Lecture: 3rd Annual Crandall Cataract Conference

Hello, everyone. And welcome to the third annual Cybersight Cataract Conference. This is named after one of the great act surgeons of our generation, Alan Crandall. And we’re so proud to be able to put this on. This was really the brainchild of Hunter Cherwek, medical director of Orbis and this is the third year we’re doing this. We have a terrific faculty, some of the best cataract teachers that I know. Nick Mamalis from Utah, Mitch Weikert from Houston, and Nicole Fram from Los Angeles and Kendal Donaldson from Miami and Abhay Vasavada from India. And the format, I asked each to teach one of their best teaching videos or teaching talks and then we’d like to follow that with a little panel discussion. You, the audience, have the opportunity to pose questions through the Zoom function. At the end, we really allocated a good amount of time for question and answer, which will, again, have you pose through the Zoom box. So we’re going to start with Nick Mamalis who will present the first case. And Nick was one of Alan’s partners at the Moran Eye Institute of Utah and I’ve asked Nick to say a few things about Alan Crandall. Nick? >> Thank you, very much, David. If we can go ahead and get my slides up. >> Perfect. Dr. Mamalis, you can go ahead and share your screen. >> Good morning, everyone. These are my disclosures. None of which are pertinent to this particular case that I’m going to present. I would like to take a little bit of time to talk about my long-time colleague Alan Crandall who sadly passed away about two and a half years ago. Alan is the epitome of a humanitarian. He started doing work worldwide almost 30 years ago. He would make trips to Ghana and worked with the Himalayan Cataract Project and was instrumental in setting up Moran Eye Centers international work. We now have a fellowship there and a full center that does outreach work not only around the world but locally in Southern Utah we have the Najavo Nation where our outreach people work. Alan epitomized the old saying that says, “if you give a man a fish, he eats for a day, if you teach a man to fish, he eats for a lifetime.” And Alan truly believed this. He was involved in teaching. He didn’t want to fly into a place where there was a great need and perform as many cataract surgeries as possible. He wanted to get the local ophthalmologists, local nurses, local technicians involved and teach them how to treat the huge problem of cataracts worldwide. Alan received numerous humanitarian awards. He received the ASCRS Humanitarian Reward, which Dr. David Change kindly donated and it’s now named the Chang-Crandall Award. For me, personally, Alan Crandall was my travel partner. Alan and I traveled the world for 35 years. We lectured and taught courses but more than that we got a chance to experience the culture worldwide. Alan was a great friend and I miss him dearly. Today, I’m going to go ahead and show you a case. You’re going to see some wonderful cases by outstanding surgeons and techniques that are unbelievable. I want to show you a simple, basic case. And what to do with a simple complication. Now, this is a resident case. This is done at our veterans’ hospital. And this is a cataract in a patient with a history of Flomax use. Unfortunately, we did not have any Omidria available. It’s a moderate cataract. We do pre-chops. We make a crack right there. You see as we’re doing this the pupil is starting to come down. So you see right now it’s getting floppy and coming down. And so the resident is really struggling to see what is going on here as she is rotating it around. I apologize for the quality of the video. But I do want to talk about what to do in some simple, well not simple, but straightforward cases of complications. Here we are, we’re working, we’re working, the pupil is coming down. It’s going towards the stab incision. And we’re still working away here. Now, you’re starting to see the red reflex show up. Now, I want to go ahead and stop it right here. I’m going to ask our panel, now, I realize the pupil is not well dilated. We didn’t have Omidria available. What is the panel seeing? Especially in the top left corner? >> It’s not a very clear view. >> It looks like there really is quite a floppy iris there and we can see that the iris is getting sort of incarcerated in the paracentesis a bit. As with all good resident cases, they can go on for a while and the pupil tends to get smaller and smaller and smaller the longer the case goes. This is early in the case and I’m a little concerned how the pupil is going to end up at the end of the case. >> What I wanted to show and I’m going to go forward. If you look right up in here, there is a little clear area here. It wasn’t apparent initially but as we reviewed the videos it became more apparent. The question is should we have stopped here? Should we have considered putting in hooks? Since the rhexis is made and we’re at the point to have a second-year resident put in hooks. We could have traded place and put in some hooks but at this point we went ahead and proceeded. Let me go a little further now. Now you see that clear space right there at the top left, what did we do wrong right there? >> Everything. >> You have to have — I don’t understand the concept that it’s too hard to put in hooks. If I start seeing the rhexis come down, we just, we put hooks in to stabilize. I think a lot of times they have floppy bags as well as floppy iris in my experience. So it’s really important, you can’t go where you can’t see. That’s always how I think about things. >> I agree with that fully. In retrospect we should have put in hooks because we had a really inadequate view and that would have helped tremendously. When we’re right here, what we did is made the first mistake and there is a clear area that you can see a little bit superiorly there. So what happened is we pulled out the hand piece before we put OVD in. I think the first teaching point I want to stress, if you’re suspecting a capsular tear of any kind, place the OVD in through the stab incision and keep the hand piece in there so the chamber doesn’t shallow and go to position zero and come out. What happened the resident came out immediately. The first thing is always put OVD in before removing an instrument from the eye. We put in a lot of OVD. There is a bit of nucleus left but we weren’t seeing signs of any vitreous coming forward. We put in ample OVD to push the capsule back and raise the pieces of nucleus up out of the bag a bit. I sped this up for purposes of going ahead. And what we’re doing now, I’m not letting the resident chop these pieces. I’m having her keep this in one big piece so we can go ahead and pull this out and get it out without the risk of smaller pieces falling backwards. So we’re just working at this in one big piece of nucleus. I want her to get all the nucleus out before anything can go south. I apologize for the movement. That is inherent. Now we came out. There is a small area of capsular tear and we’re trying to get cortex out. What is happening right there? >> Vitreous. >> Vitreous. Exactly. I was under the mistaken impression that I thought the hyaloid face was still in tactor, which we allowed the resident to go ahead and remove the nucleus. If you look, there is an oval opening in the posterior capsule and this little strand of vitreous coming forward. Now we have to change what we’re doing now, with that strand of visit tree you coming forward we had to go on. What does the panel recommend at this point. >> I think it would be to inject the visco before we withdraw. And do tram to recognize the vitreous. And then decide the strategy for resecting. >> It’s hard to tell how much of a posterior capsular violation we have here. The viscoelastic cannot only help protect the cornea, keep back the vitreous from coming forward but help to get the pupil bigger so we can see how much loss of capsular integrity we have. I can’t tell from the video, maybe it was more obvious in person how large this area is. >> In person, it was an oval opening that was approximately 3 mm by, maybe, 2.5 by 1.5 mm. It was not that big of an opening. The rest of the capsule was intact at this point. Unfortunately, not only did we not have Omidria available at the VA hospital that day, we didn’t have triamcinolone available. We’re trying to regurgitate. For the third time, we did not put the OVD in. Three times we made this mistake. Obviously I’m not well trained on training someone else to do this. We made a second stab incision and now we’re doing a manual vitrectomy. I know Dr. Vasavada has wonderful videos of working through the pars plana and working through the vitrea. But, unfortunately, I’m not comfort with the resident going through the pars plana. We made a second incision. And finally the fourth time we figured that you should put OVD in before you come out. The capsulotomy anterior was still intact. We’re putting OVD in and reforming the sulcus. We have to extend the wound to 3 mm because we’re going to put a 3-piece lens in the sulcus. So it’s important, you cannot get that big B cartridge in through a 2.4 mm incision. So we go in and rotate the injector sideways and slide the haptic into the ciliary sulcus. And as the piece is coming out, we roll the bevel down taking great care to not let the haptic go into the capsular bag. And slowly unfold the optic. Again, I apologize for the centration. You get the idea of what we go through when we’re at, working with residents every week. Now what we do is gently rotate that haptic, the second haptic into the ciliary sulcus. >> How are those eyelashes? >> Yes. Again, we didn’t properly drape. We could have put for Tegaderm on there or something. We’re going in and removing the OVD and taking great care not to extend anything. I’m sorry, we didn’t show where you optic captured. I’m going to stop that there. I want to highlight some points of what we did wrong on that case. When you’re suspecting a capsular tear, never come out of the eye. Always keep your handpiece or phaco in the main wound and place the OVD and then come out of the eye. If you have poor pupil dilation, that is an invitation for problems because you can’t see what you’re doing. Do not hesitate at that point to put some iris hooks in to widely dilate the pupil and control the floppiness of the iris. In terms of seeing if there is any vitreous there, I think triamcinolone is a wonderful thing to use and will stain the strands of vitreous. If you’re going to remove the vitreous and you’re not comfortable in the pars plana, make a second stab incision and remove the strands of vitreous. I can go ahead and ask the panel to jump in and make any comments at this point. >> Nick, I think that case may have taken a couple years off your life. I think it was maybe more stressful than it had to be. >> I tell the residents they saved any gym membership because my heart goes to 150 when I’m with them without doing an elliptical. >> You don’t have to get a stress test, you’re fine. >> I agree with Nick, they should practice with iris hooks or rings before they come into the OR. So they have familiarity just watching videos. Videos like these or other videos are such a great tool to help them warm up in advance for cases. We know we’re going to get cases like this all the time where the pupil doesn’t dilate. If you think about wanting to use it, for example, the hooks or trypan, and it’s going to make life easier, just do it. It’s not only good practice but it can save you some stress. The other thing about the second incision for the vitrectomy, I thought that was a great point. I usually try to make my second stab incision farther away from the wound so I can bring the vitreous farther away and it’s not coming towards the wound. That was a good point about not doing the vitrectomy through the wound. In combination with Ken log, make sure the pupil comes down. I would put a 109 I would say. >> That is what I was going to comment on: You have an open capsule case and I hope at the VA they have intra-cameral antibiotics that you can use. >> We do have intra-cameral because moxifloxacin is mixed with it and we can use that. In terms of rings, they have great experience using Uvn rings. The pupil is initially well dilated and we always say, well, that will be okay. It’s well enough dilated we don’t need the ring. And the residents before the rings were available were good at putting hooks in and now they’re not. That is an area to stress in wet labs is getting proficiency in using hooks. >> Nick, can you put the video back to where it was before you start the CC. I guess it’s the beginning of the case. We’ve all been here, we’re all going to be here this week, this month where you sit down and go, well, the pupil is not widely dilated but looks adequate. And then you get away with it and say, well, I’m pretty good at these medium pupils. And I think the key is, of course, here you know the patient is on tam and it’s not going to stay that way. The case is beautiful and points out the importance of making that decision before you get started. Because as you said, once you get into it, like right there, you know, that’s a case where it looks like for many cases we find, I think the key was knowing they were on tamsulosin. >> That’s a great point. I’m not quite the showman that Dr. Agerwall is. He would say oh my god, what am I doing here. How could I do that. How could I not see that. When you’re in there you don’t notice it: But when you review the videos, you say, we should have done this, we should have put a ring in there. And they’re getting good at putting in the malyugin rings, we use that a lot. In retrospect we should have started with the ring. The pupil is about 6.5 or 7. But knowing they were on the tamsulosin, that would have been a less difficult case. >> I think I find that — with trypan blue, every time the fellow is doing that, I make a point with respect to the — which helps sometimes. And low IOP or — you all have described the importance of that low fluid pressure more in the front of the eye than behind. It really helps. Nick, wonderful teaching case. And you brought out so important points that we will remember. Thank you. >> All right. Nick, thank you so much. If you could stop sharing your screen, we will get to our next presentation of Dr. Nick Weikert. While Mitch is pulling up his presentation, you know. >> We have some quells about, you know, what kind of iris hooks to use. >> Go ahead, Nicole. >> I like the flexible Alcon grace upper iris hooks because I can put them under my main incision. I think I learned that from you, Dr. Chang. And the MST hooks are also nice. They’re a little stiffer. >> Take it away, Mitch. >> All right. So dense cataract, dense surgeon. This is an 84-year-old gentleman with a 4 plus Brunescent act and poor dilation and poor tamsulosin use. This IFIS risk will probably need capsular stain. Kendall, what’s your preference for these cases from the get-go? >> You said for capsular stains specifically? >> And how would you approach this? >> Well, for this case I would definitely use trypan blue and put in Malyugin ring which is my preference. Iris hooks can be used as well. But either is fine. Whatever you feel more comfortable with and have access to. >> I agree. In this case I’m going to use iris hooks. I marked the location of the hooks beforehand and I can place my paracentesis away from the hooks and I know my incisions won’t interfere with each other. That hook to the left there is where I want my paracentesis to be. We want to see the whole capsule when we stain it. I will put the hooks in with cohesive OVD ahead of time and then stain the capsule and paint the capsule underneath and wash out the cohesive and replace with dispersive OVD. There was a telltale sign in these dense lenses. And we’ll come back to that in a second. Here I have liquefied cortex. Nicole, what would you do at this point? >> Suck it out. I mean it’s not just dense, it’s intumescent and dense. I usually would go in with a 27 gauge and then pull back on the syringe and then initiate. >> Yes. In retrospect I should have gone in ahead of time with the needle. When I injected the dispersed OVD, you can see the liquefied cortex being pushed to the periphery. That is a great sign ahead of time you have liquefied cortex. You kind of know what to do it with. I went in with the needle after I initially saw that. I tried to do it as quick as possible. You don’t want that to continue to expand. And here, since I had the opening in the capsule, I’m using a cannula. Luckily, everything was okay and we can continue with the rhexis here. In these cases, I like to err on the side of 6 mm from the rhexis so it’s easier to get the pieces out. You don’t need much hydrodissection since the cortex is already liquefied, and now I’m starting the phaco. You guys probably noticed this well ahead of me. What do you see here, Abhay, what is going on. >> I think it’s a mobile, very hard nucleus and we really need to use more energy and less push, mechanical as well. >> Yes, exactly. Kendall, anything else? >> I would maybe use a chop, switch to chop opposed to trying to make a groove here. But I would definitely hike up the longitudinal power significantly here so I don’t move that around. Just like Abhay said. We don’t want — we can see the capsule was a little more friable and I’m sure you felt that as well. We can kind of feel it as we start to tear the capsule around and that is consistent with a zonular weakness. >> I do feel better, because you were delayed in recognizing what I was delayed in recognizing, too. Yes. The whiteness over the incision. There was a wound burn. Nicole, what do you do right at this point? And why did it happen? >> Okay. The wound burns that I’ve treated and seen and had are because I have so much OVD in the eye and you hear this ding, ding, ding, right when you go in and sometimes you ignore it for some reason. That is when you should switch and increase the vacuum. Switch and aspiration to clear all that dispersive out, especially in a shallow chamber eye. At this point, you just got to get the lens out. And then you have to deal with how you’re going to close this. But at this point you need to keep going and get the lens out. >> I agree. So we’re not getting much leakage after that wound luckily. So I’m still a divide and concur guy even in these dense lenses and I really hate — I kind of still do, the machine settings are pretty good now. With our settings, at least on the Stelaris that we have in the surgery center we can cut through the lenses easily. But we have the plates to deal with that are thick. It’s hard for me to chop a nucleus without a groove, without getting down there because of the plate. But I applaud people that are more tactile at doing that. You have to be really patient with these. You want to try to remove the piece and the connections completely, otherwise you use a lot more ultrasound. What protections do you take, Kendall, when dealing with these really dense lenses with ultrasound. >> One tool we might want to consider if able is a MY loop that can help with dense lenses with a posterior plate. Just another note, I would have seen wound burns like this when the sleeve wasn’t properly fit or there was a hole in the sleeve or the wrong sleeve is used. Make sure your equipment is set ahead of time. If you start to see a wound burn, look at the phaco tip and make sure the sleeve is intact and it’s the proper sleeve. I have definitely seen that. Fortunately, we don’t see things like this much anymore. >> The other thing can be a really deep eye. As you go through in a deep eye and tip down, it can pinch off the irrigation around the phaco needle. >> That’s a good point, too. >> So I fill with OVD a lot. Not only at the beginning, I will fill multiple times to protect the corneal endothelium. Sometimes I go in with a spatula. If I have a connection that is really hard to break, you can lift up the spatula and phaco across the connection to break the pieces into smaller pieces and that can facilitate the removal. If you’re able to really divide the nucleus up, they’re usually not that bad. The problem comes when you can’t [inaudible] the pieces, I think. We got the nucleus out here, the capsule is intact. And everything is going well. This shows that MY loop that Kendall was talking about. I think we’ve all seen these before. This is another dense lens, it’s a snare that we can pass around the lens. So we’ll see, we will expand the snare to the right and sweep it around the lens and go a little past midline and come back. We use a second instrument. Because as you start to contract the snare, the lens wants to pull out of the capsule. So you can see here we’ll go in, I’ll cover the distal part here. As it’s contacting the snare. You don’t have to deal with the posterior connections because you’re cutting the lens from the back to the front. And usually, two passes is enough with a lens like this. Once we have the lens separated and the quadrants, the removal is a piece of cake. So a couple things you have to be careful for. The My loop is 5.5 mm from front to back when fully expanded. If you have a really thick lens, it can be difficult to get it all the way around. You want to stain the capsule, which you’re going to anyway. But you want to see the capsule as you pass the loop around it. Here we are now, we’re injecting the lens. Now we have to suture the wound. There are many ways to approach this. We can have the panel discuss this. I’m going to mutt multiple sutures in here and not try to close the wound completely with the first suture. I’m using 90 nylon instead of 10. I’m doing slip knots back and forth until I get the wound closed. Seems to work there and I have a leak but it’s not through the incision, it’s through the suture track. Nicole, what would you do here? >> Cry. And then get it together. You know, I mean I learned a lot from, you know, our mentors. And when you’re trying to suture these kind of sick corneas together, it’s like you go from disease tissue to disease tissue and it keeps licking. You have to find fresh tissue. Even if it’s half way through the cornea. And I try to do a mattress style technique or go from fresh tissue to fresh tissue and that has helped a lot. >> Agreed. This was a few years ago. That’s back when we had re-sure sealant. I was able to close the leak. We don’t have that anymore but if we still had it, I would have put an air bubble in the AC. If you put air against that, it will stop the leaking and you can get a sealant on there well. Unfortunately, we don’t have this anymore. >> I’ve done this with cyan acro late or go get crazy glue. And I see them in postop and it comes off and you’re managing the leak again in the office. I will be careful. Lisa Arbisur sutured it closed and did a — and sutured on top of that which I thought was genius. >> I have seen that as well. Did you put a bandage contact lens on top of this, too. >> I did. I did. And luckily, you know, they were fine the next day. And continued to do fine. After that, I’m not a big fan of cyan on top of suture. That doesn’t stick in my mind. You’re caught between a rock and a hard place with that. I agree with going through fresh tissue. Any other approaches to suturing an incision with a wound burn? Do you make any relaxing incisions or anything like that? >> I agree with Nick’s comments about the mattress suture may be a little more effective than the interrupted nylons that you did here. Nick mentioned pulling up the conjunctiva. If you can’t close this, that layer of conjunctiva I have done before and it’s magical. It can cause some astigmatism because you have to put two 10 or 90 nylons to bring the conjunctiva up and over but it works magically in a case like this. >> I think we’re destined for a little astigmatism anyway. >> Two questions, say you thought you were okay but then at the slit lamp, the pressure is in single digits or close to zero and you see, okay, you’re leaking through one of those suture tracks. What do you do at that point? You know, you thought you were okay and now you notice the slit lamp on postop day one that you have a high pot news eye. What’s the management. >> Try to detect where the leakage is. If you can pinpoint the area of leakage and add glue or a contact lens, I think that can be helpful. We have to watch for choroidals and sometimes add atropin to decrease the aqueous production and help with the choroidals as well. But try to identify the area where the actual leak is and see if we can close that somehow. >> Sounds good. And Nick, sorry, Mitch, when did you take out the sutures? How long? >> I waited probably 6 weeks to take the stitches outs. I wait a really long time for these. And I don’t take them all out at once: I take one or two at a time and work my way out of the hole that I dug for myself. >> Super. >> Great case. >> Great case. Thanks so much, Mitch, that was fantastic. We’re going to our third speaker, Nicole Fram is going to talk about a very common problem that we don’t speak about enough. >> Okay. Can everybody see my screen? >> Looks beautiful. >> Okay. Great. We’re going to talk about navigating negative dysphotopsia. Just so we’re all on the same playing field, what induces negative dysphotopsia. It’s a dark arch off to the side. A shadow present post-op day one and 97 percent get better but 3 percent persist. As we talk about, they are very focal 3 percent. Especially in my practice. The working ray tracing theory is there is an illumination gap. The shadow is caused by non-illuminated nasal retina that is bounded posteriorly by the intended light ray and bounded anteriorly by light rays that missed the optic. And Erie and Simpson and Holladay did amazing work on this. The nasal capsule and high power IOLs can be associated with this as well. If we can move the optic forward, then we can move this illumination gap outside of the retina to perceive it. That is what all the strategy has been based on. This is just a baseline video of a secondary reverse optic capture. The work of my partner. Looked at elevating the optic on top of the nasal capsule in particular but the entire optic up. If we did this and did this mainly in the acro soft platform, it moved the shadow more anteriorly and these patients, 96 percent of the time, had improvement. You can see you dissect, be careful of the zonule and this acro soft material can be easier to reverse optic capture. Here we had a solution and someone that was pretty happy with their surgery. You can elevate the optics and you can get more of a shift. Dr. Chang’s colleague, Brian Lee read the paper and said, okay, I have a patient with negative dysphotopsia and did this optic capture. And this patient came into my office and said you have to deal with it because it didn’t work. And she had persistent symptoms for about 6 months. She came in and said I’m going to show you what helps me. She is a lovely lady and she is not crazy. She is special but not crazy. And we wanted to figure out a way to help her. I was really having an issue because I’m like, well, if moving this optic didn’t work, what can I do for her next. And we know from the papers, the rate tracing and theoretical models that possibly changing the material and moving it more forward can help. I offered her this solution which was that I was going to remove this IOL and put a different IOL in the sulcus and move it more forward and suture to the iris. I’m showing how to amputate the haptics. Previous, I wanted to show there was a beautiful example of secondary reverse capture. The optic is on top of the anterior capsule and the haptics are inside the capsule bag. And they’re pretty fibrosed. This is the acro soft platform. Fibrosis of the terminal bulb. We’re taking MST scissors and amputating, so these are 23-gauge scissors and forceps. And retract back and when you amputate, make sure the cut edge is covered by anterior capsule. We can leave it there. We’re going to put a new lens in the sulcus. I just remove through there a 3 mm incision. And we put this silicone IOL in the sulcus. A lot of people say, iris suture fixation can cause a tremendous amount of inflammation but if the capsule is there and there is not a lot of endophaco — we find the rate is similar to any suture as well. This patient had improvement. So the problem is, we had another patient come to us and they said we read your paper. I had a patient with a small eye, a big optic. And it was a Technic platform. We put the IOL in the reverse optic capture position but that caused zonulopathy as you can see in this picture. And we’re learning something about this. In our paper, we looked at acro soft platform less than 23 diopters. We don’t recommend reverse optic capture in short eyes and shallow chambers. Looking at the chamber before surgery is also telling. If they had a thin lens thickness and shallow chamber, this is a big caution in terms of reverse optic capture and moving more towards removal and replacement and putting lens in the sulcus. This patient needed to learn to live with the MD. We didn’t want anything in the sulcus. And we were able to save the capsule bag. And, interestingly, her dark shadow went more peripheral and more inferior. So go figure, all of this is very multifactorial. The treatment algorithm that we have for ND or PD, reverse or anterior optic capture or sulcus placed. Or sulcus placed and I prefer iris fixation so it doesn’t move and also pulls things forward. For positive, the only thing available is to change the material at this point. Hopefully, in the future we’ll be able to use certain technology to predict who might have this ahead of time and change the optic. And then the work of Erie and colleagues looking at a 7 mm optic that can help us tremendously in these cases. I just want to finish up with one of my favorite pictures of Alan Crandall and David at a Park City meeting and we miss you Alan, every day. Thank you so much. >> All right. Thanks, Nicole. Nicole, I’m going to have you answer the audience has posed a question. Any tips on the capsulorhexis to prevent negative dysphotopsia and oriented vertically or horizontal. If the haptics were on the horizontal axis, then you wouldn’t have an edge. >> Yes. So these are great questions. In terms of, we had colleagues that say ever since I started making a 6 mm capsulotome I don’t have as much MD. That is interesting. That is based on the work that was done with the nasal capsule and the implications there. I have had patients that have no capsule overlap and still have negative dysphotopsia. I’m not sure that is 100%. Bonnie Henderson wrote a great paper on this. It wasn’t significantly different after one week. So it may decrease temporary negative dysphotopsia and that’s part of the 97 percent that improve but not necessarily permanent dysphotopsia. What is interesting is Erie wrote a paper on what happens at the optic haptic junction and there is scattering that happens there. There are certain IOLs that have a broader optic haptic junction that may, it may be that if we put those horizontally, we get a decrease incidence. I think it’s something we still need to look at. >> Good answers: I want to go back to one more point. If you’re putting a three piece in the sulcus, can you clarify, what if the surgeon isn’t secure about iris suture fixation and they want to do CCC Capture, will that have any chance of working or — >> I think it’s, you know, I think it’s the same concept, it may move it out and down. If I have someone, I had a case where there was a high powered IOL, I didn’t want anything in the sulcus and I was stuck. I couldn’t do reverse optic capture. So I did a nasal capsulectomy. When they cut the nasal capsule with relaxing incision for 4 to 5 clock-hours there was a 65 percent improvement and that is consistent with what we’re seeing where it moves out and down. And I think it’s because that optics does move forward a little bit. But if you do optic capture, you’re going to get the effect. Especially, you know, you’re not going to move the optic forward enough to allow for the light rays to miss the nasal retina. >> Nicole, I really appreciate the work that you and Sam are done on these negative dysphotopsia. My treatment strategy has changed a bit on these severe negative dysphotopsia and I can’t make them better, I’m buying them a ticket to Los Angeles. So thank you for doing this. >> Thank you. I care about these people. Everybody says they don’t see it. I see a lot of it. >> We all do and my last question would be, what are your tips in terms of counseling people. Most people don’t need a surgical procedure. But people are going to come in all the time with this early on. Any tips on what seems to work best in terms of counseling people? >> That’s a great question. I think the first think you do if you say it. They will say everything is great, this only happens with perfect surgery. I say I know what you have. I look at the retina and do a visual field to make sure I’m not missing anything. If they tell you I know what you have, 97 percent get better and play a Jedi mind trick on them and hopefully it goes away. If it doesn’t, you assure them I have strategies that can help you. It’s more common in left eye. Sometimes it’s bilateral. Sometimes you’re stuck and you have anisometropia and have to do the other eye. You can do reverse capture with a three piece in the other eye, not a one piece. There are things you can do to help. >> How long do you wait? >> I wait at least 6 months. At least. The other pearl is that I ask them initially after the first week or so, is it coming and going? Is it in different lighting? If it’s coming and going — this hasn’t been published yet — I believe their neuro adaptic. It’s reassuring when they say it’s only in certain lighting and not there all the time. >> Perfect. That was a terrific set of cases. Thanks for presenting those. Our next presenter is Kendall Donaldson. So whenever you’re ready, you can take us to your case. >> Perfect. Thank you. Are you guys able to see my case there. >> Perfect. >> That looks good. >> Yes, Dr. Donaldson. If you can swap the display, that would be perfect. >> Up top by the end show, tips, and swap display. >> Top left. >> Top left. Mute and stop video. >> See where the timing is where it says 47, 48. >> No, I don’t have a time. Wait. Okay. Got it. >> Okay. >> Is that working well? >> Better. >> Perfect. You can see it well? >> Looks good. >> Okay. So I wanted to share a case that I was somewhat traumatized by. I wanted to talk about traumatic cataract today. This is a young lady, 21 years old. Was involved in a dispute with her mother. She is 21-year-old girl is developmentally delayed. On about the level of a 7-year-old. She got in an argument with her mother and they were flipping around the cord to the TV and the cord to the TV hit her in the eye. And basically, de-hissed the iris superiorly, you can see this photo dialysis here. And caused a cataract. A lot of fibrotic reaction. She had seen three other providers and they said it was not reparable. She was not responding to light on this side but was developmentally delayed and on the level of a 7-year-old. We did a B scan, it looked normal. The neuro ophthalmologist got on board and it looked like she should have good visual potential. Normally I wouldn’t operate on this but we did proceed with surgery. We didn’t want to write off this eye. I wanted to share this video with you. At the end, if you can tell me what you would have done differently. I sped it up significantly. Basically, doing a peritomy here. I’m going to start by repairing the iris. The iris is so disorganized I’m trying to break this case down into simple steps and I have to get the iris out of the way before we can work on the cataract itself. So making a couple paracentesis. I’m going to use viscoelastic to dissect the iris off the anterior capsule which I’m assuming is violated and became one with the cataract itself. I’m using the dispersive viscoelastic to protect the corneal surface. I’m manipulating a lot here. And you want to check the depth of the chamber and check cell depth. So here, I’m making scleral flaps and this can be done in a number of ways. You can make scleral flaps or do a pocket here to repair the iris and pass the sutures out. It’s through the sclera. She is bleeding more than I was expecting at this point. But making the — larger. And I’m going to pass the proline sutures here in two locations. So making will the scleral flaps here and trying to get everything set before I pass the proline. And we saw earlier, you mark the paracentesis ahead of time which I didn’t do here so we’re trying to find it. Makes it easier to locate when you have to. So a CIF needle is there. About a millimeter and a half behind the limbus. And again, now I am getting a pupil somewhat. I think repairing iris defects is kind of fulfilling and fun. It really can make a big difference. This pupil is going to be atonic long term but we’re now creating a space where we can handle this cataract. And this isn’t a very difficult thing to do. So these are just simple steps when you break it down. And now we’re going to have a pupil again. So of course, any traumatic cataract is a bit unpredictable in its behavior. So we have to be prepared for everything in a case like this. We have several different IOLs including an ACE, a one piece, a three piece, a Zeiss, I’m using several tools because I want to make this easier. We use trypan blue here. And now we’re replacing this with dispersive viscoelastic. We have one mass here and we made 2.5 mm incision. I’m going to try to make a capsulotomy, which I’m expecting to be difficult. I’m running into a lot of fibrosis here. A lot of times you’re using some of the disposable retinal scissors and stuff can be helpful. Always pulling towards the center because it could potentially behave irregularly. I like to err on the side of a smaller capsular rhexis. This is a 21 year-old patient so I’m expecting the lens to be soft so I can suck it out. But we’re running into fibrosis here. Definitely not normal. We get an irregular capsulotome. A lot of times you have to come back and pull it around again to make that a little more regular. But also, now we’re just trying to loosen up the lens within the capsular bag. We were not able to phaco this lens. A lot of this was just fibrosis. There is no vitreous loss. We’re using it to eat away at the fibrotic material, and even opening up the capsule to a more normal, round opening. Still not really sure what kind of lens we’re going to put in this eye at this point. We’re prepared for everything and I’m assuming I will have to do a vitrectomy here. But the capsular bag is intact but it’s fibrotic at the periphery and we’re thinking this is not going to be a stable capsule. We’re going around and loosening up the sulcus at this point and decided to put a 3-piece IOL in the sulcus because we didn’t want to take a chance and we had a good space there for the sulcus at this point which I was happy to see. We felt we had a reasonable space there. We put this lens in the sulcus. Got lucky. Again, a couple things that I didn’t do here that we probably should have done is we have this atonic pupil which is larger than average. I wish I took some of the retinal forceps, disposable forceps and pulled down on the iris to bring the pupil down a little more. Just securing the wound here. Fortunately, we have a nice 3-piece lens over the visual access and closing the peritomy here. That’s pretty much the case. Let me just show you the outcome here. I love having two screens. So she was a 20/50 postop week one after surgery. We were very impressed and happy to see she has some visual potential. She ended up being 20/25. And her IOL is not centered. The iris is also irregular. She was complaining of some glare but she is very developmentally delayed and she was functioning well. Overall, everything went well. I think there are a few things I could have done differently: Let me stop sharing here and maybe the panel could help me out on some recommendations about what they would have done if they would have gone further with iris repair. Trusted the sulcus. Mitch, what advice would you have given me or what would you maybe have done differently to help the outcome of this case. The vision is good. It’s not the most beautiful outcome. >> I think it’s a great outcome. Congrats. That’s an amazing outcome actually. I kind of agree. I think sometimes more is less. I wouldn’t have maybe gone after all that iris repair in the initial surgery. That is something you can always come back and do later. You can see how the iris is to work with later and how the lens is sitting. If you start to repair the iris and close the pupil and the lens is unstable or has problems later, you have to open it back up to deal with it. I think you made a great decision there. One thing I did notice in the biometry at the beginning, the spikes for the lens were close together. The lens thickness was small. You knew that the material was being resorbed there. I think it’s amazing you didn’t have a bigger capsule defect. I imagine somewhere the capsule was violated to get that lens material reabsorbed like it was. But I think it’s an outstanding outcome. >> Kendall, I think you made a good point that I want to stress, marking the paracentesis when suturing the iris. We have all had times where we put in the second suture beautifully and catch the iris and pull it out and it’s not pulling through. You have a little tiny bit of the cornea on the needle when you’re going through. If you mark it, make sure, it will save you having to pull that out and start all over again. The second thing, I think Mike Snyder makes this point, using a micro forceps to hold the iris when pushing the needle through will help you get it through the iris easier than poking and pulling it through. Something with counter traction will help you get the needle through the iris easier. >> There was a nice technique using a trocar opposite where he wanted to pass the sutures out of the eye. It allowed to pass the needle across the anterior chamber and easier not to tag the cornea when doing a double armed suture throw. It’s a good technique. >> Abhay? >> I think two things. I use 90 pro lean now instead of 10-O. You showed it beautifully how to suture it and the outcome was fabulous. In a traumatic cataract with anterior capsule split or a large one, I try to do PCCC, the posterior capsule doesn’t have much of a fibrosis. And then capture the optic into the sulcus or in the back because they come out sometimes. But this was a different case. So I think that is really what I do now. Wonderful, excellent outcome. >> I will add a point. Sometimes with a fibrotic capsule you just can’t tear it. One can do a can opener just to get through it. In the end, really, what you needed was the posterior capsule. But to Mitch’s point, in young people, there is no nucleus. And sometimes it’s just liquid. As you start your can opener, the fluid all comes out and so I’ve done this where I simultaneously did a can opener posterior capsulotomy because you basically go right through. Keep that in mind with a young traumatic cataract. And of course, young people are often disproportionately the patients with these cases. Abhay, last comment? Yes? >> I was just going to say, like I said the sulcus wasn’t completely normal and we had to reopen it and I had trouble most op with CME. And she had a little uveitis that went on about 3 months, honestly. I think there may have been irritation and it took longer to heal. Being aware these patients can get CME in these complicated patients and keep them on drops a lot longer. >> Great points. Great. Thank you, Kendall. We have one more case and then I’ll remind the audience the last portion of the symposium is dedicated to question and answer. So please type in questions for that section. So our last case is presented by Dr. Abhay Vasavada. >> Well, I have no relevance to financial interests on this presentation. I recognize colleagues that worked at the hospital. The question is when should I operate. I typically wait for 3 years of age because I find it’s more complicated. A good time taken during examination of anesthesia is very important. And UVM and V scan and everything else really allows us to strategies the program or the plan for the surgery. I’m trying to remove this bar that I’m having here now. Just hold on. Come here and do it. The challenges for the surgeon are two really. Preservation of the bag and the pars plana lensectomy and vitrectomy. What I would prefer is the preservation of the bag. IOL fixation is something to keep in mind and for preservation in the bag is something which I find fussy. It’s to make sure there is no vitreous before you proceed and make a small paracentesis and use preservative trams into the eye. The next thing is to tamponade the vitreous face. Use Healon, cohesive viscoelastic to manipulate the capsular opening. Then, hold on, there is some issues here on my presentation. Then it’s the hydrodissection and visco-dissection. Using this scope, so the bag is protected and then removing the soft lens material would be easy. For me, bimanual approach is the routine. And irritation and expiration for injecting the dispersive viscoelastic. Every time you take it out, this will stabilize the bag. And typically, I use what was mentioned earlier, [inaudible] you can also use the capsule hooks and I find this good enough. Because the rhexis is small, generally, now that I have an empty bag and less pressure, I try to enlarge to an appropriate size to prevent fibrosis. And easy implantation. Using the retinal scissors and taking time under cohesive viscoelastic and making an opening and focusing and taking my time lifting that fibrotic capsule up as well as to the center, allows me a good opening. And using Cionni ring. And if the subluxation is 50 percent or more, I use double element Cionni ring. But you can have an option with a single. But that kind of two-point fixation I think [inaudible] And I take a flat to make sure that the knots don’t get exposed. Because knots are very inflammatory and does produce granuloma in knots that are exposed. So I bat it — there are many other techniques. As long as you bury, it’s fine. That is my technique. We published the management which was quite satisfactory using the flap situation. But monitoring them with the — all kinds of investigation, glaucoma, and stability and posterior segment is very important. If the subluxation is very — as you can see in this case, [inaudible] is an option. I do myself with irrigation and pars plana vitrectomy, but if you have a — that is much better. I inject a cohesive — viscoelastic, I inject Healon five on top of the lens and the lens remains there, it won’t move. And you don’t have to chase it. I call it a sand wish lensectomy. Healon five and irrigation from the bag and use an appropriate vitrectomy cut. IOL fixation depends on a couple of things. Whatever you’re familiar with. I have two options, Gore-Tex scleral fixation using PMMA lens with an islet inside. Gore-Tex under the flap like the Cionni thing. And it works quite well. It needs a larger incision and meticulous closing at the end. I also now resort to the — technique where I do — my preference is preservation of the bag but if I feel they need a vitrectomy. I do a slit away. I do some kind of modification of the original technique. But in principal, it’s the same. Producing a strong — so it holds that. The trailing haptic by bringing the needle out. By using this marking system to make sure the alignment on both ends are the same. If there is a difference, I change the penetration at the final second penetration of the training haptic accordingly. I use the heat cautery which is a very simple thing. But then if it looks quite okay, we have the options of preservation of the bag and the — with various IOL fixation options. So thank you so very much. Thank you. >> Very nice, Abhay. Any comments panel? Nicole, I know you have to leave a little early. Any comments you want to get? >> Any time I watch your surgery, it’s such wonderful surgery. The only thing about the iris hooks is sometimes they’re not polished and don’t go out to the equator. The EST modified capsule retractors or the McCool sometimes work a little bit better. But sometimes it’s so far that the only thing that will reach are the iris hooks. I understand that usage. I think you showed the centration using digital marking beautifully. And I think in these cases where you have to trim a lot with these pediatric cases, it’s going to be even more important. So I’m taking that pearl with me. >> You know, Abhay, you showed something that was interesting and you didn’t mention it. Capsulotome in children is difficult because the capsule is extremely elastic. I tell my pediatric colleagues that kids are like rabbits and they are. When we do research work in rabbits, doing a capsulotome, you really have to pull to the center. Like a Brian little technique all the way around. I noticed when you were showing the capsulotome, you were pulling to the center when you extended rather than pulling around and I think it’s critical in the younger people with the elastic capsule, that is how you do the capsulotome so I doesn’t run out. >> Thank you. >> I will often use CTR and CT segments in these kids. And sometimes when they’re so dislocated I have to put the CT segment in first and pull the capsule over before I can insert the CTR and that’s worked well for me in the past. I use Gore-Tex as well. I will typically make a groove and try to bury the knot and let the suture lay in that groove. I have seen Steve Saffron make a — groove between the two sclerotomies so the whole suture is covered by a little sclera but not quite a full flap. All of these techniques work well. Because as you said, the one thing we worry about is the Gore-Tex eroding through the sclera over time. You need a thicker flap, 350 microns is a good thickness for a flap. >> We have some audience questions about this general topic of IOL fixation without capsular support. So someone is asking about nylon or proline for suturing to the sclera. And can you go through a little more of the rational and where you can obtain Gore-Tex? Anyone want to take that. >> I forgot the name of the company but it’s available in the USA only, I believe. It’s 7.0 Gore-Tex. It’s a long thread. And you cut the needles and use the 25 gauge forceps to thread it and take it out for the sclerotomy. But if you want to use proline, 5-0 proline is something that would long last, last very long. 9-0 and 10-0 will degrade with time. >> Someone brought up nylon in the question, too. Nylon will not last. Nylon will break down rapidly. Proline will break down especially 10-0. So even 9-0 eventually breaks down because it’s in vascularized tissue when you’re doing fixation. Don’t use nylon. If you’re going to use proline, go to at least a 9-0. And these are children, so the suture has to last 60, 70 years. We will see what is going to happen with these over time. >> So one thing we don’t have in the US but is more available internationally is Iris Claw IOLs. What about implantation of that? >> I think iris prolapse is a good idea as long as it’s in the posterior chamber, behind the iris. Quite often because of the movement, it can over a period of time, can impact the endothelial cell count. So posteriorly, iris fixation is a good option. You are muted. Kendall. >> Quick question, that was a terrific case. I know you chose to use a one-piece IOL but your opinions about one-piece versus three-piece IOLs in these complex cases just in case we have to go back in later in case something is dislodged and do you feel like the haptics can add structure to the capsular bag? Do you ever use a 3-piece versus a 1-piece. I know you put the 1-piece in the bag. >> I do use 3-piece IOL quite often now. But if it dislocated, there is a neuropathy and the bag IOL complex dislocates, I find that centration and stability is not that great when I resuture that bag. Recently now with the help of a retinal colleague combined co-management, we remove the entire thing and use the YAMA technique. I tried it and it generally works well. So 3-piece is a good idea to start so I agree. >> Another question do you recommend Zepto or femto for capsulotomy in a subluxated cataract? >> You can do whatever. If the subluxation is mild, you can do whatever technique you have. But, generally, for the subluxation, the crossing is not uniform and you end up with a weaker capsule. I have given up on the Femto capsulotome in a moderately subluxed lens. It’s really not predictable. >> I will throw in a comment about Zepto which is using a suction-based application of energy through a ring. You don’t want to do it in a subluxated cataract because there is vacuum applied. So it will probably, you know, you may worsen the Zonulopathy due to that. The suction does draw the capsule up microscopically, it’s probably a contraindication. But it can work nice in the case that Kendall showed where you have some fibrosis. Because it’s using not cautery but a mechanical energy due to vaporization of the fluid between the ring and the capsule. It can be too thick, eventually, but you’re no worse off because if it doesn’t go through, you can essentially, you have ab-scored the capsule. Abhay, Dr. Pollock is asking how do you prepare the triamcinolone before you inject it? >> I dilute it and make it, I use tubercle syringe and take 1 ml concentrated and use it straight away. >> Okay. Good. I think that if you don’t have the commercial brand available, you can use the one that’s — Kenalog brand, triamcinolone. You don’t want to inject the fluid because that’s osmotically not correct for the anterior chamber. So you can let the flakes, let the bottle sit and let the suspended flakes go to the bottom. Pull off as much dilutant as possible and add BSS to the bottle and that is one way if you don’t have the commercial version available. The concentration isn’t really that important. Because you’re really just staining the vitreous by suspending flakes in that. Another question for that last case, Abhay, how do you calculate the IOL power in these cases, I presume with a subluxated lens. But maybe in the pediatric cases in general? >> I think this is a growing eye and over 85 percent of the actual lens — by 18 to 24 months. The subluxed case is generally more than 3 years. I under connect by 10 percent. Not very much. >> How did you close the main incision? I presume, it’s a good question and there is low sclera rigidity in pediatric cases and pericorneal incision may not close as easily. >> I take 1 mm width is one suture. Usually, I end up with 3.2 mm keratome. I take three sutures of nylon and not Vicryl. And we need 10 or 90. I remove this with the first [inaudible] which is from four to six weeks time. I don’t want too much astigmatism. I don’t use Vicryl because they break and the mother gets worried because the mucous collects at those fragments. Because I do the UA anyway, I don’t mind removing it at that time. As many sutures as necessary. >> Great. We have a couple questions for Kendall’s case, the traumatic cataract. One being managing glaucoma. If there — not only in this specific case but maybe more in a general sense. Go ahead, Kendall. >> , any case of a traumatic cataract but that also effects the iris can lead to glaucoma and scar tissue within the angle. We start with drops. I don’t do glaucoma surgeries myself but sometimes they may need a tube even down the road and sometimes it’s concomitant. But it would be staged and in this patient we had troubles with the pressure. Sometimes I combine procedures with my glaucoma colleagues and we put in an — that could be effective more immediately or a bar valve that takes 6 weeks to open. With Uveitic glaucoma, unfortunately they do need tubes. Another question was regarding an iris cerclage to bring the pupil down to a more normal level. I have done only a couple cerclages in the past and haven’t done them recently because of Amar Agerwall and his fourth-row pupilloplasty. I feel that is just an easy technique. I didn’t use it in this technique and I talked about how the pupil wasn’t beautiful but it was functional and the patient did well. If I were going to try to work on that pupil more, I would have considered a fourth row pupilloplasty. You have to be careful as well, because you’re putting more tension on the iris root there that is not really stable in the area of the — dialysis. I think the fourth row pupilloplasty takes 3 minutes and it’s a nice technique. There are some great videos online if anyone wants to learn how to do that really helpful technique and easer than a cerclage. >> I think the key is that just an interrupted suture is, even if you put in two on a very dilated pupil, the pupil ends up being round because of the circumferential pull. What suture do you use for the pupilloplasty and the Irido repair. >> I use a 10-0 nylon. But the 10-0 nylon is what I use. How about you? >> I also. I think for the Irido dialysis, I use the trans-scleral needle, which is a little sharper. There are many ways to do it, you can dock it into an externally placed disposal 25 needle. But I think 10-0 seems to work well. Nick, would you agree with the longevity of that? Different from an IOL fixation. >> I think the iris is not going to be under the tension that the — that an IOL is going to be under. Often times in an iris when you’re fixating it, a 10-0 is adequate. But we don’t know what is going to happen in 50 years. But I think a 10-0 in this setting is okay. You don’t have to go to a 9-0. >> I don’t see this tear loss. Maybe there is scar tissue induced in the periphery where we pass the sutures through the edge of the sclera there. I haven’t seen it tear forward ten years later like we do with IOLs. >> And a nice adjuvant treatment is the intraocular diathermy that you can use to dilate certain areas of the iris if you want to round it out. Amed taught us that. >> A lot of times it can centralize the pupil easily. >> We had a bunch of questions about IFIS. Two of the five questions for IFIS. One of them is atropin, I think Nicole uses that. One question that always comes up is do you stop the tamsulosin. I think if the patient was on it for six years and the pupil doesn’t dilate, in that situation, it doesn’t help. But often you get a moderate dilation. I have found that it does help. It’s two mechanisms. There is some permanent atrophy of the dilator muscle. That is why stopping it alone isn’t reliable. But there is a receptor blockade that you’re going to alleviate by stopping for 72 hours. And one thing I have been doing is because often to do both eyes, you know, you’re going to do that over maybe a 4-week period is we asked the patients PCP to switch them tadalafil. It’s the generic for Cialis. It’s a non-alpha blocker that works for the lower urinary tract symptoms of BPH. I’m aware of one fairly large study where patients were randomized and there was no net difference in those two groups. So it’s a nice way to give them some symptomatic relief and eliminate the alpha blocker for however long you want and it certainly can’t hurt. >> I’ve been really impressed with the utility of Omidria in keeping the pupil from coming down. If you start with a small pupil in an IFIS case it’s not going to do much. But if you start where the pupil is greater than 6 and a half, 7 mm, those are the ones that come down and the Omidria helps prevent the pupil from coming down and tends to stiffen the iris. I think it’s because of the fact that it has the phenylephrine in it. And our colleagues in Europe have the commercially available phenylephrine, 1 and a half percent they use. And they all said that helped to decrease the amount of times they had to use iris hooks or a ring device when using the phenylephrine. I think in the U.S. we can get a hold of the Omidria and the Omidria with the phenylephrine it in, prevents the pupil from coming down and prevents it from getting floppy. I find that helpful in the cases where the pupil is initially moderately dilated. >> I think if you don’t have access to Omidria, you can also do sugar cane or preservative free 1 percent lidocaine which is really cheap. I think that’s an alternative. Not every patient can get Omidria and not everyone has access to it. I think Omidria is excellent as well as an alternative. >> There is always the debate of hooks versus a ring in these patients. I’m in the hooks camp. Because the hooks tether the iris to the limbus. Whereas a ring expands the pupil but it’s still floating around in there. You can still get some IFIS in the worse cases with the ring compared to hooks. That is just my preference. >> Just for our international audience, Omidria is a brand of VSS that contains phenylephrine and ketorolac. It’s not available outside of the U.S. and it’s also very expensive in the United States. So I think you’ve all made the point that any alpha agonist can help to sort of saturate the receptors. With the IFIS it’s the tone of the iris that, the rigidity is from the dilator muscle and its tone. Phenylephrine is available, that’s first choice. Epinephrine is a widely available, a very low pH, you would never inject it directly: You have to dilute it maybe 4:1. As long as you do that, epinephrine is also inexpensive and widely available and works well. I think there was one question, are there any tips when you’re about to start the case that you’re going to have IFIS in a case with tamsulosin. If you inject lidocaine or VSS and you see quivering of the pupil, you know it’s not rigid. So for sure, I would just advocate if you’re not going to use mechanical devices to use a alpha agonist like phenylephrine or epinephrine or Omidria if you have it available. But put in retractors. Is it a brunescent lens or other risk factors. When in doubt, err on the side of taking the extra time to make the pupil larger. That was, that was so beautifully illustrated by Nick’s case where the rest of the time the inability to have a good retinal reflex really made a difference. All right. Any final, let’s see, I think we’ve gone through most of the questions. Just a note to the audience, that this seminar will be posted on Cybersight later today, probably within 4 hours. So you can go back and review it or tell your colleagues about it. Where it will be permanently archived on Cybersight. One question, do you consider iris stretching to be a contraindication in IFIS? Mitch? >> Yes. Short answer. Yes. >> Any manipulation is going to trigger some miosis and you don’t have a good dilator muscle — so that’s a nice point that the doctor raised there. Great. Well, we’re at the end of our 90 minutes. I do want to especially thank our marvelous faculty. These were great teaching cases. A great panel discussion. I hope the audience got something out of this. And thanks to Orbis and Cybersight for hosting this. And also archiving this and so many wonderful educational resources for all of us to learn from, from the comfort of our desktop computers. I wish everyone a good week end and again, thanks to our audience for joining us. >> Thank you. >> Thank you. >> Thank you. Bye.