little differently depending on which one you’re using and you need to get a sense of how hard do I need to push with different viscoelastics. I have seen this poor junior resident so excited to get his case done. He had taken some Healon, it had come out of the fridge. And he went right through the posterior capsule because he was used to pushing something that pushed through a little easier and he thought he was putting a bolus of viscoelastic in front but instead put his cannula right through the bag.

[DP] I actually do that, oh, go ahead.

[Susan] Go ahead.

[DP] I actually do that on all cases, Jeff, not just your next 25. I do that every single case is fill up the bag before you come out with the I/A because you have to learn from your previous issues. Don’t let the chamber shallow ever! Ever, ever! If you can avoid that. Go ahead, Susan.

[Susan] I’m just going to connect the dots here because most of us have had Alan teaching us. And I think the key point here is every case is a case where you bring your best game. And if you’re bringing your best game, you’re training yourself for those difficult cases. To learn the Little technique on your first white cataract is a mistake. All of these techniques can be learned on a simple case. And that just means bringing your best game.

[David Chang] I think that’s a great comment. The other thing I would say, and hopefully that is the purpose of everyone spending part of their weekend with us learning, is that you have to mentally rehearse what you’re going to do as well. Not only the skills but mentally what would I do. And that’s what each of you did so well today by pausing the case and kind of letting everybody think through what they would do and that’s an equal part of what preparation is about.

Our time is up, it’s gone by so quickly I can’t believe the hour and a half is over. Thank you, first of all, to all of our faculty for those cases. A lot of preparation to edit those videos. And I also would like to add my thanks to Orbis and Cybersight for continuing to bring us all together with quality live education and using their platform. With that, again, I think and finally thank you to Alan Crandall for inspiring all of us to be better surgeons and to try to help others around us through our teaching to be better surgeons as well. Good bye, everybody.

[Susan] Thank you.

[Jeff] Thank you, bye, everyone.

[Vaishali] Bye. Thank you.