Lecture: Surgical Approach to Dense Cataracts

DR OTERO: Well, good morning, good afternoon, to everyone. And welcome. My name is Ernesto Otero. I’m professor of ophthalmology at the Barraquer Institute in Bogota, Colombia. And we’re gonna talk today about the surgical approach to dense cataracts. These are my financial relationships. None of them related to this presentation. So how do we classify cataracts? And there are various classifications around the world. But one that I like the most is the Barraquer classification by Rafael Barraquer in Barcelona. And the reason I like it the most is because it gives us the idea of the density of the nucleus. And it’s classified from 1 to 10. And it correlates with the LOCS classification system in that the N1 and N2 are the LOCS I, the N3 and N4 with the LOCS II, N5 and N6 is LOCS III, N7 and N8 is LOCS IV, et cetera. So as you can see, this gives us the idea of the hardness of the nucleus. It will help us orient the treatment of our patients based on the hardness or the density of it. So when we talk about dense cataracts, basically we are talking about N7 and N8, N9 and N10. That means a LOCS IV, a red cataract, a brown cataract, or a black cataract. So what are the challenges with hard nuclei? Basically, there are two main challenges. One is minimizing the damage to the endothelial cells. Because these cataracts are so hard, we’re gonna need a lot of energy, we’re gonna be manipulating inside of the anterior chamber. Hence, we have to again limit the amount of energy in the eye. And we need to protect the endothelium. And the other challenge with dense nuclei is disassembling the nucleus. Because it’s so dense that fracturing it is sometimes difficult and hard to achieve. So what is the pathophysiology of endothelial cell damage during cataract surgery? First is a mechanic trauma. We can traumatize the endothelium with irrigation fluids if we have a misdirection of our cannulas hitting the endothelium. We have trauma through tumbling of pieces, when they’re flowing inside of the anterior chamber. They can bounce back and forth, damaging our endothelium. Or we can traumatize the endothelium with our instruments. Be it with a phaco tip or with the intraocular lens or with our other instruments. And then there’s toxic trauma. Which is basically TASS. TASS, as you all know, is toxic anterior segment shock syndrome. And basically is a chemical injury into the endothelium and the iris, due… It’s really hard to know what causes it. But it’s been thought that it could be caused by intraocular anesthetics, antibiotics, detergent from the washing of the instruments, and preservatives. These obviously can decompensate the cornea and lead to an endothelial transplant. And then there’s thermal damage to the intraocular structures, which are caused by heat and energy. And this is a beautiful diagram by Alio in Spain. In which we see how liberation of free radicals basically produce initially a swelling of cells and then shrinkage with damage to the chromosomes and the nuclei. Producing endothelial cell apoptosis and death. So can we protect our endothelium? That’s always the big question. Can we really take care of protecting the endothelium? And there are various experimental studies that show how we can protect the endothelium. And the question next arises: Do viscoelastics really protect our interocular structures? And the answer we’ll see in a few minutes. But basically we have two types of viscoelastics. We have, as you know, cohesive viscoelastics, in which they have basically a high viscosity. The chains of the viscoelastic are basically very small chains. And again, they adhere to the intraocular structures. And they are ideal in creating spaces and maintaining spaces. They’re easy to insert and they’re easy to remove. But, again, because the chains are linked to one another, they basically produce less endothelial cell protections. As opposed to dispersive viscoelastics. In which the chains are, again, shorter. They have lower viscosity. And they adhere much better to the tissues. They’re harder to remove. They’re harder to insert. But as they stay within the eye, obviously they help us protect the intraocular structures. So here, various types of viscoelastics. We have dispersive — in which we have Viscoat, Cellugel, Ocucoat, we have visco-dispersive, a combination of viscous and dispersive viscoelastic, DisCoVisc, we have cohesive, Provisc, Healon, and Amvisc, and very cohesive, in which they’re very dense and very good to create spaces but not so good to protect the endothelium. So again, by creating space within the eye, we have a greater range in our movements inside of the eye. And if we have a retained OVD, and it adheres to the endothelium, then the risk of damage due to thermal energy is minimized. But what does the evidence show us? Basically I’m gonna show you three studies. That will show us how the OVD is retained in the eye. How the OVDs protect from thermal damage. And how does the endothelial cells behave after injection of OVD? So this is a study, again, published in the Journal of Cataract and Refractive Surgery, in 2005, in which they made an assessment of the retention of different viscoelastic devices. It was done on New Zealand rabbits. They basically evaluated six OVDs. They did a phaco of the crystalline lens, then once they finished, they injected silicone oil, and then measured the distance with confocal microscopy between the silicone oil and the endothelium. So if the OVD was retained within the eye, it would be easy to evaluate. And these are the results. Basically here we see the cornea, the endothelium, and we see the silicone oil and the distance between the silicone oil and the endothelium. And we see that the Viscoat, which is a dispersive viscoelastic, had 187 microns from the silicone oil to the endothelium. And the DisCoVisc, which is a combination of cohesive and dispersive, basically a combination of Viscoat and Provisc, had 325 microns. So this study — evidence that, again, if we use dispersive viscoelastic, it will be retained in the eye after phacoemulsification. And why do they think that it is retained? It is due to a negative electric charge of the OVD that basically adheres to the endothelium. The next study evaluates the thermal protection of the OVD. So basically what they did is also evaluated in rabbits’ eyes — evaluated six different types of OVD, and compared it to BSS. BSS at normal temperature and BSS at lower temperatures. Basically what they did was remove the nucleus with the cortex, then they filled the AC with OVD or BSS. Inserted the phaco tip and did ultrasound again. And with the thermal camera, they measured the temperature generated on the cornea, and the dynamic increase of that temperature. And what the results showed was: Here we can see in this graph the preoperative temperature and the temperature generated on the cornea with different types of OVDs, with BSS at 22 degrees Centigrade, and BSS at 4 degrees Centigrade. And as you can see, the least temperature observed on the cornea, when they introduced the tip and did ultrasound, was what BSS — at 4 degrees Celsius. And the second was dispersive viscoelastic. So that means that not only the OVDs are retained in the eye after emulsification, especially the dispersive OVDs, but also they limited the amount of heat that is transmitted to the cornea. And then the last study that I’m gonna show you today is a study that evaluated two types of OVDs. With a soft shell technique. And the impact on the endothelial cells. And they evaluated the endothelial — not only endothelial cells. The number, the endothelial cell count. But they also evaluated the central corneal thickness. As you know, if there is swelling, what we’ll see, or if the cells are not working adequately, what we’ll see is increase in the central corneal thickness. So they randomized it in two groups. And here we see the outcomes. The pre-op corneal thickness, the post-op — as you can see, there’s swelling, there’s increase in the thickness, at day one. It starts reducing at day seven. And it goes basically back to normal baseline at day 30. And group two, which had DisCoVisc — we see that basically the behavior is the same. And when evaluated, the endothelial cell count — basically see the behavior using only dispersive or DisCoVisc — is basically the same. We see the same number of cells and a very low variation between the two groups. So now we understand and we know that OVDs really protect the endothelium. And if we want to use it, it’s better for us to use dispersive viscoelastics. As they will be able to limit the damage to the endothelial cells. Next is: What techniques should we use during or treating these very dense cataracts? And the consensus is that the most efficient techniques with these dense cataracts is to use phaco chop or chopping techniques. In the chopping techniques, basically what we do is follow the cleavage lines of the crystalline lens to fracture it and divide it up. Because the lens is so dense and so hard, if we basically find these cleavage lines, it will be easy to fracture. Just as we do when fracturing wood. We don’t have to go through and through in our wood. We just need to find the cleavage point, and then we’re able to break it in different pieces. So the same happens with the crystalline lens. And there are two types of chopping techniques that we can use. In these nuclei. The first being the horizontal chop technique, in which basically we embed with high vacuum, high energy, and low aspiration rate, into the nucleus, and low flow rate, into the nucleus, and once we grab and have a good hold of our nuclei, we’ll go with our chopper to the equator of the nuclei, and bring our instrument towards the phaco tip, following those cleavage lines, and break it in different pieces. This is my preferred type of chopping in dense nuclei. As our movement is from the periphery to the center, and not vertically. So that limits the damage or the strain on the zonules. The other technique is to do a vertical chop. So basically what we do is exactly the same. We embed our phaco tip in the nucleus, and then with a vertical chopper, this chopper that has a very fine and sharp point, we embed it in the nucleus in the center, and we basically bring it together and make this posterior and anterior movement to find the cleavage lines and break the nucleus in different pieces. So here is that technique that I use with dense nuclei, a horizontal chop. So as you can see, I’ve removed the cortex, and I embed myself in the nucleus. And we can see how it is — I’m able to chop it in different pieces. So here I’m embedding — again, using low flow. We don’t want to repel the segments. We just want to keep them there, and we’re able to emulsify. And here, as you can see, we have the sentinel bubble that is always there, always still. So that is a sign that our dispersive viscoelastic is there and is working. If I had aspirated the viscoelastic, this bubble would be tumbling all around, once we aspirated. So we can see that the dispersive viscoelastic is well within the eye. Because we see all these bubbles, again, staying still. And again, this is patience. You just have to grab pieces and go on fracturing. So now let’s see some videos. And I’m gonna give you some tips of how to approach these cataracts. So this is our first case. As you can see, it’s a brunescent cataract. Very dense. So it is very important, as I said, to use — stain the capsule. These lenses tend to be so dense that there’s very little or no red reflex. Then, after staining, we inject our dispersive viscoelastic first. Coating the endothelium and then our cohesive viscoelastic to create what we call the soft shell technique. The cohesive viscoelastic will push the dispersive viscoelastic against the endothelium. And as we saw, due to different electric charges of chondroitin sulfate, it will adhere adequately to the endothelium. Then we do a rhexis. In these cases, it is very important to do large sized rhexis. And the reason is because these nuclei, again, are so big within the bag, we need to have a good enough space to manipulate it. And because we’re going underneath the anterior capsule, to engage the equator of the nucleus, then we want it to be big. Generally 6 or 6.5 millimeters is good. In terms of hydrodissection, it is also important not to — because we won’t see the wave going behind the nucleus, because of the density — then what we want is to just inject a little bit of fluid to liberate it, and then we’re able to rotate it, and then we know that the nucleus has been separated from the capsular bag. So here, as I said, we embed ourselves in the center. We don’t have to really go all that deep. A rule of thumb: If I find that the phaco tip embeds in the nucleus, then the probability that I can chop it is very, very high. So, as you can see, again, we use high power. No torsional — it’s very important not to use torsional — just longitudinal ultrasound. If some of you have the possibility of having torsional. Because we don’t want to create a big hole. We just want to create a small hole that basically covers the phaco tip, so we can have good holding power, and we’re able very slowly to chop it. We don’t want, also, we don’t want to have a high flow, as we don’t want the flow of liquid into the eye pushing the nucleus posteriorly. And, again, separating it from our phaco tip. We want to be very, very efficient, once we’ve fractured it into the pieces that we want. Again, we’ll continue to fracture it in even smaller pieces. And that helps us limit the amount of ultrasound. Once we’ve done this — and as you can see, I have — I’ve pulled the sleeve backwards, when I’m doing the chop technique. Again, that allows that phaco tip to go deep into the nucleus. Once I’ve been able to fracture it, then I can proceed to chop it into little pieces. And as you can see, I’m using the chopper to basically — pressing it against the phaco tip with vacuum, and then once there’s occlusion of the phaco tip, then I’ll do ultrasound. This, again, limits the amount of ultrasound that we’re doing. Again, there’s no rush. You just don’t sit in the center and start doing a lot of ultrasound. So you just always grab the pieces, once the tip is occluded, we’ll proceed to do the emulsification. At this stage, as you can see, we stop, without removing the phaco tip, and then we inject a dispersive viscoelastic again. And that helps protect the endothelium. How often should I insert dispersive viscoelastic? As often as you want. And as often as you feel comfortable. Generally what I do in these dense cataracts is approximately every 3 of CDE — as you know, CDE is basically a measure of the energy disseminated. This measurement is generally used in the phaco machines. So every 3 of CDE, I’ll use it. You can use it or you can do it about every minute of phacoemulsification. That is acceptable. Again, err on the side of injecting more than injecting less. Then, once we’ve removed the nucleus, the cataract goes as usual. In this case, as you can see, we had 9.78 of CDE, which is an excellent number. Generally when I have cataracts that fall in the range of N3 to N6, I’ll have around 3 to 5 of CDE. So 9.78 is very good. Generally these dense cataracts I expect to have around 17. So you can see in this case I was very efficient with a phaco time of… Total ultrasound time of 45 seconds. So these are very good numbers. And here I wanted to show you the parameters that I used. So generally I used a high vacuum, 450, of vacuum. As you can see, it progresses, so as I push the foot pedal, it’ll rise, the vacuum. I maintain an IOP of 70 and I have a high aspiration. I want those tips to flow into the phaco tip. And I don’t want to be looking for them. I have 95% of torsional. So when it hits 95%, it will send some bursts of longitudinal. That is because these phaco tips tend to occlude with the fragments that, I say, are very dense. And using burst or using microburst, that’ll help us with the efficiency of the ultrasound delivered into the eye. And this is the first day post-op of this patient. As you can see, it’s a very nice and clear cornea. There’s a little bit of edema up here. Next to the incision. But overall, it is a very nice and clear cornea. The other tip is: It is very important to know when to convert. Some cases, like this one, are very dense cataracts. So when you have an older patient, with such a dense cataract, in a pupil that doesn’t dilate very well, you should suspect that there is zonular weakness. And this is something that you should always keep in mind. As you can see, this capsule is fibrotic. We see all these folds that are generated under the capsule. It is tough to do a rhexis in these cases. Because, again, that fibrosis is hard to manipulate. Sometimes we have to go around the area of fibrosis. We have to do it, again, very, very carefully. As you can see, it’s a rhexis that is very difficult to manipulate. And again, sometimes it’s tough to do it as large as we want. Because it is adhered to the underlying cortex. And in these cases, again, Trypan blue or staining the capsule with whatever you want is ideal. And again, very slowly, very gently, manipulate. These cases are a real challenge. Because, again, they have a mixture of complexities. Starting from the capsule. Then you suspect that the zonule is weak, and as you can see, we did a fairly good job — or I did a fairly good job — with the rhexis. A fairly good job liberating the nucleus. And as you can see, it doesn’t look as dense as the other one. But then when I try to fracture it, it’s very hard to fracture. It is very elastic. It’s like gum. In which, again, it’s really hard to find the cleavage points. And I’m gonna advance this a little bit. So, again, as you can see, very tough to fracture. Even though I was able to embed myself… I’m not able to move it. And there you can see that when I was trying to… And I’m gonna repeat this. When I was trying to fracture it, how the capsule and everything shifted. The whole bag and nucleus shifted to the center. So then I switched and I tried to use the Akahoshi chopper to try to break it. And you see that it’s really not fracturing. I’m not able to break it. Again, I’ll give it another chance, very slowly. Look at the edge of the capsule. The blue capsule. That’s stained. How it moves, when I try to bring it to the center. You can see how it moves towards the center. And that is a sign of a capsular weakness. So in these cases, again, the center is full of heroes. So that’s better — that’s a saying that we have in Colombia — so it’s better to just put a little stitch on our incision. Do a peritomy. Superior peritomy. I’m gonna advance this a little bit. We do a superior peritomy. And we basically… Luxate the nucleus into the AC, as I did. And going behind or posterior to the incision, we use the 15-degree blade to create an incision. At the surgical limbus. And then we create a cornealscleral incision for us to convert to an extracap. Again, it’s always important to use our Westcott scissors, oriented — our scleral scissors, doing a 45-degree angle, and then with the loop, we’ll just extract that nucleus. So here, we’ve made a good choice. Because we basically… If we kept on trying, we would most likely have a zonular dehiscence, vitreous in the AC, and our case would be complicated. And we just put some stitches, aspirate, and introduce a 3-piece IOL in the bag. So it’s always important to know how to convert, and know when to convert. Are there other options? Yeah. And I wanted to show you doing a FLACS, femtosecond laser cataract surgery. In a dense nucleus. So the advantage of the femtosecond is that it basically helps us with the incision. It helps us with the rhexis. And depending on the femtosecond that you have, there are various programs that create a fracture of the nucleus. Either squares or in fragments. You could do four. You could do eight. You could do sixteen. Basically making that nucleus less dense or prefractured. And that would enable us to do a rhexis. One of the limits that I find when doing this is that, in these very dense nuclei, the femtosecond has a tough time going through. Because of the opacity. The other thing that I find is that it tends to do the rhexis based on the size of the pupil. So generally, although it’s very predictable to do, it’s very tough to get a rhexis as large as we want. Because we’re limited by the size of the pupil, when we engage the femtosecond laser. And the other thing that I find with these cases is that generally they don’t really crack the nucleus. They don’t fracture the nucleus. As you’ll see, here I tried to do 8 fractures. Or 8 pieces. And as you can see, basically what I have to do is go back and do my horizontal chop technique. Because the lens is basically not fractured. Again, it works… Yeah. Does it bring any added value in these cases? I don’t think so. I’m gonna, again, move a little bit forward. And as you can see, I have to just go ahead and fracture it as I generally do. Until I’m able to fracture one of these pieces. And then I continue removing the lens. So if you don’t have a femtosecond, again, don’t even bother. Because as I showed you, it really doesn’t have a great added value in these cases. And the other technique I wanted to show you is in black cataracts. So there’s always the question: Can I do phacoemulsification in these black cataracts? And the answer is yes. But always prepare yourself. So as you saw, I used sub- Tenon’s anesthesia. And I created a small peritomy. Why did I do this? Because there’s a very high chance that I might need to convert if I see that I’m able to fracture the lens, I’ll continue with the case. The periphery is softer. Always try to go from the periphery to the center. And generally the cataracts have a posterior leathery surface. In the posterior portion of the lens. So that we should leave for the end. This is a game of patience. Inserting dispersive viscoelastic. And again, with a lot of patience, going on inserting the tip and doing ultrasound. And leaving this for the end, able to successfully emulsify our cataract. Using a lot of dispersive viscoelastic to protect the endothelium. What purpose does it serve if we emulsify this nucleus but then end up with an endothelial transplant. I want to show you how the lens holds in place. In the bag, it will hold very well. We close our incision, conjunctiva, and aspirate the viscoelastic. Again, we can do it always. If you find that it’s not embedding, you should convert. This is the first day post-op. Again a very nice and clear cornea. Looks very good thanks to using the dispersive viscoelastic. And there are other options. Don’t always stick to doing phaco in these cases. That’s why this is a surgical approach to dense cataracts. Not phaco for dense cataracts. This is another case I wanted to show you. These morgagnian cataracts — what we have is that the cortex is reabsorbed and liquefied, but the nucleus is very dense and small. So it’s tough to grab it, hold it, and fracture it. In these cases, my recommendation — you won’t be able to emulsify it. It’s doing small incision cataract surgery, or SICS. So in SICS, what we do is a superior peritomy. Because this bag is in tension, we don’t want to have an Argentina flag, so what we do is insert a 27 gauge needle, or a 30, bevel down or up, with the interior chamber closed without viscoelastic. You go in and puncture the anterior capsule and push on the nucleus, the liquefied material will come up into the AC and relieve the tension from the capsular bag. We create the incision 2 millimeters posterior to the limbus. You can do a little bit larger, 7 millimeters. But what’s important with these types of incision is you create a pocket that has a wider diameter. Next to the limbus. And a shorter one at the incision. Then we continue our case. Put some Trypan blue. Some viscoelastic. And as you can see, as I inject my dispersive viscoelastic and cohesive, we want to press on the anterior capsule, so more liquid comes out. And then we find where we did our little incision with the needle. And you’re gonna see that more of this liquefied cortex is coming in. Then we inject more cohesive viscoelastic. Want to press on it, so it doesn’t radialize and then we would be able to do a rhexis. We use the 2.2 to do our central incision. And here I’m aspirating more of this liquefied material. And as I aspirate it, we see our nucleus, our dense nucleus, coming into view. Here with 6 or M6, we want a large capsulorrhexis. We want to bring that nucleus into the anterior chamber and… So we can extract it. This technique… I’m gonna tell you… I learned from my friend, Santo from India, in one of our Orbis programs in Ghana in 2019. He gave me a lot of tips to do it. What we want to do is to extract this nucleus with cohesive viscoelastic. I’m injecting a lot of it. Separating and bringing the nucleus into the AC. This is not a very large nucleus. It’s a very dense one but not very large. The trick is the creation of the wound. Again, we could have a whole webinar on how to create it. But once created, it’s very easy. SICS has the advantage of an anastigmatic incision. Because we’re working posteriorly to the cornea. Basically the induction of astigmatism is compared to a 2.6 millimeter corneal incision. So it has that advantage. It has the advantage of being a self-sealing wound and the advantage of enabling us to remove the cataract without fracture. What I’ve also tried is going in and fracturing the lens in two. With the chopper. That allows it to come easily through the wound. So now it’s not necessary to close that wound. I would like to do it, but it’s not necessary, because we created a tunnel. It is anastigmatic and self-sealing. So here we see, again, how our case ends very successfully. And this is the first day post-op. We can see our stitch that we did with the nice and very clear cornea. To conclude, dense cataracts are tough cases, really challenging. Always do either regional or general anesthesia in these cases. You should prepare yourself for complications. You might need to end up fixing a lens to the sclera, might need to do vitrectomy, might need the help of vitreoretinal surgery. Prepare yourself for that. Use regional or general anesthesia. I like sub-Tenon’s, because it increases the pressure of the eye. Protect the endothelium with dispersive OVD frequently. As often as you want, if you’re doing extracap or SICS, you can use any type of OVD. Do chopping techniques, I prefer horizontal over vertical as the strain on the zonules is less. Use high vacuum, high power, stable flow rate. We don’t want a surge when we occlude the tip. Plan beforehand. Make sure you’re gonna be able to do it. If you have any doubt, convert to an extracap. That will make your case very successful. So I want to end up by thanking all of you for being here today. I want to thank Orbis for creating the opportunity to show you how to approach these very dense cataracts. Thank you very much. Okay. Now I think we’ll be open to questions. So I have some questions over here. What are the phaco settings that you used? I showed them. High vacuum. Again, high flow rate. And medium to high ultrasound power. It’s not dangerous to hydrodissect such a dense cataract? Yes. That’s why I said initially that hydrodissection should be done with a low amount of fluid. You’re not seeing the wave going behind the lens. So you need to do just a little bit of fluid to liberate it. And then you can go around. If you see it rotate, that’s enough. The big problem with hydrodissection is if you create what we call a capsular block. The lens moves forward and the fluid has nowhere to go and it ruptures the capsule. So move slowly. Very good question. Would scleral tunnel have a better outcome than extracapsular? Yes. If you plan for it, you can do it. I showed SICS. If you’re comfortable with that technique, you can do it. I trained doing extracap. The problem with conventional extracap is the astigmatism. You need to know how to manage it. When to start removing the sutures to control that astigmatism. But SICS is an excellent option. Would you be able to display the phaco settings? I don’t have it with me. But with the chopping technique, what you want is high power, longitudinal power, no torsional, which would create a big opening. You want longitudinal to embed. High power and high vacuum. But in this case, you want a low flow. We don’t want the liquid to separate the nucleus from the tip. Again, high power, high vacuum. Rapid aspiration. We want to embed and have a dynamic rise to create a good vacuum. If you use — not a peristaltic but vacuum pump, obviously it’s easier to do that technique. So that is what you should do when embedding yourself in the nucleus. Your technique for soft cataracts? Very good question. I think we have time. Let me see if I can show you my technique for soft cataracts. Andrew, am I good to show a short video? >> Yeah. A short video would be okay. DR OTERO: Good. So let me show you… I’m gonna share my screen. This is my technique for soft cataracts. It’s the technique I use for cataracts from… Let me close this so you can see. This is the technique I use for cataracts between N3 to N6. The soft cataracts. Called a Dodick prechopping technique. Dr. Dodick was my mentor at Manhattan Eye and Ear. I use the hooks to engage it at the equator. And you can chop into pieces. These are the Dodick choppers, with a blunt tip and sharp side. You go parallel to the capsule, verticalize the chopper and fracture into three pieces in this case. And this is a denser cataract. An N5. Here we can see the fluid going around. As I said, we introduce the chopper through our paracentesis and main incision. Go parallel underneath and through the capsule, engage through the periphery to engage the nucleus and fracture. Two, three, or four pieces is enough. This is a case I did at Orbis. Flying Eye Hospital in Panama. And an even denser cataract. As you can see, I’m engaging the nucleus at the equator. Bringing it together, and I fracture it in two pieces. And this is another one. Even softer. The same trick. Hydrodissection. Here we see the golden ring. That’s where we have to engage and nucleus and fracture again. And you can continue to do your chopping technique. That is my technique for soft cataracts. Have you used (inaudible)? No, I haven’t. In hard cataract with leathery posterior plate… That’s a good question. If you can fracture the periphery but the leathery posterior surface is there, you can emulsify and go all around and leave the leathery back plate as the last piece. When you remove all of this it moves forward and you can emulsify. Another technique I learned from a colleague from Brazil — he does a divide and conquer, creates a central groove, two or four, and then instils viscoelastic and flips the nucleus around. Leaving the posterior plate facing the cornea, and does another groove and continues to emulsify. You can do what I said. Removing the periphery and leaving the leathery plate for the end. Is aspirating liquefied cortex better than doing it under visco? Very good question. You can do various things for liquefied cortex. The risk is creating the Argentinian flag. We don’t want to create an Argentinian flag. If we have the anterior chamber closed, when we do the puncture, if everything is closed and no fluid escaping through the wound, the liquid will basically flow anteriorly, and the pressures within the nucleus and anterior chamber are basically the same — there won’t be any tension to create the Argentinian flag. That is why this technique, using a syringe — you cannot aspirate. If you go in and aspirate you’ll create a gradient of pressure and have Argentinian frag. The other thing you should do is put BSS into the needle so there’s no flow through the needle. The other is to do YAG, make a little opening, and because the chamber is closed, fluid will go from the bag into the anterior chamber and there’s no risk of Argentinian flag. The other option is, using viscoelastic, creating wounds and incisions, putting in cohesive and dispersive, so it stays within the eye, doing a little puncture, let fluid come, and do spiral capsulorrhexis. The problem is because you have greater pressure when you puncture, it can create the Argentinian flag. Does stop and chop technique have a place for cataract? The answer is yes. You can still do it. The problem with doing stop and chop technique is you’re gonna use more ultrasound. When I started my presentation, I said there are two challenges. One is the technique. You can do well with stop and chop. But limiting the energy to the endothelium. If you do that technique, ultrasound times tend to be higher. How about using Zeiss Miloop? I have no experience with Miloop but I’ve seen presentations using it. It’s a loop that fractures very well the cataracts. What I’ve seen from people who have done it is that when you do it, you have to basically with your other instrument hold it, because as you’re pulling the loop, it tends to bring the nucleus anteriorly. The answer is yes. The other option is the ultrachopper, developed by Luis Escaf in Colombia. It’s a knife that’s attached to the ultrasound, the handle of the ultrasound, and basically you can create a very fine groove. Not a thick but a very fine groove. It’s a knife that goes in, and you can go in with your chopper and separate the nucleus. So that’s another option. Miloop is another option and ultrachop is another option. Alcon used to produce the ultrachopper. I don’t know if they do anymore. I’m not sure if it’s available in the market. I have one in my institution. He gave it to me as a present and it works very good. Would you display your phaco settings in these cases, including chopping? I think we’ve gone through that. You used dispersive viscoelastic… Yeah. It works. I haven’t seen many studies using (inaudible) as a dispersive. Not sure it will work. You showed it for quad, not chop. We went over that. How do you do the phaco chop? I think it was clear how to do it. What do you think of stop and chop… We went through that already. How frequently is it done in Western countries? Good question. Very little. In Latin America, places where it is done… We tend to have dense cataracts in Africa or India or Asia. It is in our arsenal. Here in the States, I believe very little. Patients tend to have cataract surgery earlier. Is an IOL placement a part of… I didn’t see it in cataract surgery videos. Great question. I shortened that because of time constraints. At the end I showed… All of them had IOL surgery, an IOL implanted. How long do you wait to remove the sutures after the MSICS? Because it’s anastigmatic, the induction of astigmatism is very low. Conjunctival suture I’ll remove after a week, at most 15 days. It tends to loosen up. The corneal suture that you saw I placed in SICS, sometimes I don’t remove it. It’s under the conjunctiva. It will reabsorb over time, basically generating no inflammation. In extracap, that you saw, those sutures I start removing depending on the age of the patient, generally a month and a half I’ll remove the suture in steep axis. Remember the sutures steepen the cornea, so removing them early will reduce astigmatism. And after a month, I’ll remove the rest. Generally if you start removing your sutures at one or one and a half months, if you have high astigmatism — if you have low astigmatism, wait until the patient is three months out. It’ll go against the rule. If astigmatism is high with the rule, start removing at a month, a month and a half, and the rest at three months. Which do you prefer, small incision limbal or sclera? Generally corneal incision, except for the black cataracts that I’m almost certain I’ll have to convert. I think I’ll have to convert. So that I’ll do a limbal incision. Do you do bilateral immediate SICS for dense cataracts? Again, that is a controversial topic. At Barraquer, we’ve done bilateral simultaneous cataracts throughout the history of our institution. I was trained doing bilateral. Especially extracaps, patients who are older. You don’t want to bring them twice. The risk of infection is even lower. One of the increased risks of infection is corneal incisions. If you’re doing a posterior incision, that’s covered by the conjunctiva, the risk of infection is very low. So I think you can do a bilateral SICS for dense cataracts. Do you use the Akahoshi prechopper to split the nucleus? Yes, if I find that I cannot fracture it and find that the zonule is weak, I’ll try to do a groove and use Akahoshi to prefracture. It works very well. The downside is you’re using more energy because you’re creating the groove in the center. So yes, the answer is you can use it. I used to do it back in the days when I was a less experienced surgeon. You saw in the video I couldn’t chop it but tried to create a groove and you saw the Akahoshi prechopper. What steps to be taken after Argentinian flag already there? So you have the Argentinian flag… It’s basically like this. So what we’ll do is create a little incision over here. And go around to create a pseudorrhexis and do another incision here and go around. Two pseudorrhexis and the radialization that was created. That will enable you to work and chop. A very good recommendation when you have an Argentinian flag is don’t work and manipulate your nucleus in the extremes. If you try to chop it over there, it will continue the radialization to the posterior and you’ll be in trouble. So always try to work over here, where we created the pseudorrhexis. Over here, putting less strain where the radialization was done. I had a few cases with weak zonules that I found during vertical chop and I wonder if I’m applying too much force with the phaco tip. Great question. I prefer horizontal chop, because when I do vertical chop, when you’re pushing and pulling, the strain on the zonules is greater. You’re doing a movement that is horizontal, centripetal. So the strain is less. That’s why I prefer to do horizontal rather than vertical. You’re pushing and it creates a tilt of the whole bag and lens complex, and that could create strain. So my advice is to try to do horizontal chop in those cases. What chopper do you suggest for these hard cataracts? The one I used, the Nagahara chopper. I like it a lot because it has a fine tip, not very long, so the risk of going into the capsule is damaging it is very low. The one I use is Nagahara. The MiLoop is what we were talking about. One of the considerations is the cost. It’s disposable. Now it’s reusable. I heard that it’s now in Colombia and the cost is not very high. So that is a very good option. What is your average CDE for brunescent cataracts? As I said, around 17. So if you do 17, if you do 20, don’t lose sleep on it. Especially if you use a good amount of dispersive viscoelastic. Can we use ND YAG anterior capsulotomy? Yes. I referred to it. Generally try to use low power YAG, 1 millijoule, until you make a little hole in the center and you’ll see the fluid coming out through the AC. And that way, you can do it. With high vacuum and high power, how low is your flow rate during direct chopping? Very good question. Around 30, 35. It should be. When you’re chopping. Again… You want low flow. You want anterior AC but you don’t want to repel your nucleus. So using around 30 or 35 should be fine. Will you use a tension ring for loose zonules in hard cataracts or simply go with extracap? I would simply go with extracap. I would simply go with extracap. Again… These cases… And as I said, if you have a pupil that doesn’t dilate very well, and a dense nucleus, always suspect that the zonules are weak. What kind of chopper do you suggest for a beginner phaco resident surgeon? I would use the Nagahara, I would use the Akahoshi. When I train my residents, the first technique that I train to use is divide and conquer technique. Creating a central groove and then chopping it with the Akahoshi. So Akahoshi has various choppers. The small incision, the universal chopper, and that is a very good chopper. The tip is not as sharp. And if you create a groove, you can fracture the nucleus adequately. Is phaco done in can opener capsulotomy? You can do it. You can do it. Initially when Kelman… Debuted his phaco technique, they did a capsulotomy. Again, the problem with capsulotomy is that if you create lots of pressure, the way of your handle — it could radialize. And break. But the answer is yes. In these cases, like the one that I showed, if the rhexis is difficult, because it’s very fibrotic, you can go and do a very peripheral can opener technique. What medication will you choose to give if there is edema after cataract surgery? You can use hypertonic saline. Again, always do preoperatively an endothelial cell count. If you have a dense cataract and there’s a local endothelial cell count, go for SICS surgery or extracap. You’ll again avoid getting into trouble. But if there is edema, again, using hypertonic saline will improve it. Generally what we see in the post-op is that if the edema is central, it will clear up. Generally it clears from the periphery towards the center. That’s what you should see. If the periphery is constant and it’s not clearing, the patient will end up in endothelial keratoplasty, most likely. But the answer is that. If we were to do ND YAG anterior capsulotomy to reduce tension, how long before phaco? It should be immediately. As this liquefied material comes out, it can generate inflammation. So generally what I would recommend… In my institution, we have the ND YAG in the first floor and the ORs are on the second floor. So generally when the patient comes in, right before he goes into the ER, you do the ND YAG. And then bring them up to the OR for surgery. Do you put CTR on loose capsules? I do. I do. Especially if I see that I’ve manipulated and I find that the zonules are weak, I’ll do a CTR. As you know, CTRs come in measurements of 11, 12, and 13 millimeters. And generally it’s an average eye sized… 12 millimeters should be enough. If it’s a small eye size, like nanophthalmos, 11, myopic eye, 13. That’s kind of the rule of thumb. Would you put CTR in morgagnian cataract? As I showed — this one, the capsules tend to be very stable. Again, the morgagnian cataract, the challenge is the liquefied cortex. And grabbing that nucleus, if you were to try to emulsify. Any tips for dense cataract with small pupil? Yeah. The biggest tip is use a pupil dilator. I like to use the hooks. I’ve tried the Malyugin ring, the PVI ring, but again, the easier to do and use are the capsular hooks. Oh, my pleasure, Francis. Any pre-op medications? Generally I don’t. Unless the patient has a high risk for infection, for example. Diabetics, immunocompromised patients, or very old patients, I will start fourth generation fluoroquinolones three days before surgery, four times a day. And that is my protocol. Then we dilate the patients with tropicamide and phenylephrine, starting one hour before surgery. And we instil an NSAID during that time. Two times, before surgery. If patients have a risk of macular edema — for example, patients I’ve had who have had previous retinal surgery for macular pole, I’ll start Nevanac or Bromfenac once a day a week before surgery and continue two weeks after surgery. What would you do if the iris keeps prolapsing into the wound site? Generally iris prolapse occurs due to three reasons. The first reason is a bad construction of your wound. Of your incision. So always tend to do it in two steps or three. Create an incision. Go lateral. And then go into the cornea. That will create, again, a valve that closes when pressure comes — increases. If you go directly in, you’re more prone for the iris to prolapse. So in those cases, it happens because… As the pressure increases within the eye, it pushes it out through the only opening that you have. For the iris to come out. So in those cases, again, try to reduce the pressure inside the eye. Then you go in with the phaco tip and you’re good. Because there’s no leakage and the iris won’t come out. In those cases, also small amounts of hydrodissection. Because that will push the iris out. And if it’s IFIS, either use phenylephrine intraocularly, or use the iris hooks. That helps to minimize it. What I do is, if it keeps prolapsing, I’ll reduce the pressure with my flat spatula, introduce the iris, and put some dispersive viscoelastic so it stays there, and then cohesive. As the dispersive stays, it will keep it — try to keep it in place. Iris hooks are better than rings? Again… That is a matter of comfort. What you’re used to using. What you like. For me, I prefer the iris hooks. They’re more versatile. And I like to use them. Because of big capsulorrhexis, how often do you… Very good question. Very little, honestly. I only use it when I have a vitreous loss and I want to make sure that it is not in the anterior chamber. So that’s when I use it. I like to really instil very few things into the eye. Just what’s necessary. If definitely I feel that there is… That the lens is not staying in place, then I’ll put some Miostat or pilocarpine. But the other thing that you can do is put a bubble of air in the AC. So you put some air in the AC. That will push everything backwards. And you hydrate the paracentesis. And the bubble reduces in size, but it keeps the lens in place. So that is a very good option that I did when we did extracaps, and I still do, when I find that it’s coming forward. In intumescent cataract, when capsulorrhexis has extended, will you straight convert to ECCE, extracapsular? No. The answer is no. I’ll try to do, as I said, two rhexes on the sides, the extension, to try to even the forces inside the eye. And what I’ll try to do in these cases, I’ll try to do a central groove, or two central grooves. So I can split it with the Akahoshi, away from where the extension was made. And generally I’m able to successfully emulsify. When do you prefer MSICS or ECCE over phaco in case of a dense cataract? Excellent question. I would prefer when there’s a low endothelial cell count, I would prefer MSICS or extracapsular, or if I see phacodonesis, if the lens is moving, I’ll go for an extracap. Unless the nucleus is not very hard. Then what I will do is do a rhexis, use my iris hooks to hold the rhexis in place. It is easier in younger patients. You don’t want a lot of tension. Because it will radiate. And I’ll emulsify. But again, if it’s a complex case, I’ll probably go for MSICS or extracap. Injecting air at the end of surgery — how would this affect them? We’ve done it for many years. There’s a lot of people nowadays saying that air is toxic for the endothelium. But again… I don’t… You know… Air is air. The cornea fits out of air. So I don’t think it has any problem. What is your suggestion for managing posterior plate of brunescent cataract? I think I went over that. Again, removing the periphery and leaving the posterior plate for the end. Burn wound. What is your suggestion to handle it? We have to be very aware when emulsifying the cataract of the sounds that your phaco is doing. If you listen… And it’s something that you learn to do. But you have to have it — you know, you’re used to listening when the tip is occluded. And when you find that something is not really working, stop. And that way, you avoid burning. I’ve had in my life… It wasn’t a severe wound, a severe burn, but it was a burn. You start to see whitish material coming out into the AC, and that comes from the wound. So the first is to try to avoid it. Generally what I find is that if it’s really not doing… It’s moving the phaco tip, it creates heat, and that’s what burns the wound. If you already have the wound, closing it initially is what is very important. And using an X suture. Basically you go inside of the wound. And then you go inside the sclera and you suture it. That creates a loop. 8-shaped suture. And then you can suture it and close it. And that suture shouldn’t be removed before three months. Because if you do it before three months, it’ll start leaking. If definitely there’s a big hole, and you cannot close it, then you’ll have to go for a scleral patch. Which is a good option. Either with cornea or with sclera, very small 3 millimeter patch. You trephinate it. And there’s something called limbal advancement, you make a limbal incision on the limbus and advance the whole area to close the wound. It’s published. It’s called limbal advancement. It was published in the American Journal of Ophthalmology Case Reports. You can find it there. Do you recommend using OVD multiple times during phaco? Yes, yes, yes. Dispersive, as I showed — every 3 CDE, if you have a machine that counts the CDE, or every half a minute or minute of phaco. Stop, put dispersive viscoelastic, and continue. How long after AC IOL insertion can we remove the sutures? The sutures you can remove — again, based on the age of patients — younger patients heal faster than older patients. But again, three months should be enough. In terms of AC IOLs, I’m against AC IOLs. I would rather you learn the handshake technique. Agarwal’s handshake technique. It’s very simple. Once you get used to doing it. It’s a very good technique. You use the three piece IOL. And fixate to sclera. Or you can also — Ophtec has the Artisan Aphakic IOL. Which is iris fixated. So by fixating to the iris, you can do it anteriorly or retropupillary. You can fixate it to the iris. And the risk of damage to the angle and the endothelium in the long run is much lower. So look into the Artisan Aphakic IOL. Or learn a fixation technique into the sclera. I have tried Yamane. I think that it is not so reproducible. The tilt is not good. And we always have a lot of trouble inserting the proximal haptic. The handshake technique is very easy to do. And works very well. Is there any beneficial effect of cold BSS for dense cataracts? As I showed in that study, yes. It lowers the temperature that’s generated in the cornea. So the answer would be yes. It protects the endothelium. Because there’s less thermal energy delivered to the cornea. In the handshake technique, how would you fixate the haptic to the sclera? Let me show you. Andrew, can I show a short video? >> That’s perfectly fine. We are also at the very hour… So just keeping into consideration the time as well. DR OTERO: Okay. I’m gonna show it. So we can see it. Let’s see if I find this video. Just a second. Yeah. Here I have it. So let me share my screen. So this is at NYU. Surgical approach to complex cataract cases. This is what I wanted to show you. Here it is. Okay. So this is a case of an AC IOL. This is why I don’t like AC IOLs all that much. The cornea tends to decompensate. So… This is the preferred technique. I’m gonna advance it a little bit. What we do with the handshake technique is you create two scleral flaps. 180 degrees from each other. There is another webinar that we could do. Secondary IOLs. In the future. But you create these two scleral flaps. Again, it’s just like a flap like a trabeculectomy. It’s 3×3. And you create these two scleral flaps. You create two paracenteses also. Right above the scleral flap. You inject OVD. So first what we’ll do is remove that lens. Here, I’ve removed it. Here it comes. You just disengage it. And remove it. And want to remove the epithelium to be able to see. And then I’m gonna use the hooks to be able to expand the pupil, so I can see. Then I create these little tunnels with a bent 27-gauge needle. So it’s a tunnel that’s right in front. This mark is 2 millimeters posterior to the limbus. And then you create this little tunnel. Then we do with the V lens… You do a sclerotomy. Again, two sclerotomies. Very important to see that you’re able to introduce your instruments. And then a three-piece IOL is inserted. If there’s vitreous, it’s important to remove the vitreous that’s there. You can do the vitrectomy through the sclerotomy. And here we have a haptic. And it’s called handshake because, again, you hand it… Let’s go back. Here. I grabbed it. But you generally hand it with one hand to the other. And you exteriorize the haptics and you introduce them into the tunnel. Agarwal described this using Titian blue. I do it without that. You introduce it into the tunnels that are created. Centering. It’s perfect. And you can fixate the haptic with the 8 shaped suture, close the incisions. This is postop. As you can see, the lens is perfectly centrated. I did an endothelial keratoplasty. And that is how the case ended up. That’s how you fixate a lens. But that should be a topic for a future webinar. For extracap, and I think this is our last question: What kind of OVD is ideal? Here you need to create space. Unless you have, again, the risk of traumatizing the endothelium is very low. So you want to create space. So the cohesive viscoelastic is ideal. Is it fixated in the tunnel and sutured also? Fixated to the tunnel and when I closed the sclerotomy, I engaged the haptic. So the answer is yes. But actually… I’ve done it without suturing the sclerotomy. Just suturing the flaps. And it sits very well. And it’s fixated very well. So it’s not necessary. I do it more out of precaution. It’s my pleasure. I think that concludes our webinar. Thanks to everyone. Andrew, thank you very much. >> Thank you for joining, Dr. Otero. We are at the hour. So… Everyone is free to go. DR OTERO: Okay. Thanks to everyone.