Live Surgical Demonstration: Complex Cataract Surgeries

>> HUNTER CHERWEK: Well, I certainly want to welcome our Cybersight community to another great webinar. Today we’re having live surgery by Dr. James Lehmann from San Antonio, Texas. James has done prior surgeries for us, and today he’ll be demonstrating complex cataract techniques with dense cataracts. James, thank you so much for joining us. I know you’ve been bouncing around the globe these days, and making time for this webinar is much appreciated. >> JAMES LEHMANN: Thanks, Hunter, and thanks to all from the Cybersphere. We’ll be getting into cataract surgeries. I’m going to start by talking briefly about doing a brief lecture about cataract surgery, then we’ll move into the surgery. I’m going to do a screen share right now. All right. So my name is James Lehmann, I’m in San Antonio, Texas, I’ve worked with Orbis for the last 20 years. I started as a staff doc and I’ve had the opportunity to travel around the world teaching cataract and cornea surgery. These are the topics we’re again review in the lecture. Nucleus disassembly techniques, conversion to ECCE, management of PC tear, and a few grab bag type themes. When we’re talking about removing the cataract, there’s basically four or five different techniques you can do. The first is divide and conquer. That’s what I’m going to demonstrate in today’s webinar. It’s what I do still after doing cataract surgery for the last 15, 16 years. You can pretty much get rid of any cataract with this technique. While it’s not the fanciest or kind of sexiest technique out there, it’s very efficient. There are also things like prechopping, stop and chop, and the different vertical and horizontal chops that we’ll talk about as well. This is what I’m going to show today in the webinar. For those learning about cataract surgery and doing your first hundred cases or so, I really say stick with divide and conquer. Once you master this technique, you can try some of the more difficult ones but this is your bread and butter. You can see in this video I’m doing a cataract surgery on a moderately dense cataract and I’m making the first trench. You want about 80% depth. People ask how deep do you go. The way that you know is once you’re about 80% depth, you start to see perpendicular striae. That’s how you know you’re far enough. In terms of depth, you want to go about 80%, and width about 1.5 tips of the phaco needle, which is about a millimeter. So once you get to that point, you know you’re at the right spot. I’m looking right there, I can see those perpendicular striae. I put in my second instrument, normally an Nagahara chopper. Hopefully that’s what you’ll see going smoothly today in the cases. So the concepts of cracking, this is my favorite second instrument, the Nagahara chopper. It has a blunt tip, it’s very narrow, you can put it in the trench. Basically you’re going to kind of roll your fingers like this, and you’re opening it this way. It’s not pushing down. That’s the most common error I see beginning phaco surgeons do, is pushing too hard posteriorly. That puts the least amount of stress on the zonules. I want to break the first hemi nucleus. If I can’t crack it, I’ll just rotate 90 and I’ll start sculpting again instead of trying to do the same thing over and over. We’ll try to illustrate that. Again, we’re putting both instruments in the trench there, we’re rotating 90 degrees. You’ll see me make another trench. Now that we’ve already cracked it, we know what the depth should be. It’s a little easier to visualize. Then I put the other instrument in the trench there and free up that fragment. I think this is a good break to move to the surgery. Then I’ll come back and we’ll talk about different techniques. We’ll move over to the surgery now. >> HUNTER CHERWEK: Thanks, Dr. Lehmann. While you’re setting up, I can present a little bit about this patient, a 60-year-old man who has a bilaterally dense cataract. He is legally blind from cataract blindness. And what’s interesting about this patient is that they’ve had prior trauma where they were in a motor vehicle accident approximately 40 years ago and have had two reconstructive plastic surgeries with some involving the right orbit. Obviously today we’re going to be operating on the left eye. For those in the audience, the cataract was so dense that we were not able to do optical biometry but immersion ultrasound was done. One of the things I appreciated that Dr. Lehmann mentioned is how important it is to master divide and conquer. If you look in the chat, you will see the fundamentals of phaco surgery. I think divide and conquer is a great default, I think everyone should start off that way so they really understand how to move within the eye and create cracks before you try to do things like stop and chop. So please know that divide and conquer is a wonderful technique that you can use on almost every single cataract. There are experts like James who have done thousands and thousands of cataracts and that is still their preferred choice. Just because you want to move to chopping and all that doesn’t make you a better cataract surgeon. What makes you a great cataract surgeon is doing the best techniques that are in your hands and give you the best outcomes. Dr. Lehmann, are you ready? >> JAMES LEHMANN: I’m ready to go. You can hear me clearly? >> HUNTER CHERWEK: Loud and clear. We have perfect vision of the eye. >> JAMES LEHMANN: Welcome, everybody. We’re looking through the microscopes, you’re seeing what I’m seeing. We have patient Mr. O here, and we’re going to be getting started. I put some viscoelastic on the cornea to help my staff so they don’t have to put BSS every few seconds. If I move the eye gently like this, you can see it’s a fairly dense cataract. You can see the density causing a little opacity there in the middle. We’re going to get started. I like to use a 15 degree blade. I’m going to go about 40 degrees from where I’ll make my main incision. I’ll enter the eye, making a 1 millimeter incision there. Then we’re going to inject a little bit of Lidocaine with epinephrine, known as sugar cane. Just to illustrate my rex us a little better, I’ll put some vision blue, although with this eye we could get away with not using it. I don’t think we have to put an air bubble. If the endothelium is healthy, the Trypan doesn’t stain it anyway. I let it simmer there for ten, 15 seconds. Then I’m rinsing it out with basic salt solution here. And then you don’t have to get it all out because the viscoelastic will do a job. Beginning surgeons always kind of lose that, the paracentesis. It’s not a bad idea to use Trypan on every case if it’s available. Putting in the viscoelastic. Then I’m going to use my .12 forceps. This is basically right in front of me, I’m sitting temporally. I’m going to tilt the eye forward, make a little incision, go straight up to the mark on the knife like that. That gives me a nice square type incision, approximately 2.6 millimeters. Now the next part is the capsular rhexis. I’m going to enter the eye, entering perpendicularly, rotate it 90 degrees. I do the same rhexis every time, I always start right here, go to that and push it forward a little bit. I like to do the rhexis counterclockwise. And when it’s blue like that, you can see it nicely. So there we have a nice flap. And in an eye with a dense cataract, you want a moderate size rhexis, you don’t want it to small where it’s hard to take the pieces out. I’ll make one 5 to 6 millimeters. Ideally it would encompass the optic of the IOL. But that’s not the end of the world if it doesn’t. You want to err more on the side of a larger one than a smaller one when it’s a dense nucleus. I always regrasp in the same places. I’m leading it over here, I’m not going out here. You’re always thinking one step ahead. I’m bringing it this way. A little maneuver, let’s say it starts to go out. Let’s imagine it’s out there. You can do the little maneuver, you grab it here, come underneath and finish it like that. I just wanted to demonstrate that technique. Hydrodissection, beginning surgeons, you definitely want to do good hydrodissection. You have to be able to demonstrate, there’s that wave, I blot the lens, you want to demonstrate that you can spin that nucleus. Until you can spin it, you don’t want to go to the next step. Here I am spinning it freely, so we know we’re good. I’m going to be able to rotate that nucleus. Now my assistant is handing me my phaco probe, I’m getting my pedals in order. My phaco tip, that’s not exposed enough. I’m twisting the collar until I’m about right there. You want the ports facing perpendicular to the needle. I use a 45 degree tip. I’m going to go back to the eye. Get in focus. Then I use automatic irrigation. I have to rotate the phaco tip 180 degrees, and now I’m in the correct orientation. Now I’m going to go to the next step. This is like an aspiration or quadrimode. Now I’m going to start with that first trench. People say, how far to go? Go from one end of the rhexis to another. You can go slightly under it but not on the first passes. Now I’m just creating space here. Just creating space. I’m eating 1 millimeter into the lens and I’m going to make that initial trench. You can see the lens is moving a little bit. We don’t like that. We’re going to go to dense cataract mode. You want to cut it nice and clean. Now it doesn’t move as much. You see that? You should have a second setting on your machine for dense. Remember, I was talking about what kind of width do we want on this. We don’t want just one phaco tip. It’s hard to put instruments in there. So we’re going to go half a phaco tip this way. Also I’m holding this with both hands. My left finger is stabilizing the tip while I’m still holding this instrument in my hand, the second instrument. I’m realigning that trench. Now you can see the lens, it’s so movable that it wants to spin. Now we got about 1.5 width trench. And see, I’m going a little bit deeper, I’m a little under the rhexis on that side. I’m improving my visualization. I’m not at the point where you see the striae. I’m going to go deeper. You’re starting to see those perpendicular striae. I’m not going to crack the hemi nucleus all the way across so I don’t have to be as deep on this side. That should be the appropriate depth. Now I’m going to insert my second instrument. And then we’re able to crack it very nicely. Look, I didn’t worry about cracking it all the way to here. I just did enough motion to crack it in that quadrant. Now I’m going to use my second instrument, rotate the lens 90 degrees, then I’m doing the same thing over here. Now, I know what depth I have to go because I’ve already cracked it once. So that was a lot faster. I found the depth very easily. Cracked that quadrant. Rotate 90 degrees. You guys can open and load the lens if you haven’t, okay? Okay. Again, the easy depth right there, put both instruments in the trench. Then it’s a motion like this, like that, that’s what I’m doing. Now the last hemi nucleus. I start in the middle. I’m going forward about a millimeter underneath the edge of the rhexis. Going a little bit deeper. So now I know I’m in the right depth because I see clearly where the bottom of the cataract ends. I’m going to crack this. We’re good. I’m going to go to mode to remove the quadrant. And I want to find the quadrant that’s the most mobile so I don’t pick the biggest one. That’s the biggest quadrant. I’m going to rotate 90 degrees and grab this little bugger. I’m going to rotate my needle tip 90 degrees and engage it under the anterior capsule. I lift it up into the iris plane. And I have a mode for quadrant. And then I’m not moving much. You can see. I’m letting the phaco tip do the work. I’m letting my second instrument feed the piece in while it dances on the tip of the phaco needle. So I’m not sitting there darting around the anterior chamber. I’m keeping the tip relatively stable, just above the iris plane. I’m halfway down on the pedal, eating all the pieces. Again, under the anterior capsule. And there we go. Now, the last piece, I removed my second instrument you. May ask, how are you going to protect the posterior capsule? It’s not needed. With modern phaco machines, the flow is so good, you’re actually making it worse by having a second instrument and having liquid bleed out of that paracentesis. You’ll see, no surge after it eats this last piece here. Really, even in infinity type machine generation, is fine. See, there was no surge at all, no worry of that posterior capsule coming up. The cataract has been removed. No pieces floating around the AC. I’m going to turn off the automatic irrigation and now we’ll switch to irrigation aspiration. I’ll get that centered for you there. I’m advancing the steps to INA. Again, I’m looking at the sleeve. And I want those ports pointing to the side. I’m removing those viscoelastic from the cornea. I’m going to remove some of the dispersive I put in because we don’t need to protect the endothelium anymore. I mean, we always want to protect the endothelium, but I don’t want to use phaco energy. Go grab the hardest cortex to get, come to the middle, there you go. This cortex, it’s very kind of lightly adherent, it’s very easy to peel. I’m just going calmly, with what the eye will give me there, I’ll go back seven here, we’ll end up across from our incision. Now we’ve cleaned up all the cortex. There’s two little wisps right there, I’ll take away those two little wisps of cortex. Cook. We’re all done there. So now we’re going to inject the cohesiveness co-elastic. Here I go straight into the eye. First I check, I’m holding my hands right here so that it doesn’t go off. We don’t want to inject and then it pushes the needle or syringe. I’m creating space. That’s the anterior chamber. Now I’m going deeper under the anterior capsule to create space in the bag to inject that IOL. Viscoelastic, very easy to remove that. My lens has been loaded by my very cable technician, Sylvia, thank you. We’ll inject it with a wound assist technique like that. I use a push-pull or a hook to dilate boo the bag. I make sure the legs aren’t stuck. They’re fine. We get the handpiece again on the visco mode. I sit here in the middle. It’s going to all come out eventually. You don’t have to go digging around the corners of the eye grabbing stuff. The chambers are a little deep so I’ll do a release of the iris like that. I push on the optic, make sure nothing is behind it. One more pass behind the eye to make sure there’s no other pieces. Give me my second instrument. My paracentesis I’m looking at here, I see a little bit of nuclear material. I don’t know if you guys can see that, that little guy right there, we got that. Otherwise we’re good. All right. We’re going to center that lens. And then I want to remove the instruments from the eye. And now the last step is hydration of the wounds. I’m going to hydrate with a Vigamox. Some of it went in the interior chamber. I highly recommend using an antibiotic intracamerally. It’s been shown that it really decreases risk. So we use Vigamox. I’m doing hydration of the wound. Maintaining a good intraocular pressure. The eye feels a little firm. I’ll touch it with my finger, feels great, I think we’re fine. Lens is centered, everything looks good, we’re done. Thank you very much. We’ll get the next patient ready. Thank you. >> HUNTER CHERWEK: Dr. Lehmann, that was a beautiful demonstration. I really appreciated how you demonstrated the fundamental techniques of nuclear disassembly with the divide and conquer technique. Some quick things while Dr. Lehmann is getting the next case ready. I really appreciated how he kept everything in focus and used Trypan blue, visualization is key. The little technique was named after Dr. Brian Little, it’s not little as far as size, but it’s a wonderful technique you should practice as Dr. Lehmann did, not when there’s a runout, but when you are in a stable cage, because it’s a wonderful way to rescue, if you do have an anterior runout. James, are you ready to continue? >> JAMES LEHMANN: Yeah, I’ll go back to screen share, thank you, Hunter. >> HUNTER CHERWEK: No, thank you, sir. >> JAMES LEHMANN: Okay. All right. So we just showed divide and conquer. And again, so I’ve done some phaco teaching in different countries like Peru and South Africa. When the folks come and they’ve done around 200 or 300 phacos, they all want to do the vertical chop because it’s so cool to look at. But you really have much more motion in the bag. You have an instrument sometimes going blindly under the iris. I really don’t recommend it until you become an absolute expert in phaco. So these are just some videos of like a vertical chop. It’s really neat, you impale the nucleus, for those who don’t know it, you put a sharp instrument there and then you fracture it. So it’s very nice when it works well. But I believe in the more difficult cataracts, especially the leathery ones, this technique doesn’t work so great. You’re unable to fracture it safely and you put a lot of stress on that capsule and the zonules. Stop and chop, this is a good intro into chopping. You basically make the first trench, then you do, like divide and conquer, you do a fracturing of the hemi nucleus. And then you remove the second — the two pieces of the hemi nuclei. Here it’s like normal divide and conquer, the surgeon is fracturing it, you have two hemi nuclei, then you impale the hemi nucleus and use the chopper to break it into the other quadrant. This is a combination of divide and conquer and chopping. This will be a good intro into it. You want to make sure you’re with your bioengineers and that your settings are right for chopping. It’s not the same settings on the phaco machine as when you’re doing quadrant removal, so you need to get those dialed in. These are some additional techniques. All right. We’re going to talk now about conversion to ECCE. The next case is very dense cataract, history of dropped nuclear in the other eye, and I’m not sure I can even phaco it. I think it’s too dense to phaco. But maybe it isn’t. We’re going to try to phaco. If I’m not able to phaco it, we’re going to convert to an extra cap. You can think about this before you get into the situations. Situations that lead to it are things like, the lens is too hard to phaco, you get a radialized tear in the anterior capsule. Or if you have poor visualization in spite of Trypan staining. Or if you have a PC tear. Or if you have unstable capsular support. These situations intraoperatively that may lead you to convert to extra cap. In these scenarios, you have extra stress and fear, that’s normal, and you freak out. You have to think, before you get in the operating room, what can I anticipate, how can I change my surgery day to minimize all the stress and fear. Some of the folks over at AIIMS looked at what situations intraoperatively led them to do extra cap. Most of them were things like posterior capsule rupture, miosis, prolonged phaco time, those were the common scenarios. And things that you can identify. So this is the key thing. When you see these things, the little light bulb in your head needs to go off that you may have to worry about the case being harder than it is. That’s a rock hard lens that’s either red or black, a tiny pupil, zonular laxity, patients that are 80 and plus, you start to get worries like this. If you think you have a situation that’s a possibility, you want to schedule the case at the end of your list. You also want to consider doing peribulbar instead of topical anesthesia. You don’t want to do an extra cap or small incision atopically, it’s uncomfortable for the patient. You could do IV access for more sedation for the patient, ideally. You want your team to be notified as well, talk with the nurse and the technicians, all the instruments you need, they need to be on standby. You don’t want to be yelling at them to go get stuff in the middle of the case and you’re already all stressed out. You need to have a suture set, lens loop, crescent blade, bipolar, viscoelastics. If you’re fortunate enough to have a mentor or boss in the building with you, have them come in for that case to give you some advice. Lastly, you can do a primary scleral tunnel. That’s what we’re going to do, I’ll start with a scleral tunnel and phaco in the middle of the scleral tunnel in case we may have to enlarge it to do the cataract surgery. That way I’m not rotating, which you can do, but I’m already thinking this is maybe coming out whole through a scleral tunnel. If I start my phaco through that, it could work fine. So, conversion steps and tips. This is from Dr. Etting. If you start a case topically and it starts to go south and you have to convert to a small incision extra cap, you want to give some adjunctive anesthesia. The best way to do that is with a blunt cannula, I like that best. You can’t stop and give a peribulbar at this point, you don’t want to risk the posterior pressure and everything. So you cut down the conj, you create a space, inject two to three ccs of Lidocaine or bupivicaine. This is something you want to practice before you’re in the operative surgery. This is a great technique to use when you have to convert to extra cap in the middle of the surgery. Make a new incision. You’re not going to extend the clear corneal wound, that’s crazy. So this is a case that I was doing in Peru a couple of years ago with a lot of posterior pressure. And so I make my wound here. You can see all that iris prolapse, a lot of posterior pressure. Basically what I ended up doing was converting to an extra cap. You don’t want to do that, like if you’re sitting temporally to do the phaco, you want to rotate 90 degrees and sit superiorly to do the scleral tunnel. That’s another thing, you don’t extend the clear corneal wound. You rotate your microscope and the body away from the phaco wound. Here I was going to try to do another phaco superiorly. But you don’t want to do the scleral tunnel on the same side that you do the phaco. You need to have a large enough incision to prove the lens. It’s about maybe 13 millimeters in the internal lip, 7 millimeters or so posteriorly. You want to choose a lens or an IOL that’s silicone and that’s three-piece. You do not want to use a one-piece acrylic lens because this IOL is going to be placed up against the iris and the sulcus. You want a three-piece silicone or one-piece PMMA ideally in these scenarios. I mentioned about using viscoelastic to push away vitreous if it’s present. Obviously you want to not be pulling on vitreous. These situations are all very unique in terms of what stage of the surgery you may need help. So it’s hard to give just overall advice in this scenario. So we’re going to talk now a little bit about the management of a posterior capsular tear. Of course this can happen. And the importance of it can vary from not really relevant if it’s a tiny little tear after the lens is in and everything’s okay, to a big problem in which fragments of the nucleus fall inferiorly. So a posterior capsular tear, the severity is determined by what step of surgery it occurs, okay? It’s very stressful for the surgeon. And the consequences can be from zero, like the lens is already in and there’s a small tear, to, you know, nucleus prolapse and the patient requiring additional surgery. It also means you have to take care of them a little differently postoperatively, which we’ll talk about. What’s worse is a nucleus sitting on the retina, that’s what we want to avoid. Again, the preoperative risk factors, the same things we talked about for conversion to extra cap. A rock hard lens, small pupils, zonular laxity, et cetera. The more difficult a case looks, the more risk for one of these problems. These are the things we can do if we anticipate a difficult case. So generally tips for the posterior capsular management. Number one, try to stay calm. Once you recognize there’s care in the posterior capsule, your natural reflex is to retract and run out of the operating room screaming. But you have to stay calm, keep the fluid running, but you can have the technician decrease the amount of fluid that’s running, keep the phaco tip in the eye, with your left hand inject. It will coat the area and won’t stay in one little glob. You want to coat that, switch to low fluidics, if you can, finish the phaco with the viscoelastic tamponade. If it’s only a little bit of a fragment or epinucleus, you can try to tamponade the nucleus and finish it. Before you put in the new lens, do an anterior vitrectomy. You have to learn the different modes on your machine. Most of the places I go, you’re using Alcon machines, most phaco machines have the same settings, either cut IA or IA cut. I want to use cut IA. Some machines have a mode called anterior vitrectomy. It goes to pedal 3 where there’s aspiration occurring, that makes life easier as well. You only use IA cut if you’re trying to remove like cortex, it behaves like an INA. The things you want to use are either anterior vitrectomy or IA. You want to irrigate high, you have fluid coming in high, and you want to cut down low. You don’t want to be cutting and irrigating from the same incision because then you’re adding more vitreous to the area. Kenalog is your friend, use it to stain the vitreous and make sure you’re removing all you can. You can practice in a wet lab by using an egg yolk with cornstarch, it makes a pretty good vitreous substitute. We’re about ready for the other case. This may be a good time to take any questions we have so far. Are there any questions? >> HUNTER CHERWEK: I’ve been answering a few, James. One question is, what is your phaco machine? >> JAMES LEHMANN: The AMO Veritas. >> HUNTER CHERWEK: I really appreciate how you kept the eye in focus at all times. How did you keep the eye centered, especially during trenching? I know one of the things you did very nicely was free up the lens nucleus by hydrodissection and rotation. How did you keep the globe centered so it was purely in line with the illumination during the case? >> JAMES LEHMANN: The tendency when you’re learning phaco is, you sit too close to the bed and your hand starts pushing the eye medially, away from you temporally, towards the nose. You have to be conscious of having a relaxed wrist and kind of relaxed arm so that you’re not jamming the eye away from you. It’s one of the most common things I see, it causes problems with visualization. >> HUNTER CHERWEK: The other thing I appreciated that you talked about, as you’re operating, keeping your hands very still. You don’t chase the nucleus, you adjust your parameters, have the pieces come to you. I think one of the biggest mistakes I see people make is they try to go after the biggest quadrant or the biggest piece of the nucleus after they’ve done the divide and conquer. You went for the smaller piece. Could you explain why you did that? >> JAMES LEHMANN: It’s like taking the jigsaw, the smallest jigsaw piece out, because once you get the smallest ones out, the others come easily. If you’re trying to get the biggest one, you’re trying to get the biggest one out of flow here. I think they’re ready for the next case. >> HUNTER CHERWEK: It’s super important to not only do good hydrodissection but good lens rotation. The more mobile the lens is, the easier the pieces will be to manipulate when you’re doing nucleus disassembly and you’ll put less stress on the zonules. As he was doing his first trenching, he was pushing the lens because it was a dense lens and he went up in power to a dense lens setting. Think it’s important not to push the lens if you’re not getting good cutting and trenching. Most people try to occlude the tip when they’re leveraging to trench. You really you should only have one-third of the phaco tip covered with lens material so that you’re not causing subincisional stress. I really appreciate, someone asked about using this technique for congenital cataracts. With congenital cataracts, each may be different and often the lens is not very dense. Sometimes you’ll open up the capsule and find out it’s a milky or liquidy cataract. Divide and conquer is more for adult cataracts and congenital cataracts often need totally different surgical planning. He asked whether we can use divide and conquer for congenital cataracts. Please note, and I’ll put this in the chat, we’ll have an upcoming webinar by one of our volunteer faculty from Columbia, Dr. Ernesto, about congenital cataracts, so in a few months you can watch different techniques for congenital cataracts. James, over to you. >> JAMES LEHMANN: This is Ms. AG, if you hear me speaking Spanish to her, it’s because that’s her primary language. You can see the dense cataract and you can see this trigeum which didn’t have an impact on the case. Thank you go over history, Hunter? >> HUNTER CHERWEK: I did not, I was just answering some questions. Maybe you can do that now, that this is essentially a monocular patient who has had prior complicated cataract surgery in the left eye and a macular hole. You’re operating on the right eye; is that correct? >> JAMES LEHMANN: That’s correct, yeah. >> HUNTER CHERWEK: This is a dense nucleus and one we may need to convert. I’ll let you talk through that if there’s any other teaching points. You had so many good pearls from the first case, I wanted to finish that. >> JAMES LEHMANN: Okay, sounds good. We’ll go ahead and get started. I’m going to start with a scleral tunnel. I have a feeling I’ll have to convert to extra cap. What I do is I grab near the limbus and grab a little bit piece of conj like that. I pull anteriorly and I do a cut. She’s an older patient. I’m able to see the bare sclera there. I close the tines on my scissors, cut forward, then I go back here and I free that up. Then I go again here, I’m freeing it up. Then I open them. I pull anteriorly. Then I cut like that. So that’s my kind of little conj flap I’m going to cut. That should be sufficient right there. I’m going to do cautery. And then while I’m doing — I’ll take the BSS that I can drip off. How much power? 80, okay. And so I’m just trying to get all those bleeding vessels. And then is it centered on the scleral tunnel area, can you guys see that? >> HUNTER CHERWEK: We see everything perfect, perfect focus, perfect centration. >> JAMES LEHMANN: Now we’re good. You can measure here if you want but I always kind of know what size scleral tunnel I need to do. I’m going to try it. Take 1.2 in my other hand. I’m going to grab right here. I’m grabbing a little bit of conj and a little bit of tinons, I’m going to dry that area. I’ll take the crescent blade. I’m holding the crescent blade and I’m holding it upside down here. I’m going to make a little groove right here in the middle. One question is how deep I need to make that. That’s not deep enough. You should start to see a little bit of change in color. That’s a little better. You can see a little bit of blue hue there. That’s about right. Now how do I know that? Just from experience. Essentially before it was too shallow. Now I see a little hint of blue there. Now I don’t go just straight in like this. I’m going to go in at 45 degrees. I’m going to dig a little. Then I’ll put the heel of that knife down and go straight up into clear cornea. But I’m not going to enter the AC. So you don’t want the eye too firm so you’ll enter prematurely. Now I’m seeing the tip of my knife. Now I’m wiggling forward. I’m up into clear cornea. When I’m cutting to extend this, I’m not going to go forward. I’m cutting backwards. So I went down like that, that’s when I cut. Now I wiggle forward again. Now I’m going backwards again. Okay? I’m going to go to this side too. I’m going to need to enlarge the posterior lip, it’s too small, which I’ll do next. I haven’t entered the eye yet. And I’m cutting, going backwards. Now my incision is probably around — what’s that, about 5 millimeters at that point? I want to extend it maybe 2 millimeters in each direction. I’m going to cut like that and then go forward using the plane of the eye as my guide. So that’s a bigger incision. And I’m going to go this way. Cutting backwards. And then back into the AC. Then backwards again. And then into the AC. That should be big enough to get that lens out if I have to. Now what I’m going to do, I’m going to use a 15 degree blade, make a paracentesis just like normal, so 15 degree blade, please. Q-Tip is fine. I’m going to go over here. All right. Now I’ve entered the eye. I’ll make one on this side too in case I have to do — you know, the stuff could have by manual INA on standby, that would be good, guys. This is a little bit of some Lidocaine. Thankfully she dilates very nicely. It’s a little bit of Lidocaine. Now we’ll put the vision blue in. This is a little big cannula. There we go. Okay. So we’ll let that blue sit for a little bit. Okay. One Mississippi, two Mississippi. Now we’re going to rinse it out. While we’re doing this, we’re looking for cues about — clues about how stable that lens is. So far, I’ve put some instruments in the eye. The chamber is pretty deep. That’s a little bit scary. But you’re not seeing like that lens go up and down. There’s no trampolining. I’m not seeing a lot of warning signs that it’s very unstable. It still may be possible to phaco. You’re learning all this while I’m doing it. I’m injecting the viscoelastic. I’m entering the eye with the keratel. Now I’m going to enter the eye like I’m doing a temporal phaco. I’m going to wiggle this in. I’m not going to cut, I don’t want to be in a different plane. I have the heel of this down. I’m wiggling up. Now I’m going to plane it out, I’m going straighter. Now I’m entering the anterior chamber, okay? This is like a phaco, just like a phaco thing. Let me see a little more viscoelastic. Okay. I’m going to put a little more viscoelastic. You saw the iris kind of went up here a little bit. So I think I could fill the AC a little more. Now I’m going to go ahead and try to make as big a rhexis as I can even if I phaco this thing. If I want to convert that extra cap, it would be nice to not have to make any relaxing incisions. So I want to go for a big rhexis. There doesn’t seem to be a lot of posterior pressure. I’m able to get centered here. I’ll make my cut like I always do. You can see that thing is a dense cataract, it does not — you can see all that fibrosis and scary stuff there. So it’s looking pretty dense. Okay? So now I’m going to grab my rhexis. And then I’m going to make a little bit big but not too big because I can always do a spiral technique. I’m always thinking one step ahead. I want it to go left but I’m pulling down. Now I want it to go down so I’m pulling right. Now I’m regrasping. I’m going to have it come up again here. It’s going fine with the rhexis. But I need to make that a bigger rhexis. I’m not so concerned that the optic wouldn’t be covered completely by the anterior capsule. So I’m going to try to make this pretty much as big as rhexis as I can. This is a good technique here. I have a little strip here. I could just stop and finish it but I want to keep going around in a spiral so it gets a little bit bigger. And since it’s just a spiral, if I run into trouble, I can just easily kind of stop it. All right. So that’s a pretty decent size rhexis, looks about 6 millimeters. I’m moving that here. Now, I am going to try to gently hydrodissect. We’ll see what the behavior of the lens is. So far it seems pretty stable. I want to lift up. It’s really kind of fibrosed into the interior capsule. I’m trying to inject some fluid. The fluid doesn’t seem to be going around. Maybe a little. I’m kind of just going under the anterior capsule lip. Let’s see if I try to rotate it, what happens? Nothing, okay. So what I’m going to do is make my first trench or I’m going to try to. And then I’m going to try to — I don’t want to get too aggressive with the hydrodissection at this point. I want to see how the phaco is behaving. Put it on dense for me. Okay. So I’m going to enter the eye again. I’m going to adjust my sleeve. And then enter the eye. I’m going to go into quadri mode. I’m going to eat some of these air bubbles so you guys get a better view. Okay. And then I’m going to go ahead and start phacoing. I’m going to back to sculpt. So it’s not much doing with the phaco. I’m able to get some of that — I can feel the phaco tip getting a little warm in my hand already. Oh, there we go. I’m making a trench, at least a little. I’m making some progress. What’s the power setting on the phaco? 60? Go to 80. I may attempt to crack it. I’m making some progress in the trenching here. I’ll zoom into it a little bit. Put some BSS on the cornea. Sorry, I’m not talking, I’m just trying to be gentle and doing some trenching here, trying to improve my view, a little more laterally there. So if I’m able to crack it, I think there’s a chance I would probably be able to phaco it. But let’s see. How far to go down on this one? I’m starting to zoom down a little bit. I’m not seeing any red reflex still. I’m going to enlarge the width of my trench a little bit. I’m seeing a little bit of a red reflex. A little more there. So I’m going to attempt to crack it. I’m going to insert my instrument. I was able to crack it. There’s reflex down there. That’s good. Since I made a crack in it, I can get a little more aggressive with the hydrodissection. Guess what, I can rotate it, yay. It looks like phaco is probably going to work. Still we’re not out of the woods by any means. So I’m just going to take it slowly and easily. I’m just doing that other quadrant. So now I kind of know what depth to get to. A little anteriorly, I could do better, like this part. I’ll try and stick a second instrument in there then break that fragment. It’s got that leathery plate. I’m trying to fracture it. Okay. There we go, we got that piece clear, but it’s still attached in the center. I’m not going to get greedy and try to get that out right now. I’m just going to keep rotating. It’s rotating easily, I’m not stressing zonules. I’m going to go back to that first area where I was. And then I’m going to try to groove down to that same depth that I was on the first crack. I’m not even at 100% power, I’m just at 80. BSS, please, on the cornea. You can see those leathery fibers. That was good. There we go, we’re separated there. And last hemi nucleus here. I’m doing the same thing, just gentle strokes here, trying not to move stuff too much. Because it’s completely free from the rest of the nucleus, it’s behaving loosey-goosey, but okay. And then I’ll try to — this one may be harder to fragment. I’ll tell what you I’m going to do, I’ll try to take out a quadrant. I’m going to try to find the smallest quadrant. I’m going to leave that hemi nucleus because it’s being a little bit funny to — so I think the smallest one will be this one here on my right, that guy. I’ll go ahead and remove that. I’m going to phaco 1, my setting to remove the first piece. I’m going to use my second instrument and gently push away this piece, going into the anterior capsule. Then I’m impaling it pretty good. I know it’s dense. I’m going to lift that little bugger up into the AC. Now I’m going to switch to the mode called quadrant which is a little more aggressive, using a little more vacuum, a little less power, so the little piece dances on the tip a little better. You can see it looks like a little Coca-Cola Gummi Bear thing. All right. Getting that last piece like that. So now there’s a little fragment right here. I’ll leave that alone. Go for this quadrant. Again, I’m going to align my tip, I’m going straight like that, I’m not going to grab it that way. I’m going to go anteriorly. I’m going to impale it pretty good, lift it up, into the anterior chamber, the iris plane. My second instrument, I can use it to crack it a little bit since it’s such a dense piece of cataract. But basically what we want to do is just be gentle, take it slow and easy, don’t do anything stupid, and try to break up the piece. I always kind of look back at my phaco wound and make sure I don’t see any burn marks. We have a scleral tunnel, that’s handier in that regard, but obviously any time it’s a dense nucleus, you can get a phaco burn if you get the tip occluded and you start to see smoke at the tip of the phaco, that can be a phaco burn and that can be a traumatic thing to fix. We don’t want to get a phaco burn. Thankfully with modern phaco machines, it’s harder, but it’s still possible. You see it when you get occlusion of the tip, when you hear the bell go ding ding ding ding. The last piece, the big daddy. It’s lot of manipulation. If I try to make a groove in this and crack it, it will be pushing a lot on the peripheral zonules. I’ll try to do a chop of that into quadrants. I’m going to elevate it, bring it halfway up. I’m going to regrab right in the middle of it. I’m going to impale it. And I’m going to bring this other nucleus, my chopper to it. There we go, I’m able to chop it there. Now we’ll go slow and easy and get these remaining — remaining connection. Again, slow and easy. Sorry if this makes for boring TV. Just trying to take it slow and easy so nothing unexpected happens. It’s always good to visualize the tip. I let that one get under a little bit. It’s always better to see what that tip is doing. And try to keep the piece dancing on it. Instead of stuck in the middle like that, you kind of want it on the side, so use your second instrument to kind of push things around so that it’s not just impaling in the middle of the quadrant. All right. So we’ve got this last piece coming. So far, so good, guys. I’m going to remove my second instrument, I don’t need it anymore. Like I showed you in the other video, it’s safer to just have one instrument in the eye, you have better fluidics. That one is stuck in the corner. I’m going to stick my second instrument in and push it away a little bit. I’m breaking my rule about going chasing and, but I’ve got to get that little piece. It’s not wanting to come. I go back to phaco 1 and use as much vacuum as I can. The power is repelling the piece or the piece is stuck partially on the paracentesis. So we’re going to try to get it. Okay. There we go. Now I’m bringing it centrally. Oh, okay. I’ll tell you what. Why don’t I move this all the way like that. There we go. There we go. Take it off dense. There’s always a kind of a play between — okay. I took it off dense. Okay. I took it off dense because sometimes that has too much power and not enough vacuum. That little piece doesn’t want to come to the phaco tip. Okay. There we go. Let’s use the second instrument to kind of help it, how about that. All right. What setting am I on? Okay. I’ve seen this before. Let’s do this. What’s my — decrease the power. 30? Okay. Take it to 10. What is my aspiration? It’s at 42. Let’s go up to 80. Okay. What I did was decrease the power, increase the aspiration, hoping it would — okay. I wonder if there’s occlusion of the phaco tip, that could be what it is, and it’s not able to aspirate. I’m going to remove the phaco from the eye. Let’s just do it in a — we’re going to try to rinse the phaco tip. Sorry about that, guys. I think it’s blocked and maybe it’s not aspirating, is what’s happening. You guys can open up the ZC blue lens. We’re just flushing the phaco tip, trying to get any kind of piece that’s there. Why don’t we get another phaco tip, just tip, not the whole phaco handpiece, just in case. Okay. Go back to — yes. Okay. So we’re going to go back and — go back into the eye, try to get that last piece. I thought we were clear. But we’re good, don’t panic, everything’s okay. Okay. That’s a little better. Let me see the second instrument. I think maybe there was a piece occluding it and it couldn’t aspirate. But it wasn’t going ding ding ding. There we go. We’re good now. All right, guys. Go back to the setting before. All right. That’s what it was. So there was a piece inside, it was just decreasing the aspiration enough to make it where I couldn’t aspirate the piece. Irrigation aspiration, go ahead and load the lens. So when that happens and it’s bouncing off the tip like that, you have to do some troubleshooting. It looks like there was a piece, it wasn’t enough to make the ding ding ding go, like it was occluded, but it was enough to decrease the aspiration so it was just repelling the phaco tip. So we’re in INA. We’re getting these little cortical wisps. All right. So far — there we go. Cortical piece over there. There’s some incisional cortex here. See, I don’t want to get out of the capsule like that. I’m going to let that sit there and I’m going to come back and get that when I’ve got a lens in the bag safely. So now, cohesive viscoelastic. Let me see a little of this stuff. We’re going to put a little more cohesive in. There we go. Now I’m injecting the lens. We’re going to use a suture, get that suture ready. First I’ll put the lens in the bag. While I’m doing this part, Hunter, I can field questions while I’m just kind of tidying everything up. >> HUNTER CHERWEK: I think a lot of people — you did a beautiful job preparing for conversion but we stayed with phaco. How did you protect the cornea, reapplying OVD, using high quality irrigation, phacoing in the bag, what are some other things you did to protect the cornea, and why did you decide to start with phaco and not just go straight to small incision? >> JAMES LEHMANN: Well, I’m better at phaco than I am at small incision, number one. Number two, I was able to make some progress pretty fast, so I thought, you know, even if you do a great small incision extra cap, there’s still a chance that you can — you may have to enlarge the rhexis, you may have a radial tear, there’s a little more — at least in my hands, a little more uncertainty than a phaco that’s going steadily well. I’ll take the INA now. So that’s why I did it. I probably should have stopped and applied some more dispersive viscoelastic, that would have been a good idea. What’s our total energy there? 103? Okay. So we did use quite a bit of energy, that’s a good point from the audience. I guess I was so caught up in the not breaking any capsule or anything that I didn’t think to do that. But that’s a great point. Reapplying dispersive viscoelastic is always a good idea. What other questions? >> HUNTER CHERWEK: One of the other questions, I think we’ve answered that one, I think one of the things everyone is asking is, what are — when someone is a beginning surgeon, this is from Dr. Ahmed, if someone is a beginning surgeon is starting their first dense cataracts, what are some techniques or things you demonstrated that you would like them to be able to do, what are some things like making sure you’re ready to convert, surgical planning, protecting the cornea, what are some other tips or tricks you would recommend if someone is doing their first three or four plus dense nucleus? >> JAMES LEHMANN: I mean, I think those things we talked about, put it at the end of your list so you’re not going to derail a whole day, right? Have a mentor nearby. And I have a plan B. Have all your other lenses in the room you may need in different scenarios. And surgically-wise, if you’re trying to phaco it, then you need to be able to verify that you can rotate the lens before you start moving on to more complex steps. I would definitely do the divide and conquer. Once you’re able to crack that first trench and smooth the eye, you’re kind of out of the woods in terms of kind of any kind of scary factors that could happen, notwithstanding — kind of notwithstanding like a — needle drivers — notwithstanding any sort of inadvertent tear of the capsule. >> HUNTER CHERWEK: From one doctor, this is a great example of an African surgery. Someone wants to know what surgical microscope are you using. >> JAMES LEHMANN: It’s an Leica, probably around 15 years old, probably the best optics of any scope I ever used, I hope the new ones, when this one breaks, are as good as this one has been. >> HUNTER CHERWEK: Is that an Nino nylon suture? >> JAMES LEHMANN: 10-oh. >> HUNTER CHERWEK: So it’s a 10-oh, not a 9-oh. >> JAMES LEHMANN: This conj one I’ll remove in a week or so. The one in the sclera, that just stays. >> HUNTER CHERWEK: Dr. Gonzalez, a shoutout. James, we all appreciate you doing a challenging case, not the typical southern Florida, southern California cataract. One of the things I think that Dr. Krishna Kumar is commenting, he says it’s most important to debulk the nucleus especially in a dense cataract. I think that’s what you did, you got the first crack. If it was not dividing well, rotating well, you probably would have converted earlier, but you were able to get that trench going, get the crack, and you did a beautiful job of debulking that central nucleus. >> JAMES LEHMANN: Thank you. Yes, if I had run into trouble, if I started pushing the nucleus away from me and not making any progress, I probably would have done a can opener rhexis and converted to an extra cap. But I don’t do those routinely, again. So a doc in India or Africa or something like that, they would probably have more success doing it that way. But I would feel like I still run the risk of having a PC tear higher in that scenario than I do if I try to keep phacoing. Once I knew I could rotate it, I knew that I was pretty good. >> HUNTER CHERWEK: James, two more, I realize we’re at the top of the hour and you need to get on with your surgical list. When is it an absolute no to phaco? Someone with low endothelial counts, someone who is not cooperative? What are some absolutes, no matter how good you are as a phaco surgeon, you’re going to say no and go straight to small incision? >> JAMES LEHMANN: If the lens is wobbly, you really can’t phaco that. You’re just going to cause problems. >> HUNTER CHERWEK: So zonular concerns, corneal concerns, or if you’re not comfortable, those are your straight noes? >> JAMES LEHMANN: I think so. If there’s history of seeing that the capsule is weird or there’s some sort of — like anything that would show you the instability of the lens. If an AC was very complex, very small, something like that, that would make me not be able to phaco it, I think. >> HUNTER CHERWEK: Two more quickies. Was this patient under local anesthesia or was there a retrobulbar block? >> JAMES LEHMANN: I did the block. >> HUNTER CHERWEK: You did block them, okay. What influences the choice of silicone versus acrylic IOLs? This is from Dr. Ini. They want to know what influences your choice of silicone versus acrylic, that will be our last question, you need to go and I’m going to jump a 15-hour flight to Mongolia. >> JAMES LEHMANN: Awesome. Yes, if it’s going in the bag and the rhexis is intact, you can do acrylic. Otherwise do silicone, that would be my advice. If it’s going to go if the sulcus, silicone is better for the iris. Acrylic I only like, especially one-piece acrylic, if it’s an intact 360 anterior capsule and you know it’s going into the bag. >> HUNTER CHERWEK: Dr. Mohammed asked if you used the — >> JAMES LEHMANN: I don’t do that, no. It’s nice. >> HUNTER CHERWEK: That’s one of the factors you consider, how dense is the nucleus, how sick is the endothelium, are there zonular concerns. I think it’s a constellation, not a single thing. If you’re ever not comfortable or there’s a risk factor you can’t control, then absolutely. I know — how are we for time? >> JAMES LEHMANN: We should probably be wrapping it up. >> HUNTER CHERWEK: Okay. Dr. Lehmann, can’t thank you enough. I want to thank our audience, this is absolutely great. We answered 45 questions for you, Dr. Lehmann, you owe us. We want to thank you for doing the Bob Ross narration, you kept your voice very calm and smooth. The thing I loved was how you trouble shot, when that last little piece was coming, you thought through the problem, you didn’t rush or get frustrated. You went through a checklist of what is going on, why is this not working. Certainly I want to give you a shoutout for staying cool, calm, and collected and thinking through a problem and not getting frustrated or jumping to a solution that, you know, may not have existed. So thank you all. I really want to thank both Andy and Lawrence from the Cybersight team for staying with us. Dr. Lehmann, I want to thank you, I know you’ve been traveling a lot, good luck with the rest of your cases today. >> JAMES LEHMANN: Thank you very much, thank you Orbis world, appreciate it.