During this live webinar, we will discuss and understand the interplay of the irrigation, aspiration, vacuum, and ultrasound parameters necessary for a successful cataract surgery. Common pitfalls that occur with each component will be addressed and strategies for optimizing settings for specific techniques will be covered.
Lecturer: Yousuf M. Khalifa, MD, FACS
Chief of Ophthalmology, Grady Memorial Hospital
Associate Professor, Emory University School of Medicine
>> All right. Good morning. My name is Yousuf Khalifa. An associate professor at Emory University in Atlanta, Georgia. Nice to have everybody here. Just sharing my screen. Ready to go. Okay. So the title of my talk is phacodynamics the key to safe and efficient cataract surgery. It’s something you have to be thinking about and taking into account when you’re developing your surgery skills or adjusting your technique and modifying techniques to be a safe surgeon. No financial interests. When you’re learning cataract surgery your view is looking at a microscope and looking at the cataract surgery and what is happening under the microscope. There is so much more going on. There is the foot pedal and you have to understand the hand piece and what is going on with that and also what the machine is doing. All these things come into play when you transition from an observer to a surgeon. Even when you’re a surgeon and had cataract surgery experience, fine tuning your technique and making adjustments you have to learn. The next slide. I am having technical difficulties here. Okay. So the next slide you see the hand piece in this slide. The hand piece has three lines coming into it on the back of the hand piece. So you look at the hand piece, there is the blind at the bottom here, the irrigation line. That is foot position one. The blue line coming into the back of the hand piece is the aspiration line, that is foot position two. The gray cord is a power cord that gives you the energy to oscillate the crystal and that is position three. You imagine the irrigation line at the bottom is pushing fluid through the hand piece. It’s traveling through the entire hand piece to the tip of that hand piece and then it’s being guided down the shaft around the shaft of the needle and out through those two holes in the side of the silicone sleeve. The aspiration line is basically a continuous line that goes through the hand piece, connect today the needle. The needle is not only oscillating but it’s aspirating. The housing-over the phaco hand piece has a piezo electric crystal and oscillates at tens of thousands of oscillation assignment minute. It’s important when you put together the hand piece that you couple the needle to the crystal. That depends on how tight you tighten the needle. If it’s not tight enough, it will sound like a dentist cleaning instrument. There is a sleeve, the purpose is to Lucille the keratome incision and carry the fluid into the eye. There are two holes on the side of the sleeve. When you have fluid coming out of the irrigation and down the aspiration, that turnover of fluid cools down the needle. You imagine when you go into foot position three, the needle starts oscillating. You get cavitation bubbles and emulsification but you also generate heat. To dissipate the heat you need fluid flow around the needle. If you hear inclusion sounds you need to slow down and think about what is going on and make sure you have enough fluid to cool the needle. If you have occlusion, that means you’re not turning over the needle and it can heat up and you can get a wound burn. I love looking at this screen. When you first start surgery, it’s good to take the foot pedal and look at the screen without a patient in the room and without a microscope. Notice the screen is divided into three sections. This section on the bottom left that has to do with irrigation. That is foot position one. In this section you see how much fluid is left in the bag. As you know in the current Alcon platform what they’re going is hiding the bag from you because they want to push and control the amount of pressure going in. It’s not a passive gravity-dependent process. There is a squeeze thing that gives you the intraocular pressure that you want. This is continuous irrigation on and off. When operating I like to have the irrigation on at all times. I don’t like to rely on my foot resting in position one when I come up. When you look at these bars here, this is again the irrigation section, notice this bar that says IOP. You notice this bar going across. This is foot pedal depth. The orange bar, you’ll notice it’s in position two and oscillating into three and back into two. You see the vertical lines, the first vertical line and second vertical line. Anything to the left of the first vertical line means you’re in position one. Between the first and second vertical line, that is position two. You’re aspirating on top of the irrigation. When you cross the second vertical line here, that is engaging in position three and you’re delivering phaco energy. That is on top of the aspiration and irrigation. It’s doing all three. The second section on the bottom right has to do with the aspiration line. You get an aspiration flow rate on the bottom right and you get a vacuum. These two boxes have only one vertical line and you notice the little bar doesn’t come on until you cross the first line in IOP. You only have two and three for position two and three shown schematically on this bottom right boxes. So, again, the bottom left box is foot position one. Foot position two, foot position three. The bottom right is two, three, two, three. And notice on the top box, there is no vertical line because it only comes on in foot position three. >> Dr. Khalifa, sorry to interrupt. Do you mind resharing your screen? We’re getting some — a black box keeps popping up. Perhaps maybe you can share your keynote and reshare it and not put it into full screen and see if that helps. >> That sounds good. Thanks for letting me know. How does that look? Are you able to see? >> Yes. We see the keynote. Maybe you can play it from here instead of full screen mode and that might help. >> Can you still see it? >> We can. I will let you know if it pops back up. >> When operating you won’t be able to look at that screen. So what you need to rely on is the sound of the machine. You hear the sound in aspiration. So now you’ll see a horizontal chop technique, the phaco is going vertical. The chopper is going underneath the anterior capsule. You hear the control of that foot pedal and when we bury the phaco tip into the lens material, you hear that noise. That is beautiful control. And then the chop. And then the crack there. The propagation of that chop. So while you’re operating you can’t be looking at the schematic on the careen. What you rely on is the sound of the machine. What you see under the microscope, you will learn to see fluid turnover and pieces coming to the tip and know what is going on. You rely on the sound of the machine when you’re operating. Here we have the phaco machine set up. You have your peristaltic pump in the second arrow there, the cartridge, the fluidics management system cartridge. The irrigating bottle is housed within the phaco machine. There is a squeezing mechanism to generate the intraocular pressure that you want. If you look at the diagram on the bottom right, you see the phaco tip, the phaco hand piece inside the eye and there is a current going from the irrigation holes on the side of the sleeve to the tip. It’s like a reverse breaststroke. This is a key concept. It’s a circuit going out from the irrigation and down to the aspiration. It’s not the same fluid, obviously, it’s new fluid. New fluid coming from the bag and it’s evacuated down the needle and back out into your disposed bag. But what I want to make sure you understand is that it develops, there is a current in a plane that happens where you have irrigation coming out and aspiration coming down the needle. It’s really important you learn to turn the bevel of that needle to change the plane in which you’re drawing material to the tip. The ability to turn that hand while operating makes you a very efficient surgeon. It’s creating new current waves in different planes and draws pieces to the tip automatically. So to become really efficient with your phacodynamics, you want to learn to turn the bevel tip. That changes the current. Also, if you imagine you all probably vacuumed your cars, you go and vacuum the car, the vacuum has a bevel to it. You always turn the vacuum towards the dirt that you are trying to grab. So you don’t always have a face up vacuum. You turn it side to side to grab the dirt. Same concept here in cataract surgery: You see the bevel on the needle tip. You want to face your enemies. One of my attendings used to say, face the enemy with the bevel tip. The way that you get the aspiration is the peristaltic pump. There is a venture re-aspiration system. There is a new system from Zeiss. Uses a different mechanism. They have four receptacles. Little volumes of fluid they’re pushing in or drawing out. But this is a good foundation, the peristaltic pump. You have irrigation going down the bottle and into the hand piece and into the eye and evacuated out using the peristaltic pump. Let’s focus on irrigation on the bottom left. I will sew you videos of how irrigation will impact your surgeon. So this is a case, you put the phaco needle into the eye and turn on the irrigation and hear the patient squirm, they get uncomfortable. You see the chamber deepen and the pupil dilates. What happens here is the irrigation is going on and in patients who are minus myo you get something called lens iris syndrome. The irrigation is going in. When you have a hypermobile diaphragm, the pressure rotates the diaphragm back and you get a Lucille of the pupil on the anterior capsule and you don’t have the equilibration of fluid going around the iris and into the anterior high Lloyd. So the chamber deepens and the rotation of the ciliary muscle causes discomfort for the patient. You remedy this by lifting the iris. You take a second instrument and lift the iris and allows the fluid to go around and you get a normal chamber depth. This goes back to a more natural position and the patient’s discomfort goes away. From a surgical standpoint, when the chamber deepens like this, it makes the surgery more difficult. You are taking deeper angles to get to the lens material and that is harder to do. You deal with a lot more focus issues. The patient’s comfort is in your interest but it’s in your interest to get a normal chamber depth when operating. So lift the iris and break the cycle of the lens diaphragm iris propulsion syndrome. That is one example of irrigation issues that can pop up. Here is another example. We’re finished with the cataract surgery, there is a leucoma here. We make a bigger pivot and aspirate. You saw the chamber shallow. Watch the posterior capsule here. The posterior capsule stays back. The second pivot, and watch the posterior capsule comes up and the pupil comes down a bit. Why does that happen? Why is it that the first pivot, when I went to grab that piece, I didn’t have a problem with the chamber but on the second one I did? If you guys can answer in the chat why you think that happened, why the first pivot, the chamber stayed stable. And then here the second pivot you see the chamber shallow a little bit. I’m going to pull up my chat box. Any answers? Why do you guys think that is happening? There’s that first one, chamber stays stable. And then you see me do another pivot and here the posterior capsule comes up. This is the way you break the bag at the end of the case. You’re all done and going after these little pieces and you pop it back. You remember that the fluid is coming down this silicone sleeve around the needle. And what you’re doing is aspirating. I’m aspirating that piece. In the first case I pivot and aspirate. The pivot is not as acute. It’s not squeezing on the silicone sleeve as much. I don’t have compromise of the irrigation. Remember, the aspiration never gets compromised. It’s coming through a rigid metal needle. The irrigation does get compromised because it’s coming through a flexible silicone sleeve. The second pivot, it’s a large swing and the wound is squeezing the irrigation and compromising the irrigation. It happens on the second pivot, I don’t get enough irrigation to keep the chamber deep while aspirating and the aspiration out strips the irrigation. That is another example of understanding where the irrigation is coming from and the aspiration so you can add safety to the procedure. Be careful with the pivoting motions and the posterior capsule coming up. All right. So when I think of pearls for irrigation, I always operate under continuous mode. I always have the irrigation going when I’m in the eye. When doing large pivoting motions, I’m really careful because I don’t want the posterior capsule to come out with the phaco handle in. If it’s unstable, I try to troubleshoot what is going on in my mind. Is the wound leaking. The sleeve isn’t occluding it. Are the lines connected properly. Is the wound too tight. You take the keratome blade and don’t enter Descemet’s membrane, you will have constriction of the silicone sleeve and that can compromise the irrigation flow rate. You can always, if you have an unstable chamber, you can increase the bottle height or decrease the aspiration rate to stabilize the chamber. That is a few pearls or irrigation. Aspiration flow rate is how quickly pieces come to your tip. Separate out aspiration from vacuum. Aspiration is how quickly things move to the tip. Vacuum is once a piece comes to the tip and I have occluded on that piece, how tightly do I hold onto it. That’s the vacuum. How quickly the piece comes to the tip is aspiration. Once it comes there and I have a hold of it, how tightly do I hold. How much vacuum do I allow to build up on the piece. They both come from the second line but you can program the machine to draw things to your tip more slowly, with a slower aspiration rate but have a high hold and high vacuum. Or you can do the opposite. Have things coming to the tip quickly, high aspiration but low occlusion. I don’t hold it very tightly. Let’s look at applications of this followability is when a piece comes to the tip, it doesn’t fly around the anterior chamber. This is a good followability. You see here the piece comes to the tip and it sticks there as you’re evacuating it from the anterior chamber. It’s important to understand that there is a push/pull here. There is a repulsive phaco energy, it naturally pushes the piece away from the tip. There is attractive aspiration that draws the piece towards the tip. When you have good followability, that means the repulsive forces of the phaco are neutralized by an adequate aspiration so the piece doesn’t fly around. If you have poor followability, it’s like this. I grab the piece. I apply phaco energy and the piece pops off. This is called chatter. So poor followability is called chatter. There you saw that chatter and the piece flying around the anterior chamber dings on the endothelium and it’s killing endothelial cells. You increase the aspiration flow rate or decrease the phaco energy to get better followability in this situation. So for aspiration flow rate, that attracts the material to the tip. It is part of the equations of followability. Now, if you’re operating and things are not moving towards the tip, you need to be troubleshooting in your mind what is going on. Is the aspiration line clogged. Too much dispersive OBD. Is the hand piece clogged. Is there vitreous in the anterior chamber. If the pieces aren’t moving with aspiration, I have to run through this troubleshooting algorithm in my brain. I don’t want to aspirate with vitreous material. If you’re getting a lot of occlusion sounds and pieces are not coming towards the tip, that means there is no fluid turnover. If I go into position three, I run the risk of a wound burn. Okay. We talked about aspiration flow rate there. And now let’s talk about vacuum. This is how tightly I hold onto the piece once it comes to my phaco tip. Here is a situation where this is another example of push/pull here. We are trying to do quadrant removal. The piece, especially the first piece, there is a lot of friction there. Because it’s held back by both sides and attachments to both sides and friction on both sides. You’re being held back by the anterior capsule. If you imagine a tug of war, that piece is being tugged back by the friction on both sides from the other two quadrants and it’s being held back by the angiotensin capsule. It’s pulling towards you, the other side of the tug of war is the vacuum. The vacuum is holding onto that piece and trying to overcome the friction of pulling it up. Now, in this situation, we had a poor disassembly. And there’s a lot of tugging away from us. We’re losing that battle because of a poor disassembly. Here it illustrates the vacuum and what it’s going. It’s trying to overcome the friction of that first quadrant coming up. So this is an important diagram in Dr. Seibel’s book. I recommend that everyone pick up this book and go through it. He is trying to show us how to build vacuum. You get occlusion of the tip. You want to be turning your tip to maximize the surface area contact. If this is my lens piece and this is my phaco tip, I would not come in like this and have to bury into the piece completely before I get occlusion. Ha I want to do is turn the bevel side ways and make contact like this and then apply aspiration. I will get occlusion very quickly. So you see the top two examples. If you have a flat tip phaco needle, you want to come in perpendicular. And that’s how you get occlusion quickly. If I have a 45-degree tip, this is the piece and this is my phaco, I want to turn the phaco bevel to match the contour of that piece so I get occlusion and build vacuum without having to travel into the piece very much. The more I travel into the nucleus, okay, the more — this is really important — the more I travel into the nucleus, the closer I get to the posterior capsule and breaking the bag. All right. That’s really important to understand. What you want to do is get the vacuum to build up with minimal travel into your nuclear piece when doing quadrant removal. That is super important. There’s a couple of pearls on that. The first pearl is obviously turning the phaco bevel to match the angle of the piece. The second is make sure you’re on top of the piece not going deep on the piece when you go to engage it. If I’m deep and apply phaco energy close to the capsule, I can break it. When trying to build vacuum, I need to start high on the piece. I want to have my metal on top of the nuclear piece when I’m going to build a vacuum. Because I do need to travel and apply some phaco energy. I want a lot of runway, a lot of lens material between me and the posterior capsule so I don’t break the bag and get a dropped lens. In the examples is not using an appropriate angle to get occlusion. On this 45-degree tip, you’re coming in not lined up with the piece and you have to travel a lot to get occlusion of the tip and build up vacuum so you can hold the piece and mobilize it into the iris plane. This is inherently more dangerous. I’m doing a lot of traveling and eating up the piece. Eating up the run way and getting close to the posterior capsule and I can break the bag. If you have a zero degree tip on the bottom piece, the amount of travel I have to do to get occlusion is high. I’m running the risk of breaking the bag. So let’s watch another video. I like this video. The overlay here is really good. You will notice the foot pedal position is — there is a bar on the left side of the screen. The top of that bar with that horizontal line is position one. Once you cross that line you’re in position two. And then below the second line, that is the phaco energy position three. You watch as my resident is trying to bring up this piece. We don’t have a goodies assembly but you see the control of the foot pedal. You’re in position two and he is getting little phaco energy. He is feathering that second line. He doesn’t want to apply a lot of phaco energy because if he does he can travel through the piece and run through the back of the capsule. Now he realizes what is going on and tries to disassemble better and decreases the friction. Position two, you see here. Again, knowing where your foot position .S what I see residents doing commonly when first starting, is they will be very timid. And go position two. And I’m like give me more. I need phaco. More. They are very timid. When they get to three, they are scared and get off the foot pedal. You have to know where the break point is between position two and three so when you cross the threshold, you give the right amount of phaco energy and not too much to break the bag. The other type of resident is the aggressive resident that goes pedal to the metal and that is dangerous. You have to be careful when applying position three. Occlusion is given, the way you know you get occlusion on these platforms is you hear dinging, ding, ding, ding. It can be a dispersive OVD situation where the OVD is not cleared and the machine is getting low flow because of that occlusion. It can be dense lens material. If it’s a 4 to 5 plus cataract I’m not applying enough phaco energy and not emulsifying the piece down the needle. I may need to apply more phaco energy to clear the occlusion to keep the fluid moving. You have to be careful if you hear a lot of occlusion, there could be vitreous in the anterior chamber you’re sucking on and it’s occluding the aspiration line. There is a concept of compliance in the tubing. So when you are aspirating, you can imagine it’s a lot of vacuum. If you have a compliant aspiration line, the tubing is compliant, it will collapse and that’s a bunch of potential energy that once you build up, when you break the occlusion, that will spring open and has to fill up with fluid and it gets the fluid from the anterior chamber. That is called surge. You will see in this diagram, you have occlusion here, the piece is occluding the tip. You’re building up vacuum. If I have a high compliance tubing here, meaning it’s willing to collapse, high compliance. It collapses, this is all potential energy. So as soon as I break that occlusion, that tubing bounces open and it has to be filled with fluid. Where does it get the fluid from? From the anterior chamber. I like to use the analogy of BOBA. I don’t know where you are in the world but here in the United States BOBA is a very popular drink. You go and they give you a straw and there are balls of tapioca in the bottom and you grab a ball and suck on it and you see the straw collapse, it’s occluded and the straw has high compliance. The tapioca will work its way through the straw and you get a gush of fluid into your mouth. In this situation, because it’s a closed system, the place that it draws the fluid from is the anterior chamber and if it draws the fluid from the anterior chamber you get collapse of the anterior chamber. The most mobile part of the anterior chamber is the posterior capsule. When I get a surge, the posterior capsule coming up. What you’re doing to break the occlusion Lucille is phaco energies. You apply phaco energy and the posterior capsule comes up and that is how you break a bag. What companies have done is they’re trying to avoid surge. They have designed the tubing of the aspiration line to be low compliance. Next time in the operating room, take your fingers and squeeze both lines, the irrigation and the aspiration line. The aspiration line is rigid. That is to avoid potential energy when building up a vacuum and avoid surgery. Okay. So the last position three we’re going to talk about here is on the top. You’ll see on the Alcon platform you have two flavors of phaco energy. There is longitudinal and torsional. Longitudinal is back and forth like a jackhammer. Torsional is rotating on axis. So longitudinal makes sense. We understand back and forth. It’s like punching a punching bag. Torsional is different. If it’s on axis and I have a pencil, if I rotate the pencil on axis, there is no translational movement because it’s a straight needle. That is why if you are going to have rotational or torsional energy, you need to have a bend in the needle you get excursion. Imagine this is a tip and it has a bend and when I rotate on axis, that bend swings in space. That is how you get your phaco emulsification energy. As you know, the way phaco works, there is a travel of the needle forward in longitudinal and then it’s so fast changing direction going back, when it moves back quickly, you create bubbles. It draws air out of the fluid and makes micro bubbles. And then the bubbles collapse and that is what emulsifies the material in front of you. The lens material. We understand longitudinal because it’s forward. As you move back you make micro bubbles all around. The way torsional works is similar, if I have a bend and will is a swing this way, as I change directions I get micro bubbles around the swing to the left. And as I move from left to right I get micro bubbles over here and so on. As far as heat generation, torsional is the more efficient of the two. Meaning, I generate less heat. So it’s common to rely more on torsional on the Alcon platform than longitudinal. Longitudinal is more powerful. If you have a dense lens, add more longitudinal to break up the lens. There are two ways to deliver phaco energy. There are three patterns of delivering that energy. On the top box, there is a green bar that says continuous. If you click on that box, you’ll have three options of delivering energy. Continuous is when you go in position 3, that phaco needle is always punching whether it’s in longitudinal or torsional punching. It’s punching all the time in position three. There is another setting called pulse. It’s punching but it takes a break. One, two, three, four and a break, off, no punch. One, two, three, four, and then no punch. Continuous is one, two, three, four, five, one, two, three, four five. Pulse is one, two, three, four … Five, no punch. And then you have the third option, continuous, pulse, and burst. What burst is doing, it’s a blend of pulse and continuous. As you go deeper into position 3, you have less off time. Meaning you punch, you take — once you floor it, typically on burst, you’re basically in continuous. In position 3 at the beginning, you would have an off time that is longer. So those are the three ways of delivering phaco energy. Let’s talk about phaco energy here. We’re grooving. Doing a divide and concur on this really dense lens, it’s black. What you notice is as I’m passing along the groove, you see this lens move away from me. This is super dangerous. That translational motion of the lens should cause a lot of concern for you. You should be very sensitive to this when grooving. What happens when the lens moves away from you, you’re stressing the zonule and ripping them. You will get vitreous coming up and out of the wound and you’ll have to deal with that at the end of the case. Watch this pass, you see a little movement. Watch the next pass. That’s a lot — look, look, that was a lot of movement. You’re ripping the zonules. What is the strategy here so I don’t have that translation of the lens when passing the groove. The first strategy is move slower. Don’t move fast. The second strategy is increase the energy of the phaco. Probably max out the torsional and then add 20 or 30 or 40 of longitudinal to go through this lens safely. Move slower, increase the phaco energy. The third thing is take less of a bite. If you imagine this is your phaco tip and this is the surface of the lens. Usually when I pass a normal density lens I’m here. I have a little clearance at the top but this all is traveling underneath the surface. What I tell my residents, you never want to be a submarine and take the phaco and go down like this. That is a disaster. You want metal on top like a boat. There is the hull is underneath the surface but you want the top of the boat above the surface. In a dense lens I may take 10 percent like this. That would be my third recommendation. Move slower and use more phaco energy, take less depth with each pass. The last piece of advice on the really dense lenses, what happens when you’re doing a sculpt is you have the width of the need and will that is emulsifying. That’s the channel you’re creating. You have a wider silicone sleeve behind you. When you emulsify there is collateral. It takes more than the width of the needle and that is fine. The sleeve can go through. On a very dense lens, you barely take the width of the needle and the silicone sleeve can’t get through to help finish the groove. What you want to do in these situations is widen the groove to make space for that silicone sleeve to get in and get the depth you need on the sculpting. On dense lenses when grooving, move slower. Second piece of advice, use more phaco energy. Maximize the torsional and add on longitudinal. 20, 30, 40, 50. Usually not over 60 because that is huge amount of energy. Take less of a bite. The bevel here, on a normal lens you’re like this. On a dense lens it might be this much. 10 to 20 percents of the bevel. The last piece of advice is widen the groove to account for the silicone sleeve getting through. All right. So I want you guys also from this video to be sensitive to that motion of the lens away from you. Do not allow yourself to do that. That right there, that is very, should cause a lots of alarm bells in your brain when it moves away like that. I wouldn’t groove this. I would use a miLOOP and break this up mechanically with a miLOOP. Okay. So here is another case. This is super important. This is what I was talking to you about before. We’re trying to build up vacuum and there was a lot of phaco energy used here. We traveled through the lens under the surface. What happened is we went all the way through the back of the quadrant and popped the bag. Notice at the top of the screen here in this eye, there is a knuckle of vitreous there that is about to give way. You see that knuckle of vitreous here and you will see the pieces drop in a second. We’re oblivious to this and we’re continuing on like everything is okay. Now you see not okay, pieces are dropping and all of that was because we traveled too far into the lens with our phaco position 3 trying to engage that lens. What happens is if you don’t get occlusion you get frustrated and you apply more phaco energy. That eels not the right technique. You need to go back and better disassembly, find a new quadrant with more material on it. If you nibbled on a quadrant and it doesn’t have a lot of material on it anymore, that is not a good quadrant to go after as the first one. You want a lot of material so when you grab it you have a lot of material between me and the posterior capsule. If I tried on a quadrant and it’s thin, I don’t want to use that one as the first. I want to find one to build vacuum on and have enough run way. You want to have enough material there that you can turn your bevel, engage it a little bit of phaco energy and build up vacuum and pull. If you have a thin piece of lens material as the first quadrant, it’s easy to travel through the entire piece and break the posterior capsule. Let’s talk about wound burn. It’s when you’re in position three phaco energy, the aspiration is blocked. You have an occlusion in the aspiration needle or it can be upstream in the tubing. And if you have no aspiration, then the pressure stays stable with no fluid flow into the eye because I’m not evacuating, I don’t need new fluid into the eye to keep that pressure. You have stagnant fluid that’s not turning over. And now you don’t have that cooling mechanism for your needle. If I hear a lot of dinging sounds. Ding ding, ding ding, ding ding, ding ding, oh, that’s a sign that I’m not getting fluid turnover and I’m worried the phaco is not turning over and can get a wound burn. One of the first signs of wound burn is inside the eye. If the phaco material is turning into a white plume of smoke inside the eye, that means I’m burning the, burning the lens material because it’s so hot. I don’t want do that. If I see a plume of milk, I stop and refill and come out and check the hand piece to make sure I’m not occluded. I might have to flush the hand piece or check it in a cup of water. If I keep getting occlusions I have to disassemble the lines but do notes operate and continue pushing through if you hear a lot of occlusion sounds in the eye. The last part here is drawing your attention to the bottom. These are all presets at the bottom. Sculpt, chop, quadrant, epi, cortex. There is a thought process here. In sculpt for example, you have relatively higher phaco energy and lower aspiration and vacuum. On chop, it’s higher vacuum and moderate to high phaco. On quadrant you have high vacuum and high phaco. You’re trying to evacuate. You want to tailor each part of the surgery with the three components of phaco dynamics. The irrigation, the aspiration vacuum. And then the phaco energy as component No. 3. Let me see if we have any comments. Or questions. Feel free, that’s basically the end of the talk. I’d love to see your comments or questions at this point if you have any. Lawrence, are you still there? Any questions on your end that you see? Or Andy? >> Dr. Khalifa, yes, I think that concludes the talk. If anybody has any questions, please be sure to put them in the Q&A box so Dr. Khalifa can help answer them. >> I see one question popped up here. What does the IP button do in the middle? IP is what’s called intelligent phaco. Intelligent phaco is trying to prevent surge. Surge is a big problem. It’s one of the main reasons that posterior capsules are broken: You get that sudden break in vacuum and you have a flow, an increased flow of fluid down the aspiration line and the posterior capsule comes up and that is how you break the posterior capsule. What intelligent phaco is doing is if the machine senses you’re building vacuum too fast. This is on the Alcon platform and it’s their pro-prior tear thing. There is a pulse of longitudinal energy to break the rapid build up. This is to try to stop the progression to surge. Hopefully, that answered the question. The next question, sit better to keep aspiration flow rate fixed or in a linear mode? Usually you want a linear mode on most situations. So you see for example here on this screen, you have linear mode. Meaning as you go deeper into position two, you have increased aspiration flow rate from 27ccs a minute up to 40. Wince you hit position three, it maintains the flow rate of 40. That is a standard approach to quadrant removal. The next question is in pulse mode when to use higher pulses per second and when to use lower pulses for a second. Good question. Notice on this screen you have your name under new resident. It’s Dr. Anonymous attendee and he or she would have a standard cataract setting and dense cataract setting. Under the standard cataract setting on quadrant, they use a low pulse per second cycle. On the dense one they might have a higher pulse per second. You program it, if you do want to play with the pulses per second, it would be a standard cataract lower pulses per second and a denser cataract, higher pulses per second. The next question is a technique for soft lens and hard lens. So for really dense lens, I like the miLOOP. It’s been a game changer for us. If you look at the delivered energy on a dense lens and if you don’t use miLOOP, you can get up into a CDE, a cumulative dissipative energy into the hundreds. With a miLOOP, you can take that lens and disassembly and get a total CDE around 20 or 30 with the quadrant removal. For very dense lenses I recommend you learn to use a miLOOP. That’s a separate talk. How to deploy it and how to disassemble the lens. We can do a separate talk on that if there is interest. On soft lenses there is a wide range of what that can mean. If I have a young 18 year-old traumatic cataract, I’m probably going not going to use the phaco. I go straight in with the hand piece and aspirate the lens. If it’s a PSC, I might use a pre-chopper. My go-to move if it’s too dense for a pre-chopper, I do a stop and chop. 3 to 4 plus NS, a stop and chop to make room in the bag with the groove. And chop the hem mys. You can go with a straight horizontal or vertical. What is important in training is you learn all the different techniques and you have a very large tool box that you can draw from based on the clinical scenario. So the next question is how do you prevent jigsaw puzzles. Sometimes the lens is broken but the pieces don’t get out. That can be really difficult. If you do a straight horizontal chop and have no groove and it’s a big lens, the pieces can be tied together. A couple of recommendations in that situation. If you have a tight four quadrants or whatever, you get six little pieces. One thing you can do is take the chopper and hold back a piece like a shoe horn and grab the first quadrant. Once the first quadrant is out, the jigsaw puzzle situation goes away. The first quadrant is the most difficult and dangerous of the quadrants to remove. Because you are trying to overcome, if that’s tug of war that I was talking about, you need to be relying on the vacuum and less of your phaco. You don’t want to use too much phaco and travel through the lens material and pop the bag. If you can’t use that shoe horn technique, what I will do in that situation is see where the crack is and groove into the crack to make room for that piece to come up. Just to create some space so it’s not a jigsaw puzzle. I will do a groove and recrack it to make sure it’s separated. On the really big lenses, it can be leathery on the bottom and you won’t have complete separation. The first thing in your mind should be do I have a complete separation of the quadrants or not. The next question, any tips or pearls for stop and chop technique? Stop and chop is an excellent technique. You create space in the bag with the groove. Before you progress to stop and chop, make sure you know how to do divide and concur. You groove to the correct depth and comfortable getting the phaco and the tip to the bottom. You want an A pattern separation. Not a V pattern because the plate in the back is still connected. Get comfortable with divide and concur. Now, stop and chop, learning to chop is tricky. There’s a couple of things to bear in mind. From a phaco dynamics standpoint you want to be on a pulsed setting. You want to be in position 3 so you don’t deliver a ton of energy and travel quickly into the lens material. From a mechanical standpoint, you have two instruments in. The first step when learning horizontal chop, you take the phaco hand piece and make sure it goes vertical. You lifted your hands so the phaco needle is now vertical. If you imagine this is your rhexis, it allows you to start at the beginning of the rhexis. The second thing that the vertical does, it gives me control of the eye. I can pull the eye back and keep it centered to do a horizontal chop. Going vertical and starting at the beginning of the capsular rhexis. I don’t want to start in the middle because as I travel I will get to the end of the lens material and the chop won’t go very far. That’s the right hand. For the left hand. This is your capsular rhexis, make contact with the lens before the capsular rhexis. Visualize contact here and as I slide forward, I want to see cortex going over the chopper. This is the lens and this is the chopper, you want to maintain contact with the lens all the time. I do not allow myself to break contact. So as I’m sliding under the anterior capsule if I break contact with the lens, I can slide over the anterior capsule and chop the zonules. That is not good obviously. If I break contact here and allow myself to travel out, I will pop the bag with the lens and have a break in the bag. You need to make sure you’re maintaining contact with the lens here, before the anterior capsule and travel, travel, maintain contact as I go around the equator and will is a lift that happens and I go deep that way. Now, in that position, right hand is vertical and left hand is vertical. I’m around the equator and travel. Do not touch. I don’t like to make contact with the two instruments. When they get close, I do a sideways motion like that. It takes time to learn it and you need to be pretty facile with your hands: You need a loose grip as you learn to do horizontal chopping. It takes flexibility. If you hold the instruments really tightly it’s hard to make those motions. What to set on the machine if doing the chopping, the phaco tip does not hold the nucleus properly and after the chop is done there is sudden collapse of the posterior chamber and anterior chamber goes up. The first thing I would say is make sure you’re turning the bevel to the side and making a good contact. I don’t want to come in like this with the bevel and travel all this to get an occlusion. Turn the bevel like this and make contact like that. That is how you build up vacuum. You want to start high on the piece. Do not engage the piece deep. As I put phaco in, I can travel through the piece and I’m in the posterior capsule. Turn the bevel sideways and maximize the surface contact. A little phaco and then I hold and up. The last part of the question is there is a sudden collapse of the anterior chamber and the posterior — so, I think what you’re describing is when you’re removing the quadrant you get a surge effect. If that is the case and you’re on the Alcon platform, make sure the intelligent phaco is turned on. The other thing is when I go to eat a quadrant, you imagine the chamber is like this. And say we’re on this side of the chamber, I don’t want to eat a quadrant over here. I don’t want to eat it deep here. So this is, you can engage the piece over here. But when you want to eat the piece, I call that the kill. You want to be in the kill zone. If this is the anterior chamber and here is the incision here, the kill zone is over here. You want to be in the iris plane and back you have space between you and the posterior capsule. I like to break down quadrant removal into three steps. There is the purchase, you’re holding onto the piece. We talked about that. Then there is the travel — so the purchase, the technique is turn the bevel sideways and make a lot of contact with the surface area and use as little phaco energy as needed to get the vacuum to build. Then you’re relying on position two, the vacuum, then you transition into the travel. The travel means I’m mobilizing the piece out of the bag and going into the kill zone. No phaco involved there. Just aspiration vacuum. When I get to the kill zone, what I do with the foot pedal is different. I go into position three to kill it or eat the piece. I strongly recommend that you try to break quadrant removal into three steps like that. It will make you much better if you have the right framework when doing quadrant removal. The next question is for IOP vacuum and phaco power, are there standard guidelines to the values here. Are all these values machine and manufacturer dependent? You are all surgeons and you’ve done clinic. I like to think of the phaco settings like doing a manifest refraction. You don’t start with whatever. You don’t put a patient on the fore opter and flip the sphere and the cylinder. You start with an autorefraction or start with a retinoscopy or start with a previous wear. When you set the phaco machine, you’re either going to start with the settings you had in residency. So you can put a USB stick into your phaco machine and download the settings and take them to your new machine in your practice. That is what you start with. The second option is to copy and paste your partner’s settings. The third option is to bring the surgical company’s representative into the OR and have them set up the machine with you. So I don’t change my parameters on my irrigation, my aspiration or vacuum on the fly. Those are sort of, that’s what I do and I don’t really change them. I might have different procedures: I might have floppy iris. I might have dense lens setting. But when I click that button, all the settings change to give me the optimal parameters for that clinical situation whether that is floppy iris or dense lens setting or whatever. So phaco energy is the one thing I will change on the fly. If it’s a dense lens and I need more phaco energy, I say increase the torsional or the longitudinal. Changing the irrigation or vacuum on the fly I don’t do. Put thought into it on the front end and program the machine so you don’t have a lot of decision to make during the surgery other than what you’re doing with the eye. What is the best targeted CDE to prevent corneal edema postop. CDE is a factor in corneal edema. The next factor is using dispersive OVD. The next factor is how close, when you’re evacuating quadrants, how close you get to the endothelium. If the endothelium is here and I’m eating pieces here, I won’t get a lot of corneal edema. The cornea can come out clear if I stay away from the cornea. That is tricky. You’re afraid of breaking the bag. What you do is lift the piece way up and phaco near the endothelium. Obviously the phaco energy is traumatic to the corneal endothelium. But that piece tumbling will damage the corneal endothelium. CDE is an important part of the equation but the depth you’re at when removing the piece, keeping your dispersive OVD in the eye. Not aspirating that dispersive OVD and maintaining it to protect the endothelium during the surgery is super important. There is obviously time, the longer you stay in the eye with a lot of fluid turnover, the more corneal edema you will get into. You want to be an efficient surgeon, not fast surgeon, but efficient and not wasting time inside the eye. The next one is what should be done if you keep having chatter? For chatter, you want to look at the vacuum setting. Vacuum and aspiration flow rate. You want to increase the vacuum and aspiration flow rate and decrease the phaco energy. That’s the thought process in chatter. You mentioned a book in the course or presentation, can you give the name. It’s called phaco dynamics by Barry Seibel. It’s a phenomenal book. You open a page, on the right side is a diagram and the left side is a description. Each diagram gives you a very important concept in phaco dynamics and highly recommend you go through that book so you become a very efficient cataract surgeon. For a really hard nucleus, longitudinal no more than 40 and torsional can go as high as 90. Sometimes on a dense lens I maximize torsional at 100. You can put in as much longitudinal as you want. I worry when I go over 40, I’m putting too much energy in the eye and will get corneal edema. If I find myself needing that much energy, I will refill with a vis coat and call for the miLOOP to disassemble the lens. I will refill the anterior chamber and put a little visco under the anterior capsule and go in with the miLOOP and disassemble the lens. If I have to use so much energy to disassemble the lens. With the miLOOP, you need less CDE to eat the pieces. Just something to consider. How about chop settings in a soft cataract? I would be careful with that. I see people get into trouble with the dive in, you can travel through the lens and pop the bag. On a soft cataract, you might not need to put any phaco energy in. You might mechanically but able to push down into the lens and take the chopper and chop up and spread without a vacuum or phaco energy delivered into the eye. Just be careful. Don’t expose too much lens tip. So you know when you have a lens, you have sleeve on the lens. So on a dense lens you want more needle exposed. The sleeve is back here. On a soft lens you want little needle exposed. The sleeve is here and this amount of needle is exposed. On a soft lens, less needle exposed and be careful diving into lens with phaco energy. You probably want to use a mechanical. You can sometimes, it will bury in without phaco energy and you can take the chopper. Next question, can you please repeat the difference between burst mode and pulse mode? The first is continuous. Continuous is easy to understand. There is, as long as you’re in three, the boxer is punching. One, two, three, four, five. Pulse mode is you program the machine to take a punch off in the sequence. So it could be three punches on, one, two, three … Four, five. Or one, two, three, four … Five. That is pulse. You can program to take two pulses off or one pulse off and deliver, one, two, three punches. On burst mode what is happening is when you first go into three, you have say 100 milliseconds of time off. As I go deeper into three, I take less time off. It’s 80 milliseconds. As I go deeper, it becomes 40 milliseconds. That is an inverse linear relationship, inverse linear control. The deeper I go into three, the less time off I have. The more punches I’m delivering. And what you have in burst, as you floor it, there is no time off. It becomes continuous. So that’s the difference between pulse and burst. The next question, when struggling to hold the nucleus for the initial chop, keeps dropping off the tip, what parameter is best to change and how to improve? The nucleus for an initial chop. What you want to do there is increase the vacuum. And then you want to have very little — a lot of times what will happen is if you’re traveling with the chopper after you’ve gone down, the chopper will knock off your piece. So what I would recommend is getting the chopper around before delivering the phaco and building the vacuum. So I position my phaco vertical, I get my chopper in the horizontal chop position ready to go, and then I buzz and then I chop. I’m ready to chop as soon as I deliver the vacuum. Some people like to get their needle in position with the phaco and put their chopper out. I find that chopper moving out knocks my piece off. That is one recommendation, the other is increasing the vacuum. The next in hard cataracts do you find it useful to combine longitudinal and torsional. Absolutely. My typical approach is to maximize the torsional first because it’s a more efficient and less heat generation. And then I do longitudinal 10, 20, 30, 40 depending how dense the lens is. Plume formation when phacoing a hard nucleus. Any recommendations on the settings? When I see a plume I’m super worried I have an occlusion in the aspiration line. I need to evacuate OVD. I put too much dispersive. The first thing that happens when I get a plume of white fluff in the anterior chamber is I stop phacoing and go into position two and aspirate the fluff and you want to see fluid turnover in the anterior chamber. If I hear occlusion sounds, I’m aspirating — not grooving or whatever and hearing occlusion sounds, I will apply phaco energy above the lens, away from the corneal endothelium and try to clear the occlusion. Sometimes you brought a piece into the needle and it’s not emulsifying completely. So applying heavy phaco pulse and come back. Then you want to see the fluid turnover and get rid of the occlusion sounds. What you try to avoid, obviously, is a wound burn. Those are my go-toes. Despite those two maneuvers, the aspirating and if I still hear, if I go back and hear occlusion sounds. I apply hard amounts of phaco and still hear the occlusion sounds. I’m going to refill with the dispersive OVD and come out and flush the phaco hand piece. Then I’m testing the hand piece in a cup to make sure I get rid of the occlusion sounds. If I continue to hear occlusion sounds in the cup. I need to flush my phaco hand piece or change the phaco hand piece: I will look at the aspiration line. One time I had a piece of cotton in the aspiration line that is causing occlusion. That is dangerous. You don’t get fluid turn over-and you can get a wound burn. The next question, how we deal if the material the flying around? That is called chatter. You want to increase the aspiration and vacuum and decrease the phaco energy a little bit to get a good followability. That is the strategy there. Next question, in some lenses that are more mature, the lens material is friable and comes off in layers in high vacuum. Which makes getting the first quadrant out difficult. Any recommendation for this kind of lens? Personally when I start seeing the layers come off, I like that. It’s making room in the bag — once I have the disassembly, there is room in the bag for the first quadrant to come off. I will remove the layers before I go after the disassembly. I like to have clean pieces. Going to take all the extra layers off with the main nucleus still intact and do the disassembly technique of choice whether that is horizontal chop or vertical chop or miLOOP or whatever for the mature lens, you can do that. Next question, how should the bevel face? Always upwards or sometimes downward? I don’t turn the bevel down. There are people that teach that and it’s perfectly acceptable. I personally tell my residents, make sure you turn the bevel side to side as you’re operating. Going back to that diagram in the beginning, you have the irrigation coming out of the side of the silicone sleeve and it’s making the circuit in this plane. If I always operate bevel up, I only get a circuit like this. If I turn the bevel, I get a circuit like this. I don’t have to move the phaco everywhere. So turning the bevel is super important. And going back to the other analogy, the vacuum, the aspiration, so you imagine I’m pointing the aspiration to the side and drawing from this side or this side with the aspiration. One of my attendings taught me to face my enemy. You want to turn the bevel to face it so the piece comes to you. I don’t like to go downward. Either up, side, or the other side is okay. I don’t like to go down. Any equation to balance the inflow and outflow. That is a really interesting question. The inflow, you said it. You say 65 mm of mercury. That is the inflow. You don’t get extra inflow. The outflow though is, there’s a lot of variables. No. 1, you have the aspiration. That is evacuating from the anterior chamber. But you also have a leak from the paracentesis and you have a leak from the keratome incision. It’s important that you try to minimize the leaks. You want good incisions. Make sure you have a blade that you’re comfortable passing and you only have movement along the X axis. There is no side to side motion of the blade to widen the wound. And you obviously have a silicone sleeve picked to fill that blade incision. So for a 2-4 blade you have a pink sleeve. For a 2-8 sleeve, you have a purple blade. You have to put thought into the silicone sleeve that you pick for that blade so they’re matched. On the paracentesis incision, you want to be careful not to torque that wound too much. You will get leak out of it with a chopper instrument. But you don’t want to widen the wound too much with the blade. Sometimes I won’t open the internal os of the wound and won’t take the shoulders to make a tighter Lucille around the chopper. What is total phaco energy we use during the surgery in this panel? So total phaco energy on the Alcon platform is cumulative dissipative energy. On other platforms I think it’s called total energy. It has a formula where it takes the longitudinal and torsional and multiplies it — in the amount, what percentage you’re at and multiplies it by time. That’s how you get the total energy. Obviously, less energy is preferable. But more energy is, if you need it, it’s fine. Part of the equation though and how you get corneal edema is where you’re phacoing. If you bring the pieces super high in the anterior chamber and phaco near the endothelium, you will get corneal edema. How to find our best personal phaco settings? That is a good question. When you’re in residency and training, you’re not going to change your attendings settings. You’re going to use what your attending uses. What I recommend is half you have done 50, 60, 70 cases you can engage in a discussion about the parameters. Take time on your own and look at what is going on with the machine. Take the foot pedal and push it and see what happens. When the patient is not in there. Don’t save the changes but play with the machine to get an understanding of what is going on. Once you have fairly good understanding of what the machine is doing, you can engage with the attending. I noticed this. Obvious very respectful. You’re coming with questions that you want to be respectful and you don’t want to upset your attending. But engaging in a discussion around how to optimize the settings. I think most attendings would welcome that kind of discussion. Another resource for you is colleagues and another resource is the reps for the companies. They have seen all the different surgeons and knowing the changes they make. And picking their brains. You want to be careful with the reps because they want to sell. You want to verify in your mind what they say makes sense. Can you tell me common phaco settings? That is numbers and stuff. That would take a lot of time. In general, your intraocular pressure if you’re on the Alcon machine, I think 65 mm of mercury is what I use on most steps whether it’s sculpt or chop or whatever. This gives you good maintenance of the anterior chamber. So on each setting, your vacuum and aspiration and phaco, which phaco you use, pulse, burst, continuous, that changes from setting to setting and be different. Recommend that you take a look at your machine. Look at all the different attendings. The machine has multiple different people, usually on it. Whoever is operating in the surgery center, you may have ten or 12 surgeons and take a look at what each one is doing and watch their video. Is it a chop or divide and concur and pick their brain and talk to them about it. What is the difference in settings between horizontal and vertical chop? On my settings I don’t have a differentiation. But on vertical chop you probably want more vacuum because you do have to hold that lens up as you go down with the chopper. Horizontal chop typically for me is no vacuum as I’m executing the chop. It’s mechanical. I’m not holding the piece with the phaco needle as I’m doing my chop. At which plane manipulation of lens is appropriate? Should we remain at center or go peripherally? Good question. What we’re talking about here is quadrant removal. Sculpt you need to be moving. Chop, you’re keeping the phaco central and going down and getting a chop. Whether it’s horizontal or vertical. How much movement you do with the phaco on quadrant is super important. That’s a great question. It goes back to this concept of dividing the quadrant removal into three steps. The first step is purchase. Get a hold of the piece and go towards the piece to do that. What you want to be doing is turning the bevel side to side. Sometimes what happens is the piece comes to you without a lot of movement. Rotation of the bevel is the first move to get pieces to come. I don’t like to fly around the AC and grab the pieces. I will try a wiggle of the phaco hand piece side to see and see if the piece comes to me. The first quadrant we don’t do that because it’s locked in. But on the second and third and fourth they are more likely to catch a current and come to the tip. The first step of quadrant removal is purchase. You have to travel to the first piece and apply aspiration and build vacuum and travel into the kill zone and be pretty stable in the kill zone. Not moving around as you’re applying the phaco energy. You want to be back in the proximal third of the eye in the iris plane as you eat the piece. So in my mind when I go to the kill zone, the piece that you’re eating is in the middle of the eye. The phaco is just shy of middle to allow the piece to tumble with a lot of clearance. The next question is precautions in vitrectomized eyes during phaco. I worry that the vitrectomy create a posterior tear or they ripped the zonules. If those two things are not present, and do a good preop to make sure they’re not, the next thing is lens iris propulsion syndrome. And having a mobile capsule like that. It tends to be quite mobile in those patients. Being careful to not aspirate the posterior capsule and pop the bag is super important. Other than that, OVD is your friend if you’re worried. Refill with OVD to protect the posterior capsule from coming up. The next question, what’s the best technique for patients with uveitis? That is a whole lecture on its own. What you do with systemic steroids and postop systemic steroids. How long has it been since the last flare up. Are they on the optimal steroid sparing immunosuppression. On biologics or antimetabolites. With uveitis cataracts you need to be careful. If they are somebody who has been active recently within the past year, really high dose oral and topical steroids. Posterior synechiae are an issue, plaques, membranes. Putting in a lens. Is there support. Uveitis cataracts are another lecture. I don’t think I can do that question justice and we’re 17 minutes over. You get cataracts and you need to do a lot more on the preop side and management on the postop side. Intraoperative it can be tricky with the tight membranes and whatnot. Next question, in sculpting the nucleus what is better, breaking it into two halfs or four quadrants. Yo imagine a big piece tumbling and it’s going to be hitting the corneal endothelium and cause damage. You want to, if you’re going to do a divide and concur, you want four pieces before going for removal. Please, I department get what you used for disassembly of hard cataracts. It’s called the miLOOP. Manufactured by a company called Zeiss. You want to train on it. It’s made by Zeiss. Precautions to run a smooth phaco for endothelial dystrophy. You want to disassemble the lens and refill with dispersive OVD. Remove two quadrants and refill. You want to be careful how high you bring the quadrants up to the anterior chamber. You don’t want to phaco near the endothelium. Multiple reinjections of dispersive OVD is a good idea. We want to avoid a corneal transplants. And maintaining space between you and the corneal endothelium and the phaco tip as you do the quadrant removal. What should be the phaco settings to tackle a crater? You have a bowl of lens material and that can be pretty darn challenging. That can be not easy to handle. If you’re left with a crater like a bowl, it’s hard to crack it. It’s hard to groove it safely without popping the posterior capsule. You can look at something, visco levitation, if it’s a thin bowl, a thin amount of material, you can use viscoelastic and visco levitate the piece into the anterior chamber and eat it or chop it once it’s out of the bag. I will take the chopper and push on the lens material sub incisionally and drive it around and it rolls out of the bag is another technique I will use when it’s cratered. I’m careful trying to groove on a crater or engage the piece. You have a then amount of lens material and you don’t want to grab it and go through it and pop the capsule. Those are two techniques I would use. How much is the cost of the surgery? In the United States cataract surgery is pretty expensive with the phaco emulsification and the lenses. So I know the companies have different pricing structures for different countries: You want to talk to the companies whether it’s Alcon or J&J. I don’t know what is available in Uganda. You want the companies to bid for your business. Don’t just go to one company and ask them for a price. You want to go to several companies and look at the entire price. If you go with J&J or Alcon and buy everything from Johnson and Johnson or Alcon, they can typically give you a discount. You want to negotiate on the cost if you’re going with phaco emulsification. Next question, what might be going wrong as some of my patients are developing a lot of postop corneal edema and some are clear cornea postop day one. Make sure when removing quadrants you stay away from the corneal endothelium. Use the same amount of dispersive OVD to protect the endothelium. And look at the technique. Think critically, are you sometimes bringing the pieces up too high. Sometimes — patients vary, too. There are patients that have tight anterior chambers and get more corneal edema. If you have a hyper and the chamber the 2 mm, they tend to get more corneal edema. There is no room to bring up the cataract without hitting. The first thing is look at the axial lengths and anterior chamber depths and see if there is a correlation with that. That would be where I start. Next question is what are the complications of this technique. There is a lot of complications that can happen with cataract surgery. I can give you a second talk on complications and how to manage them but common ones is intra-operatively a posterior capsule breaks. Vitreous loss. Dropped lens. Iris trauma. Descemet’s attachment. Then you have less serious things like a [inaudible] ballooning. What kind of anesthesia and so on. A complications talk is outside of the scope of this discussion. What is the technique for soft cataracts? If it’s really soft and a young patient, I may go in with a hand piece and aspirate the lens without the phaco probe. If it’s a little more dense than that, my go-to move is a pre-chopper. I find it to be safe, you need to make sure you understand the technique and use it. Divide and concur is completely acceptable for soft cataract. I think vertical chop is difficult with a soft cataract. When people are good at something, they can do it. The important thing is you develop good techniques and have multiple different techniques you can employ. The next question, how would you proceed if after sculpting and unable to crack the lens, the posterior plate is leathering. That is why the miLOOP is so beneficial. If you have a leathery plate, I will pull off the miLOOP and disassemble. One technique is to flip the lens in the bag. Say there is a groove, one technique is put viscoelastic material in and you have the leathery plate up and you can grab on it and groove it. Those big lenses can be super challenging and to have to groove deeper and you’re worried about popping the bag. MiLOOP has been a game changer. What is the cause of dancing unstable or irritable capsular bag and how to manage? That is — that can be surge, if your fluidics are not good or leaking wounds. Another can be a really big cataract with a really big bag. If it’s an 85 year-old that’s a huge bag with a lot more — it’s been stretched — vitrectomized. A bag that, the anterior hyaloid is not there to support it and it bounces up and down. For those situations, bag careful and making sure you stay away from the posterior capsule. Being careful as you finish off a quadrant that you’re back in the chamber and — a lot of times when eating a quadrant you want to move forward. Resist the urge to move forward with the phaco. You should move backwards as you’re eating the capsule. It’s 10:25 and we were supposed to end at 10:00. I love all the questions and I’m sorry I can’t get to all of them. I really appreciate everyone’s time and thank you for being so engaged with the questions. I have enjoyed it. Thank you. Andy, Lawrence, we’re good? >> We’re good, thank you so much for joining Dr. Khalifa. >> Thanks, guys.