During this live surgical demonstration, Dr. Lehmann will perform one cataract surgery and one DMEK surgery with brief lectures in between the cases. Questions received from registration and during the webinar will also be discussed live.
Lecturer: Dr. James Lehmann, Ophthalmologist, Focal Point Vision, San Antonio, Texas, USA
DR. HUNTER CHERWEK: Welcome, everyone, to another Cybersight live surgery. I definitely want to thank the Cybersight team for making this possible. I also want to welcome Dr. James Lehmann, one of our top anterior segment surgeons. He’s going to be doing two surgeries today. One is demonstrating cataract surgery in a truly dense nucleus and that has been pretreated with a femtosecond laser. The second is a cornea procedure demonstrating DMEK. Certainly we’ve all seen in the last ten to 20 years how the cornea revolution has occurred. Joining us live from San Antonio, Texas, is Dr. James Lehmann, who again, will be demonstrating two procedures today. And certainly if you have questions, please look in the chat and I’ll be putting content from Cybersight that will be relevant for this live session in the chat as well. Over to you, Dr. Lehmann. >> DR. JAMES LEHMANN: Hi there, thank you, Hunter, for that kind introduction and thank you, participants, for tuning in. It’s around 11:00 in the morning in San Antonio. I’m going to start with a little presentation, so let me share my screen. So the webinar today will consist of basically two surgeries, a cataract surgery and then a DMEK surgery. We’ll start with the cataract surgery. While my staff is getting the patient prepped, I’ll give you a little bit of an introduction. I’m in San Antonio, Texas in private practice. I have volunteered with Orbis for the last 20 years, more or less. My financial disclosures are down there. This is a femto-phaco case. I’ll show you some common interoperative problems and how we can overcome them during surgery. Then we’ll take a little bit break and I’ll show you a DMEK surgery. Prior to that I’ll talk about choosing between DSEK and DMEK surgery. So the steps of femto-phaco are the steps of normal phaco. I have to do the laser, prep the patient, et cetera. I’ve covered these in previous webinars. Instead of going over them again, you can go to the Cybersight.org website and search my name and find previous webinars where I went over phaco basics. The main thing is each step in phaco builds on itself. If you make an error early. What femto-phaco can do for you is make the divide and conquer part a little easier. If you’re putting a Toric lens in, it can sync with a camera or with a topographer instead of having to do the old fashioned way with marks on the outside of the cornea. So it has some nice benefits, and it’s evolved. Here is a little video, it’s almost like a suction ring. Fluid fills the capsule. The laser comes in and you can see we dock in with the help of an assistant there, then the laser goes through its steps. That’s docking the laser. It’s very comfortable for the patient. It’s only about 15 millimeters of mercury, it’s not like Lasik where they feel 40 to 60 and the vision blacks out, that doesn’t happen. In the first steps of femto, many times we’ll use the femto just to make the rhexis and to break up the nucleus and we’ll still make our own para and main wound, you can make them a little more posterior. This is a dispersive visco elastic. We use the forceps to peel off the free floating capsulotomy. This is the nice thing about femto. You want to make sure there’s no tags and nothing runs out. You have to do a lot less hydrodissection with femto, that’s nice. Then it’s just divide and conquer. So we talked about the steps. Now I’ll talk to you about some pro tips and then some common scenarios that we want to overcome. So when you’re doing cataract surgery, some things I’ve learned over the last 15 years are to Nick the vessels to mark your incision. When I’m teaching docs how to do cataract surgery, they lose where their paracentesis is. If you make it at the limbus, you get a little bleeding from the limbal vessels. The other thing is you want to hold the cannula collar and you do OVD injection because when you push the plunger, the tip of the cannula can go through the anterior chamber, which would be bad. You never know how tight the tech has put it on there so you always want to hold the collar of the cannula for any type of injection, for antibiotics or BSS or anything like that. When you’re doing the main incision you want to aim for a square-shaped incision instead of a long rectangle. Then when you have a mature cataract you want to make a very small rhexis to start and kind of spiral it out. And then there’s no need to dissect — hydrodissect a mature cataract, that’s another tip I’ve learned over the years. Lastly, when you’re doing cataract surgery and learning it, get the subincisional cortex first. That’s the easier during the irrigation and aspiration part. So I’ll show you that on this next case. All right. I’m going to go ahead and go on to the surgery now and we’ll come back to the lecture. So I’m going to stop the share here. >> DR. HUNTER CHERWEK: Those were some great pearls. I’ll definitely be putting in the chat some of the updates that you reference from your prior webinars as well as from the cataract surgery. When you’re ready and at the operating, just let us know. >> DR. JAMES LEHMANN: We switched over to the OR scope camera [inaudible]. >> DR. HUNTER CHERWEK: Fantastic. When you’re properly gowned and at the microscope, let us know. You brought up a lot of great teaching points I want to reinforce. I find a lot of people, when they’re beginning phaco, minimize important steps. For example, the wound construction or the paracentesis. And a lot of people will struggle because paracentesis is either hard to locate because they didn’t nick the vessels or they go in at an odd angle and they have trouble cannulating or going through. I want to draw attention to how to construct the wounds so they’re not tight and not leaking but also so they’re easy to identify and easy to enter. Certainly we have a beautiful view here, the limbal vessels are in perfect focus. We can see the pretreatment of the capsulorhexis. You can see there is a tinge to that red reflex. We know this is probably a denser nuclei. I know you did the patient’s right eye previously so this patient knows what to expect, they’re under a topical anesthetic. James, if you’re ready, you can take over, tell us what you’re seeing at the slitlamp. >> DR. JAMES LEHMANN: Thank you, Hunter, for that introduction. As Hunter said, this is a dense 3 plus cataract, you can see a yellowish hue to it. These are AKs already done by the laser on her axis of astigmatism. So we’ll begin. We’ll go in with the paracentesis here and you’ll see me enter to get a millimeter width there. I nicked a little bit of a vessel there to help show where it is. People have different amounts of limbal vessels. This is just sugarcane, we call in America, which is Lidocaine with unpreserved epinephrine. I’m going to inject that. You can see some bubbles whirling around the AC. Now this is a dispersive visco elastic. This has a plastic guard on it. If it didn’t, you would hold it right here so it wouldn’t eject out of that lure lock system. That’s just another pearl. So we’re going to enter. I know where to enter because of moxie. Got to mark the vessels. There we go. Now we go across the chamber, inject the dispersive visco elastic and see the bubbles clear away, nice deep chamber, now I have a pair of 0.12s. Now, I’m going to fixate the globe by keeping the tips closed and entering my paracentesis. Then I’m going to enter right at the limbus and kind of come up and I’m going to enter to that little mark right there. And then so the extent of — about a 3 millimeter this way, a nice, square incision, I know that’s going to seal nicely. Now, the capsulotomy has already been done by the femto. You can make sure it’s free, lift it up with this hydrodissection cannula. You can see I lift it up like that, that tells me it’s free. Now I’m going to blot down and remove any gas that’s there, see how little gas came from the laser? Now I’ll do the gentle hydrodissection, especially on a dense cataract, you want to do hydrodissection gently, you don’t want to see the eye prolapsing. You can see more bubbles come. After you hydrodissect, you always the want to push down again, release any fluid so that you don’t get high pressure, you don’t get the lens prolapsing forward. A little more hydrodissection. Now, you can even try to spin the nucleus a little bit. It’s starting to spin slightly. So we should be okay. But just to be safe, I’m going to go back and do a little more. So I think we’re pretty good mobile nucleus now. Now I’m getting the phaco ready. I’ll move the camera so you can see the phaco tip. You want the phaco tip and the color of the phaco tip to be — that’s pretty good. You want that much space. I’m using a 45 degrees Kellman tip. This is my second instrument. It’s basically a horizontal chopper. It’s not sharp at the bottom but it has a little bit of an edge here. I find these are the easiest second instruments. When you’re learning phaco, finding out what second instruments you like the best is part of the learning curve. Now I’m entering the eye, rotating my tip down. Then I’m going to go to the peristaltic. Going back to the scope, which is high energy, low vacuum. I’ll try to find the suture line made by the laser. I’m cutting here, pebbles down 50%, fairly dense cataract, I’m able to cut it. I want to go in the same line that the femto already made. We’re going to try to assess the depth we’ve done so far. I can put the phaco tip all the way there. You can see a little bit of a fracture line. This should be deep enough to be able to crack on a femto case. So I’m going to insert my second instrument. And I’ll put them both in that groove. I’m pretty easily able to spread and crack that. That’s about all the cracking you can be to do, you don’t have to crack it all the way to the center. Now I’ll rotate my tip 90 degrees that way to create room. Then I’m going to go out to the periphery of the nucleus and rotate the lens with my second instrument. I’m in scope still. I’m going to continue to get 80% depth. Now I’m going to put both instruments until the groove and open it. I have a free quadrant. To be thorough we’ll do all quadrants broken free before we remove them. It’s a thick, firm nucleus, you could tear the capsulotomy. You want things to move easier out of the capsule. We’re about 80% thickness there. Crack that. Kind of attached in the middle still, a leathery backed plate. There we go, now it’s free. We rotate another 90 degrees. I’m going to go right to the middle of it. You can see it’s fairly dense. Those pieces want to come up so I’ll switch to quadrant mode and then I’m going to eat those little pieces that want to come up. Now, back to sculpt. I have a really good view of how far down I need to go. Okay. That’s really good. I’m all the way to the bottom, almost. Now I crack with ease. And now they’re free. I saw the red reflex down there. Now I go to quadrant mode. And I’m going to rotate this tip so that I can get the biggest purchase of the quadrant, okay? And you always want to go across the interior chamber to grab the piece. You don’t want to be grabbing a piece like this, that’s awkward and you can tear the capsule. Now I get to the point where I burrow the tip in a little bit. Now I’m keeping constant vacuum and I’m extracting that into the iris plane and I’m putting the petal down to phaco emulsify it. Now we’re going to eat this piece. It’s an off-on burst-type mode that allows less heat to the tip of the phaco so we don’t get a phaco burn. Make sure you’re tracking with your eyes all those little pieces running around the anterior chamber. I don’t see any pieces around. We’ve got one quadrant removed. I’m going to rotate to see if there’s anything stuck together. Those two pieces are stuck so I’ll spread them apart a little bit. This one looks like the most free one over here. So I’m going to rotate this one around. I always go across the chamber to get the piece, I don’t want to grab it over there. I’ll use my second instrument to keep this piece back. I’m going to grab it, burrow my tip into it, lift it up into the iris plane and you can go to town on it. You can still see it’s maybe attached in the back plate because it’s bringing the other piece up with it. That’s okay. Now, a little piece has floated over to my wound. You always want to keep track of that. I’m going to push that back in, bring my tip over here and grab that, grab this piece. And now we’re going to phaco emulsify this piece. Always want to use that second instrument to kind of keep things moving, keep things dancing on the tip of the phaco. You don’t want to just be burrowing in and not getting anywhere. You want to see things moving around, fluid flowing into the anterior chamber. Last quadrant. We’re going to spin it around. We’re going to grab across from it, throw the tip in, lift up. Okay. So everything’s fine. I am remove my second instrument. Modern phaco machines, they don’t get a trampoline effect when you remove that last piece. I’m about 50% energy here. You can see how stable the chamber is, nothing trampolined up. In modern phaco machines it’s almost more stable to take out the second instrument than to leave it in where you get regressive fluid from the eye. You can jiggle the eye to see if there’s pieces floating around. That looks fine. I’m going to turn off the continuous infusion, remove the phaco tip. Then the technician is preparing it for me. So far everything is going smoothly. We’ll move to IA. You can see the collar on the INA handpiece the same length. Continuous irrigation on. Go for the subincisional cortex first, it’s the easiest time to get it, because the whole bag is being supported by the rest of the cortex. And that makes your life easy, especially in a floppy capsule, when you’re trying to get the last pieces. This is a nice firm capsule, so it’s good. You go around and remove the cortex very smoothly. Almost done. Going across. This is the easiest part to get here. So we did the hard part first. That’s another tip. Now I’ll change to what’s called vacuum or polish and I’ll go get that little fragrant on the posterior capsule. Now all the little remnants are gone. You can see the nice round capsulotomy, all the cortex and cataract removed. I’m grabbing the collar like I talked about. This visco elastic doesn’t have the guard. I screw it in, I make sure, I do it subconsciously, and hold it right there so when you inject, it doesn’t go anywhere. This is now a cohesive visco elastic. Our goal is to expand the capsule in the bag as big as we can get it. You can put a lot of it in there and not be scared. This is a Johnson & Johnson one-piece acrylic lens. The technician has already loaded it for me. Looks like it’s in good position. All I have to do is make that little knob and we’ll get it into the eye. The way I enter the incision, I go and rotate maybe 30 degrees, and then I use two hands, inject that bugger into the capsule right there, remove, then I use a push-pull, enter the eye, push the lens down posteriorly and free it up if it’s stuck to the center of the optic like that. That optic’s free, so we know we’re good there. Now I can use the irrigation aspiration on visco elastic which has more vacuum and more flow. Then you can kind of keep it in the middle of the eye and put the pedal down and all that cohesive visco elastic comes from behind the optic. You guys can’t see because it’s very subtle but you see little change in reflection and patterns on the posterior aspect of the cornea when you’re removing that. So we’ve removed all the visco elastic. The lens is centered nicely. Remove this from the eye. And now the last part comes with the hydration of the wound. So this is intracameral. I go into my main wound and do hydration on the lateral aspects of the wound. You can even put some into the roof of the incision like that. And now I’m going to come over and check what the pressure is in the eye with the paracentesis. You notice it firms up nicely. There’s no egress of fluid from here. I check the incision, you guys can touch gently here, it’s staying dry, we’re good. The case is over. I’m going to take off my gown and we’ll undrape the patient and I’ll talk to you a little bit more about cataract surgery, thank you. >> DR. HUNTER CHERWEK: Thank you, James. I really like the techniques he demonstrated. No matter what kind of cataract you’re facing, dense or soft, you can always use this divide and conquer technique. What’s important is the patient he showed, we trench or groove the cataract, get down to the right depth, his first crack didn’t go all the way across, James was very patient and made sure that leathery plate or that adhesion was broken. You always want to make sure the segments are completely mobile. James, you’re now ready to answer questions or continue your lecture. There are no questions that I saw in the chat. But obviously we encourage people to put them in. If you want to go back to your lecture and kind of go through some of the pearls for this surgery and the next surgery, that would be great. >> DR. JAMES LEHMANN: Thanks, Hunter. All right, everybody. I’ll continue with the lecture a little bit. These are some common intraoperative issues we deal with. What do we do if the chamber deepens suddenly like that? This is an old video but it shows it nicely, especially in a myopic eye, when you insert any instrument in the eye that has fluid, you can cause the chamber, kind of a reverse capsular block syndrome. Put the tip of the handpiece under the iris and lift it up and free it up and the chamber will get a good depth. Patients often complain of pain when this happens. If it happens with the phaco tip, you can’t stick the phaco tip under the iris but you get your second instrument and lift up the iris. Again, that’s what you do when the chamber — when the chamber deepens suddenly. If it’s an INA handpiece, you go and lift the edge. If it’s a phaco tip, use your second instrument. How deep do I groove? This is the question I was talking about when I was doing the case. This is not a femto phaco. You see these little stria, these horizontal stria in the groove there that tell you you’re at the right depth. Once you get the right depth, you start to see the protein fibers in the lens change and you see them like this instead of in random fashion. So that’s how you know you’re at 80% depth. When I was learning phaco, nobody taught me that. I kind of figured out over time once you started to see the grooves look like this, you’re at the right depth. Okay. This happens often. In this case, it was the same. What if I don’t see a wave when I’m doing hydrodissection? A very common error when you’re learning phaco is to be too aggressive with hydrodissection and then you get iris prolapse and then you get visco elastic coming out of the eye. If you don’t see a wave, you have to keep going to different spots in the anterior capsule area and injecting gently, always pushing posteriorly on the lens to get any kind of pressure released. Here is a mature cataract. Again, this is that same thing. If you don’t see a wave, just do little gentle amounts all the way around, pushing posteriorly after each injection and eventually trying to spin the nucleus. If you can spin it a little bit, you’re golden, okay? What if I can’t rotate the nucleus? You can see I’m at the right depth here, I have the little stria going there. I’m able to crack it. If you can’t rotate the nucleus, this is a common problem. Here I do that first track and try to rotate it, but look, nothing wants to rotate, the lens just kind of shifts over. Now, what you can do is try to remove a small piece of it and just try to debulk the nucleus in situ. I made another groove, not a whole quadrant, just an eighth of it, I broke that, now I’m trying to remove that section and that allows you to free up the nucleus a little easier. I remove that section and now I have more room. Sometimes then it’s easier to rotate it at that point, because you can fracture it in pieces. That’s still showing in the back. If you’re doing divide and conquer and you cannot rotate the nucleus, you can always repeat hydrodissection, that’s the first thing you can do. Even if you already started phac’ing, you can always go back and do hydrodissection. If that doesn’t work, go back, and [inaudible] just remove that, and then crack, and you’re able to free up a quadrant. And then once you’ve removed a part of the — like over a quarter of the nucleus, it’s going to spin a lot easier, okay? So this is tricky. I wish I had a case where I was doing this and I wasn’t able to rotate it to show you that. Maybe on my next webinar I’ll purposely try to not rotate it so you can see how to do this, because this is a nice maneuver you can learn. Again, if you can’t rotate it, repeat the hydrodissection. If that doesn’t work, remove an eighth of it and then back crack and try to spin out that last half nucleus and once you’ve got that removed, you’re good. Okay. The last thing I’ll show you is managing a leaky wound. Here I’m doing stroma hydration. Maybe I made this tunnel too short. Now I’m injecting the paracentesis again. You’ll notice fluid egresses from the eye. I keep doing it and keep doing it. If this happens, you don’t want to leave an eye soft, because when you see them the next morning they’ll have iris coming out of the wound. What you have to do is repeat the stroma hydration several times, if that still doesn’t work then you need to put a suture in. When you do the stroma hydration, you can do the lateral aspects of the wound or inject into the roof of the wound. Here the better part of valor is accepting you didn’t make a great incision, suturing it, and remove that suture in one month — one week, rather. Any questions, Hunter, about phaco? >> DR. HUNTER CHERWEK: The incision size, I think you used a 2.6, is that correct, sir? >> DR. JAMES LEHMANN: That’s correct. >> DR. HUNTER CHERWEK: And it’s a triplanar wound. If you have a white, bulky lens that’s under a lot of internal pressure, are you able to use femto pressure? >> DR. JAMES LEHMANN: You can. You can. From my experience, it’s pretty good in those mature cataracts, it makes a nice capsule. It does it fast enough where the fluid doesn’t come up. If you suspect that you didn’t get a capsulotomy well, femto I would put tripan in and see what’s going on, I wouldn’t trust that it did it 100%. >> DR. HUNTER CHERWEK: At the end of the day case you had your lens where both optics were in the bag, the optic were covered by the CCC but maybe not perfectly centered. Is that something you worry about or do you find that as long as the lens is in the bag and the entire optic is covered, you feel like you’re safe and not to fiddle around, because obviously the lens can shift a bit until it Saran wraps in? >> DR. JAMES LEHMANN: I programmed the femto to do a 5 millimeter rhexis. Normally it will cover the optic because most optics are 6 millimeters so you have a good margin of error on each side. It doesn’t have to be perfectly centered on the rex I guess. Sometimes it doesn’t want to, especially if the bag is a little floppy. As long as you’re covering the optic, it’s good. >> DR. HUNTER CHERWEK: The first person wanted us to ask, do you ever use a soft shell technique for removing the lens? >> DR. JAMES LEHMANN: I don’t find it’s necessary. The soft shell is helpful if you’re having a hard time like keeping the pressure flat to do a nice capsulotomy. I think it’s a really [inaudible] you can always inject more dispersive if you feel it’s needed. Most of the time these corneas respond fine. >> DR. HUNTER CHERWEK: The last question, from Dr. Ahmed that just came in, do you use the temporal side for the paracentesis in all your cases or just in cases where you don’t have good exposure? What is your preferred location? >> DR. JAMES LEHMANN: I always operate temporally. I’m right-handed so I’ll make my main incision somewhere around the most temporal aspect and the paracentesis would be kind of 40 degrees, 40 degrees to the left of my main wound. >> DR. HUNTER CHERWEK: I like that because obviously we know where natural astigmatism occurs in most patients. By having it temporal, you relax some of that astigmatism. You’re not changing your technique based on the patient’s brow. Some doctors I know get really nervous if they always operate superiorly and they have a patient with a sunken eye or a high brow. I like that you do it the same way no matter what, that allows more standardization. >> DR. JAMES LEHMANN: In most countries I visit, the surgeons still operate anteriorly. Temporal surgery for cataracts is much easier. You’ve got more space. I’m a big fan of it. >> DR. HUNTER CHERWEK: The last thing which I loved was, obviously you were trying to create a safe working space by debulking the lens by the divide and conquer space at the center of that plus sign. But also you were able to get that first quadrant and bring it to a safe space at the iris plane. Do you always like to keep the phaco tip and the iris plane during quadrant mode? >> DR. JAMES LEHMANN: Yeah, that’s the best place to do it, that’s the safest, less trauma to the cornea, less risk of damaging the capsule. >> DR. HUNTER CHERWEK: I agree. The thing that I really appreciated about that case was, you always had control. You’re not going to get into complications if you maintain control and don’t push a bad situation. And I think by maintaining that center space where, as you said, you’re farthest from the endothelium, farthest from the posterior capsule, you’re in a good space. James, there are questions still coming through. How are you for the next patient or are you ready for more questions? >> DR. JAMES LEHMANN: They’re getting the patient ready. I still have probably about ten minutes, I think. I’ll go ahead and talk about DMEK. >> DR. HUNTER CHERWEK: Exactly, and I’ll make sure we answer the rest of these cataract questions offline. Please start with the DMEK. >> DR. JAMES LEHMANN: Why switch from cataract to DMEK? In my surgery day, I’ll do X number of cataracts but we’ll have some cornea cases thrown in. This is a kind of a representation of what my normal surgery day would be. To give a background to those who don’t know, endothelial keratoplasty, DLEK was invented in 2004, now what we do in most uncomplicated eyes is DMEK, which is exact anatomic replacement. This is kind of the evolution of endothelial keratoplasty. There’s better vision and less refractive shift. You can see this picture here, that’s postop day one from five years ago, they can look that good. No DSEK looks that good, that soon. Donor cornea selection is different in DMEK. When you’re doing PK, you want the cornea with all the other good qualities. Age, you want it young. In DMEK, I don’t go lower than 45. The main reason is that the DMEK scroll scrolls too tightly the younger you get and it makes the surgery more difficult. So kind of 45 is the range for donors, 65 the top range. They tend to diabetics. Pseudophakes we don’t use because they protrude into the DMEK. When I see a patient, how do I decide DMEK or DSEK? This is DSEK. They’re both good. The main thing would be DSEK is used in more complicated eyes and DMEK is used in more uncomplicated eyes. If there’s ACIOL and you’re not going to take it out, you pretty much have to do DSEK. DMEK has the risk of more returned visits for bubbles. If the patient lives really far away, or has a hard time getting to the clinic, then you would maybe shift towards DSEK. The other thing is, in the U.S., the eye banks prepare the DMEKs for us but you’ll most likely have to do that in your home country so you’ll need a comfort level for preparing the DMEK tissue which oftentimes is as deep as the learning curve for the surgery. The main thing is the complexity of the anterior chamber. If it’s shallow, if there’s any angle closure, if there’s a valve, most of the time I’ll tend to do DSEK in those cases. If the cornea is really cloudy, you don’t need a good view for DSEK. If there’s iris [inaudible], those I would tend to do DSEK as well. And then the lens status has to be addressed as well. I don’t do combined like DSEK surgery. If it’s complicated, I would do the IOL exchange first and come back and do DSEK. If it’s straightforward and use of fused with a cataract, he would do phaco. These are cases in which we would not want to do DMEK surgery. On the top left you see an old school style ACIOL. The eye looks angry. That one needs to have an IOL exchange first and then go and do a DSEK. Same in the upper right. In the lower left, all that fibrosis, that patient has had long standing corneal edema leading to fibrosis. Those, most likely that view is get a lot better and you can consider DMEK but you’re going to be safe bet to do DSEK in that surgery. Lastly, no iris tissue, that’s a DSEK for sure so you don’t have to worry about the disk falling to the posterior chamber of the eye. Sometimes if you can’t get a good view of what’s happening, you can do an anterior chamber OCT prior to surgery and it can help show if there’s distorted anatomy. If you don’t have a good enough view, you should be doing DSEK in that patient. Again, summary of preoperative planning for DMEK, I generally do peribulbar, patient needs to be able to lay flat the first night of the surgery. Uncomplicated eyes, in the U.S., most Fuch’s dystrophy patients. I do the interior iridotomy. I’ll talk about the instruments and then I’ll show you the surgery. So the good thing about DMEK surgery is you don’t need a lot of fancy instruments. You have a cataract set and a reverse Sinskey, a Trephine to mark the 8 millimeter center of the cornea. That’s about it. I use this as a hand-held slitlamp. People get the stamp on the tissue and that’s a good way of doing it. I learned it this way with the lamp. I’ll stop there and then I’ll go ahead and do the surgery and we’ll finish talking about DMEK, okay? >> DR. HUNTER CHERWEK: That’s perfect, Dr. Lehmann. As you get ready, we’ll talk again. All of these techniques and all of these materials are available on Cybersight. If you look in the chat, please visit the Cybersight e-library. Certainly our team is always welcome to feedback. If there’s videos or lectures or materials you want, please let us know. Certainly cornea is a growing area for us. This is the first time we’ve done a DMEK surgery live on Cybersight. So certainly we’re excited for James to demonstrate. I think as you have questions, please let us know, whether it’s about the bubbling technique, whether or not you need to do an iridotomy. What you look for the next day and how you treat that patient is very important. I see James is still prepping the patient and is on mute so we’ll talk more about the procedures. What’s important, like every case and every procedure, is patient selection and patient education. Patients have to understand their role in the successful bubble and positioning. If the patient is not able to do that for a multitude of reasons, then certainly that’s something to discuss. So not one size fits all is appropriate when looking at a corneal technique. And certainly, as Dr. Lehmann said, we want to look at the other components of the eye. For example, this patient has already had a successful DMEK in their right eye. Today we’re doing the left eye. But during the exam, Dr. Lehmann noticed a corneal retinal scar. It’s really important to do a complete eye exam, especially of the retina and macula, so you know if the patient is visually limiting findings or pathology in the retina. Dr. Lehmann, I see you’re at the slitlamp. We’re in perfect focus. Are you able to take over? >> DR. JAMES LEHMANN: I will. Okay, ma’am, we’re going to get started. We have the patient. As Hunter said, this is — she still has pretty decent vision, around 20/50, a history of cataract surgery. That’s the iridotomy I did. I use traction sutures because sometimes, especially on an eye where you can’t deepen — you can’t flatten the chamber to get the graft unfolded, sometimes you have to rotate the eye into different positions. That’s where these traction sutures come in handy. I know a lot of surgeons don’t do these. When I learned it, this is how we did it and it definitely comes in handy. Especially if we start doing this case — reload that for me — if we can’t shallow the chamber, it’s easy to rotate the eye and be in control of it. I’m just tying the silk, tapered needle. I like to hold these three-quarters up the way here. You go 2 millimeters posterior to the limbus, you grab it, you push the needle into the sclera, you feel it grab. You can use a spatula needle or you can use a taper needle. You don’t want to use a cutting needle, you’ll go too deep into the sclera. I’m tying the silk suture. This is kind of old school. A lot of docs don’t do this anymore. I would rather do it now and if you can’t shallow the chamber or can’t get the graft centered, it’s very helpful. The next step is to mark the central 8 millimeters. This is an optical zone marker. You want to do this over the geometric center of the cornea, you don’t have to mark it right on the pupil. Now I use a fine marking pen and put dots where I’ll put my ring. We’ve got the cornea marked, we’re good to go. Now I use a super sharp 15-degree blade and make two paracenteses. You want it a millimeter and a half in width. I’m going to come in on the iris plane and make a 1.5 incision. Now I’ll inject some cohesive visco elastic, I’m holding the cannula area there. Cohesive is very important because when you do score endothelium, you need to remove the visco elastic and if it’s dispersive, it makes it harder. These wounds can be pretty short. You don’t want it to go into that area where the graft is going to be. You’re going to suture it anyway so it doesn’t have to be such a long tunnel. So I’m just going like that, all right? And now, if you put BSS on the cornea for me, I’m going to focus right on the cornea. This is that reverse Sinskey hook. I want to score it, 8 millimeters. I can move pretty gently and freely, fast like this. If you see me and I’m like, ugh, ugh, then I’m too deep into the stroma and you’re causing tags and tears. I rotate, enter the anterior chamber, start right here. You can see whitening, that’s all. I’m moving pretty fast around this circle and scoring. You want to be able to flow gently, not go around twice, in that same line I was in because I want to make sure that thing is completely torn. With DSEK you can have some tags and stuff left behind. With DMEK, you don’t want that. I’ve gone around twice. I’m going lateral to where I’ve started and I’m putting a little pressure. You can see, you can see it starts to come now, and it’s coming in a nice — you pull in in the center here, it’s coming as one big uniform piece of endothelium and decimays. I’m pulling out of the wound. Now it’s on the cornea. You see the straight tire. This is kind of the attack decimays membrane, came out all in one piece, I’ll unfold it for you guys if I can. You kind of get the idea here. It came out all intact and nicely. There we go. That’s what we removed. Right there. Okay. Now we send this to pathology to confirm the diagnosis. Now I’m going to put a little BSS on the cornea to get you a good view here again. All right. So now we have to preplace a suture. I’ll take my suture. After we inject the graft, the last manipulation of the main wound you do the better, because sometimes it can expel itself. Reload that for me. Okay. So we’re going to put this 0.12 right here, that’s my paracentesis, that’s my main wound. They’ll have to go get me another suture. Sorry about that, the suture fell. We’ll just get another one here. You can turn the room lights on, guys. All right. I’ll do INA here. So we’ve got to move the visco elastic. I’m using the INA handpiece. And this is pretty easy. You just be real thorough, make sure you remove all the visco elastic. All right. I don’t see anything fluttering. Sometimes you can see tags fluttering, that tells you there are little parts still there. I don’t see that. Now no more visco elastic in the AC. My tech is handing me the suture, I like to hold it three-quarters of the way up. Now I’ll use my 0.12 and insert my tip into the wound, get an idea of where the lip is. There we go. I’ll preplace this suture. And I’m going to hold the scleral end. And then that suture is preplaced. I’ll pull it through halfway. Can I see the retratas real quick? A little bit of decimays membrane is still present right here. And I’m going to remove that little tag right there that I saw. Okay. Now we’re good. Now I’m going to prepare the tissue. I’ll take the cornea tissue. So this is the cornea. This cornea has already been peeled and stained. It came preloaded. I’ll get you in the scope here again. It came preloaded. At the eye bank. You’ll see it here in a second. It comes on this sled like that, okay? It’s in a tube. I’ll show you here. I’ll zoom out a little. Okay. So here you see it floating in the tube. This is a glass cannula. This area right here, that’s the graft. It’s already been stained and peeled. And it’s free floating in solution. So what I need to do is I need to connect it to this thing, which is a 3 millimeter syringe. So what I do, I’m doing this all over a petri dish in case I drop the cannula, the glass cannula. I uncork it on one side. I come in, I’m putting a little bit of fluid, just a little bit. Okay. Now, I’m going to remove this side. That’s gone. And now this is going to drain out that preservative. You can see it starts to fall down. You can see the difference in the viscosity of the two materials, as I lock this cannula on. I’m going to inject and keep it in an elevated plane. The graft will stay in the same place. But the medium will come out. You can see that viscosity change. So now we’re kind of flushing out the medium. Now we’re full of BSS. Now I’m going to put it horizontal. And I’m going to advance it a little bit. Now I’m trying to advance that tissue. A little bit to that real narrow neck. I’m going to get it to right there. And then I’m going to transfer it to the male stand. You can’t see me doing that. I’m done prepping it. I’m going to go back to the eye. Now we’re going to inject it. Then my technician, after the injection, will hand me tying forceps. You can see that again. Now I’m getting the tissue again. Can I get another 3 cc syringe? That syringe came off the back. That was unplanned. But we see what happens when that happens. I’m going to reattach one. You don’t want that to advance out the end of the tube. I’m going to firmly kind of retighten that nice and firm. We’re pretty good there. And then I may need 0.12s. I’ll advance it into the neck of the injector just a little bit more. That’s good. Now I’m going to my wound and I’ll inject it. Now watch. I’ll use this and rotate it so that it won’t come out of the wound, so it’s perpendicular to the wound. Now it’s like that. Now I need little tires. I’m going to zoom out so you can see the tires. The eye is pretty flat right now. A little BSS on the cornea. Then I’m going to tie my incision. This is just a 311. There’s 3. Lock my knot. One, one the other way. Scissors. Then I’m going to cut my suture and rotate the knot and barrier. Then this suture comes out two or three weeks after surgery. Here’s the suture back. Okay. And I’ll take the BSS on a 10 cc syringe. Now we’ll inject and get this in the right orientation. This is where DMEK is kind of fun. If we tap on it, we’ll get it to unfold. Right now it’s pretty much folded in half like a clam. So it’s in the correct orientation, I can see it’s curved to the right orientation. But if you give me another cannula, just another — that one right there. Sometimes you can get lucky and you can hold on one side and you can like open here like that and you get it to unfold like a bouquet. Now we’ll get it to open a little bit. So now it’s in the right orientation, you see. Now, I need to verify that. So I’ll deepen the chamber a little bit. By injecting some fluid. You’ll give me the flashlight. I’ll use that little flashlight and we’re going to see if it’s in the correct — did you guys just lose video feed or no? Can you see it? >> DR. HUNTER CHERWEK: James, we’re in perfect focus. >> DR. JAMES LEHMANN: Now we’ll confirm the correct orientation. I’m using that beam. We’re seeing two pictures here, two edges of the graph. I’ll illustrate that. It’s in the correct orientation. Turn the room lights on again. Give me a little bit piece of — give me one of those pieces of paper over there. All right, guys, I’m going to move away from here and show you what I just saw. Here is a piece of paper. I’ll zoom out. Can you all see that piece of paper? >> DR. HUNTER CHERWEK: We can, yes, sir. >> DR. JAMES LEHMANN: It’s either like this or like this. This is bad. You want it like this. You want to see two sides of it like two rolls. If I shine the light on it and I just see one roll like this, it’s not right. You want to see two humps like this, okay? And that’s what I saw. So I know it’s in the correct orientation. So, move back. It’s sitting in perfect orientation in the eye like a tricorn hat. Now I have to get it in the right spot. I’m going to use a little air, this is a 30 gauge needle on a 1 cc syringe. I’m going to pull up this much air, just like that. Then I’m going to bend the needle a little bit like that. I’ll come back. I’m going to go through my paracentesis and I want to gently put this under the graft and put in an air bubble which will pin it to the posterior stroma. I can’t find my paracentesis. There we go. I’ll get it under the graft. Now I’ll put an air bubble. I want one air bubble, not three. We got that there. Now I need the BSS. Now I’ll fill the AC a little bit. The graft is pinned and it’s unfolding already, we’re good. Now you just need to get this last fold-out. This is why I talk about rotating the eye. I rotate it so the bubble is centered on the graft. Then I’m going to push on that fold right there and look at it just unfold. Now I’ll push there. Now it’s totally unfolded. It just isn’t centered. I’ll rotate the eye a little bit superiorly so the bubble is correct underneath the graft. Then I’m going to put these gentle strokes like this, golf strokes, I use that to center the graft. It’s almost centered. >> DR. HUNTER CHERWEK: Your surgical game is much better than your golf game, Doctor. >> DR. JAMES LEHMANN: I wish they were both good. Now we’re centered. Maybe it could be a smidge superior. Anyway, we’re good. We want to get that graft to stick nicely. Now this is more air. I’m going to go underneath, making sure I’m under the graft. I’m going to augment that air bubble by putting more. You still see everything is good, we see the outline of the graft, we know we’re good. This air bubble isn’t enough, I want it firm. I need it firm for 45 minutes. After I make it firm, the patient will go out to holding and hang out for a little bit and come back and I’ll remove enough air to clear the inferior. Now, this is the real tricky part. This is what you learn when you do DSEK. I’m not going to put this cannula back in the eye and inject air because any air I inject will come out as I’m pushing down on the wound. So I have the cannula prepped already. I’m putting it halfway into the paracentesis. And I’m injecting air. And that’s going to — that’s how I firm up the eye. Even though there are a bunch of little bubbles, it’s all fine, I still see the edge of the graft there. So now that’s a firm-ish eye. That’s what we want. So all those bubbles will coalesce in the next few minutes while the patient is in holding. Anyway, that’s DMEK surgery. The graft is stuck, it’s centered. I’ll remove these traction sutures. The patient will lay flat for 45 minutes. I’ll go back and remove the air bubbles. That’s it, guys. I can finish the DMEK lecture. >> DR. HUNTER CHERWEK: Perfect. We have about five questions at the moment for you. >> DR. JAMES LEHMANN: Okay, go ahead. >> DR. HUNTER CHERWEK: The first one is, you know, obviously back when you were doing your fellowship, they talked about the triple procedure where you did a full thickness PK, the cataract extraction and an IOL. Are they doing combined DMEK surgery where they’re doing phaco or cataract removal at the time of the DMEK lamelar Keratoplasto? >> DR. JAMES LEHMANN: Yes, if it’s uncomplicated phaco, uncomplicated DMEK, I do them together. >> DR. HUNTER CHERWEK: You mentioned DMEK sometimes requires more rebubbling than DSEK. Is it because it’s flimsier tissue? What is the issue in your mind? >> DR. JAMES LEHMANN: The tissue, you stick it, but it wants to curl away, it always wants to push itself away from the posterior stroma. I use an air bubble to stick it until the cells wake up and stick. Preparing DMEK is more difficult, the cells can be damaged. So it just won’t stick. DMEK is just riskier, it’s less certain of the outcome as DSEK, even in the best hands. Like that surgery, I didn’t have to rotate that graft but one time, maybe. That still could not stick, like it’s a little out of your hands as a surgeon. You do the surgery well, you ensure it was prepped well, but sometimes the graft is just — just don’t want to stick. That’s the difference between DMEK and DSEK. The answer is maybe there’s more concussed endothelial cells. >> DR. JAMES LEHMANN: Right. >> DR. HUNTER CHERWEK: And mechanically, how they scroll, as you said, they’re trying to push away from the stroma they’re trying to readhere to. How long do you have the patient — I think you said 45 minutes. How long do you have them keep supine both in your ambulatory surgery center, and how long do you tell them to stay supine when they get home or in the car ride home? >> DR. JAMES LEHMANN: We have them lay flat 80% of the time just the first night and check them and see how they’re doing the next day. Most of the time DMEKs are stuck on day one and we don’t make them position anymore. Probably 10% have to be rebubbled, even in great hands, 10% have to be rebubbled. I lost you for a second, Hunter. >> DR. HUNTER CHERWEK: I apologize. Which gas did you use for that bubbling, was it just room air? >> DR. JAMES LEHMANN: I just use air. >> DR. HUNTER CHERWEK: How much volume do you estimate you inject on the primary bubble, the second bubble, and the third bubble, like as you do these, what is the volume? I know it’s probably more visual and by feel. What are you estimating? >> DR. JAMES LEHMANN: You want the eye firm, that’s the thing, you want to touch the eye and it feels like the pressure is, you know, 40. You want it firm. If it’s too soft, I don’t think you have enough force, sticking that DMEK to the posterior stroma. I don’t know the volume because you actually deepen the chamber with the air bubble. But it’s enough to make the eye firm. Then they go hang out 45 minutes, you bring them back in, you reduce the air bubble to about the size of the graft when the patient’s lying supine, so that translates to like a three quarter full AC afterwards. >> DR. HUNTER CHERWEK: So it’s not a set volume, it’s more of how anatomically the bubble is functioning and sitting in the eye. Just so we heard you correctly, you’re going to have this patient supine for 45 minutes, bring them back into the operating room, and look at things, and potentially lessen or shrink the bubble just a bit just so it fills the circumference of the graft? >> DR. JAMES LEHMANN: The diameter of the graft, yeah. >> DR. HUNTER CHERWEK: Yeah. Is DMEK contraindicated for patients with chronic uveitis, are you hot to trot with DMEK? >> DR. JAMES LEHMANN: No, I’ve done this in patients, young patients who have HSV or even CMV endothelitis, it’s okay. They don’t last that long, you have to keep them on viral prophylaxis, but if it’s CMV you could do ganciclovir. >> DR. HUNTER CHERWEK: The last question, Doctor, one of the questions is, is there any indicator or things to look out for when the graft doesn’t adhere or center properly? What are some subtle, clinical things you’re looking for that could suggest there’s not good adherence, not good contact or not good centration? >> DR. JAMES LEHMANN: You want the DMEK stuck to the posterior stroma not to remnants of endothelium. So you want to make sure you strip a little bit bigger. You want to make sure there are no folds in it, that’s easy to see. But centering it can be difficult. Like the way you’re trying to throw it to the middle, sometimes you can’t center it and you have to redo the whole thing, like reject it and get it to fold again. Sometimes there’s a strand of vitreous you can’t see or there’s [inaudible] in the AC, that can sometimes do it. Sometimes it gets stuck in the angle and it’s a pain in the butt to get it centered. In that situation, you’ve got to sometimes start back at the first step. I can show that here. >> DR. HUNTER CHERWEK: Why don’t we get back to your lecture, I think you’re going to answer the last question in your talk, because I know we’re at the end of the hour. >> DR. JAMES LEHMANN: I have about ten minutes, guys. This is the steps of DMEK. This is what I showed new the surgery. You can see me stripping slightly outside where I made those dots, because you want to make it a little bit slightly bigger. You don’t want it way oversize because you get this ring of edema. You want to do it at least in a way where you’re not going to have overlap of the posterior endothelium that still remains in the graft. This is a DMEK phaco. You can see the patient is pseudo phacic. Sometimes even with Miochol, it doesn’t come down all the way. A lot of surgeons don’t like it for this reason but if you get enough confidence in your technique, you can do it, you can add Miochol. These are the steps I use to get it to stick. First I unroll it and I confirm the orientation. Then I unfold it and I center it. We’ll go through these again here. So when it’s been injected, if you need to flip it, this is how you do it. You inject fluid underneath it. And then you kind of get it to unroll. I’ll show this on a loop. So when you have it in the eye and you know it’s not in the right orientation, you’ve got to make it flip. The way you make it flip is you inject fluid underneath it. You create a fluid wave on the surface of the iris and it makes the graft flip just like that. That’s when you need to flip the orientation. That’s how you do it. Now, you got to get it to unroll. Most surgeons nowadays, and what I just demonstrated is like a double tap. So if you need to get it to unfold, you either tap it or you release fluid away from where the graft is. You’ll see here. Here I’m just tapping it, trying to get it to unfold, it’s starting to. It’s two scrolls there, that’s nice. It’s pretty good there. That was pretty easy to unscroll there. That’s the easy way to tap it, okay? But sometimes that doesn’t work. Sometimes you’ve got to release fluid. That’s what I’ll show here. So now, I touch on the incision, look right there. You see how I touched on the incision, and it opened up that bouquet a little bit. You can either tap or you can open an incision and you get into that orientation. That’s the fluid coming out of the eye causes the graft to open in that direction. You can see me tapping and then I’m going to go in the paracentesis here and I’m going to injures I’m tapping that paracentesis and look at it open up nice. We had a lovely tricorn hat in the surgery. This is what you want. Once you get in this orientation, you have to determine, is it upside down or is it in the correct orientation. That’s what we use the light for. You see here in the little side here, we want to see those two humps like this. You want to see it like this and not like that. You can use a flashlight for that or it can have the F stamp or the S stamp. I don’t like the F stamp because it has a big F. You can see the humps here, that’s what we like. Then I have it in the right orientation. Now we’re going to put air underneath it to stick it to the posterior stroma. Small air bubble, boom. Now we want it to unfold. So you just touch on that point and get it to unfold. This is the fun part. Makes you feel like a hero. Sometimes if you can’t get it to unfold, you push between the bubble. You can push between the bubble and you got it to unfold just like that. This is that same thing. You can sometimes rotate the eye, if it’s being stubborn. In this case I have too many air bubbles in the eye, that’s not very esthetic. You push between the bubble and the fold and sometimes the bubble will roll up and undo it. And then if it’s locked like this, you can rotate it, get some pressure, and then you touch on the point that have fold there and that opens nicely. So once we have that graph centered, then you put if a full air bubble so you start by making sure you’re under the graft, augment the bubble that’s under the graft. You fill the AC but that’s not firm yet, that’s just filling it. Then you go in with a 3 cc syringe and fill the eye firm. Then the patient lays flat for 45 minutes. You bring them back and you remove some of the air. So in conclusion, the phaco tips and tricks. Remember, nick the vessels to mark incisions. Hold the cannula collar for OVD injection. Aim for a square main incision. Get the subincisional cortex first. The way you know the groove is [inaudible] until you go [inaudible] perpendicular to the tunnel. The DSEK decision tree. It’s hard to do a DSEK, that’s what that stuff is saying right there. >> DR. HUNTER CHERWEK: Dr. Lehmann, those were great summary points, you demonstrated beautiful, femtosecond assisted cataract surgery and the DMEK procedure. A few more DMEK questions. One is, and I wanted to save this for the summary, what is your preferred anesthesia for DMEK, is it topical, is it a block? >> DR. JAMES LEHMANN: A block. I have tried to do it topically and patients have too much discomfort. Block is the way to do. >> DR. HUNTER CHERWEK: I wrote in the chat, that’s based on the patient’s selection and comfort and the surgeon’s comfort. I love those sutures, how you can rotate and move the eye to your advantage, that’s something you have to do when the patient is blocked. What do we do if the graft is oriented in the wrong direction? So you did that flashlight check, you looked to see, and instead of having the dome, you actually have those two curls. How do you flip or rotate that? >> DR. JAMES LEHMANN: That’s the fun one. That’s the flip. >> DR. HUNTER CHERWEK: Yes. >> DR. JAMES LEHMANN: Right here. You shoot fluid underneath it like that and it causes the graft to tumble over. >> DR. HUNTER CHERWEK: Correct. Maybe you could show that one more time so we get that triangular — in case not everyone knows that hat. If you see you’re in the wrong orientation you can do a jetstream from the side port, right? >> DR. JAMES LEHMANN: Yeah, if you’re in the wrong orientation, you’ve got to go back to step one which is trying to get back to here. This is where you want to end up. If this is wrong, if this is wrong, this is right in this video, but if it’s wrong, then you’ve got to go back and inject fluid underneath and make it spin. >> DR. HUNTER CHERWEK: What if the air bubble or there are small bubbles between the flap and the stroma, how can you identify this and how do you correct it? If there’s something between the graft and the new stroma bed or the cornea, what do you do to remove those bubbles? >> DR. JAMES LEHMANN: Just the nature of the tight fit, bubbles generally will not stay between an attached DMEK and posterior stroma. If there are, you can just massage on the top of the cornea and it will put them away. Now, sometimes when you’re injecting subsequent air, it causes a fold to happen in the graft. If you see that, you have to extract air and do some maneuvers to get it open again. >> DR. HUNTER CHERWEK: Then the last question, and I realize you have other patients to get to so thank you for beautiful demonstrations, Dr. Lehmann, what are the most common diseases you’re using DMEK to treat? So Fuch’s, what are some diseases you’re using DMEK to treat? >> DR. JAMES LEHMANN: I use DMEK, I probably do — all the transplants that I do that are endothelial, it’s probably 80% DMEK, 20% DSEK. I’ll do DMEK in PVK and Fuch’s and even in some glaucoma valves, if it’s a pretty straightforward eye. So pretty much that’s my go-to. But if there’s other things like an iris defect, if there’s an angle closure, if there’s mostly like abnormal anterior segment, I’ll go to DSEK. But 80% of them get DMEK. >> DR. HUNTER CHERWEK: You get on with your day. Thank you for such beautiful demonstrations. All of these will be recorded and put in the Cybersight library. If your colleagues are not able to attend live, they can review this. Dr. Lehmann, thank you as always for all you do. Anything else you would like to say? >> DR. JAMES LEHMANN: No, thank you for being the emcee and I thank you to Orbis for giving me this opportunity. I appreciate it. You all have a good day, ’til the next time. >> DR. HUNTER CHERWEK: Take care, everyone. >> DR. JAMES LEHMANN: Bye.