Live Surgical Demonstration: Divide and Conquer Cataract Techniques

[Hunter] I’d like to thank our Cybersight community for joining us today. We’re very lucky to have Dr. James Lehmann from San Antonio, Texas. He’ll be joining us in surgery demonstrating two phaco cases to stress the fundamental techniques that every phaco surgeon should know. We’re going to start with a lecture, then we’re going to do a live case, finish the lecture in between the cases, and then have James demonstrate the entire case from beginning to end as the second case. Again, I want to give a warm Cybersight welcome to Dr. James Lehman, joining us from Texas. Dr. Lehmann, how are you today? [James] Hi, Hunter, thank you for that introduction. I’m doing well and hi to everybody in all the different time zones. We’re in San Antonio, Texas and I’ll get started with the lecture. Again we’re going to be talking about live cataract surgical demonstration. A little bit about myself, I’m an ophthalmologist, a cornea and cataract specialist in San Antonio, Texas. I used to be an associate ophthalmologist on the Flying Eye Hospital about 18 years ago and I’m a volunteer faculty for the plane now. No relevant financial disclosures for this talk. We’re going to start with a few poll questions to get an idea where everybody’s starting. Lawrence, if you don’t mind pulling up the poll. I have performed phacoemulsification 1. Never, 2. 1-20 cases, 3. 21-100, or 4. More than 100. [Hunter] And Dr. Lehmann, even though you’ve done thousands of cases, you’re still using this technique. So certainly this is something that everyone should learn and have in their armamentarium. We see a good divide here. We’re about a quarter of never done phaco, a quarter have done 10-20 cases. A quarter have done between 20 and 100 and then about a quarter have done under 100 cases. So we have a wide spectrum of experience, but it’s great that you’re going to demonstrate all the fundamental techniques that every phaco surgeon should know. [James] Yeah, I think the divide and conquer is a baseline technique that everybody should learn. And then if you find that you like stop and chop, flip, all these different techniques then you can go on from there. But this is a good foundation for everyone. Here’s a question about phaco. Where should you perform phacoemulsification of the nuclear pieces? What part of the eye? In the capsular bag? In the iris plane? In the anterior chamber or in the vitreous gel? Of course, we’re talking about divide and conquer in this technique. You guys go ahead and put your answers in. But this is a good thing because when you’re watching my case, you’ll see where I leave the phaco tip when I’m eating up those quadrants and what plane you want to be in. I want to tell you ahead of time because you can’t tell that just from looking at the video. In the capsular bag. The iris plane is the correct answer. I’m glad nobody put the vitreous gel, that would be problematic. But the iris plane is where you want to be. Not too high, not too low. If you’re up too much by the cornea, you run the risk of getting a lot of corneal edema, eating up that viscoelastic you have. In the capsular bag there’s not so much room and you have the fear that the capsule will come up the phaco tip. Another question here. This goes into a little bit about how we take care of your patients. Which of the following has been shown to reduce the risk of endophthalmitis? We’re talking about shown in a randomized controlled trial. Topical antibiotics after surgery, oral antibiotics after surgery, intracameral antibiotics during surgery, or subconjunctival antibiotics during surgery? Which of these has been shown to reduce the risk of endophthalmitis which is our most feared complication? We’ll see the results here, intracameral. Okay, so y’all got that one right. That was shown from the Aravind group in a huge study of tens of thousands of patients over the last year. The only other thing to my knowledge that’s been shown to decrease the risk is using betadine before the case. And then the last question here is the ideal size of the capsulorhexis. Do we want it small at four millimeters, do we want it bigger than six or do we want it five? What size is the optic and how does that relate to the size of the capsulorhexis, so go ahead and plug your answer in here. Different lenses come in different sizes but most commercially available IOLs have six millimeter optics. Okay, so five millimeters. That will be our goal. And so people can use markers on the cornea if you really want to get it the right size, the deal with the magnification of the cornea. But five millimeters is the correct one. These are the objectives we’re going to go through today. We’re going to understand the steps to perform phaco, we’re going to learn the proper ways to do it, and then we’re going to talk about how to avoid and manage any complications. Okay, so phaco is like a house of cards. This is something my boss told me when I was in residency. The first step is patient preparation, then we’re going to make the incisions. If you don’t prepare the patient properly, or you don’t make the incision right, it makes every subsequent step more difficult. So that’s what I’m saying when you got to do everything right so that you have a chance to have a successful, quick, efficient case. The steps we’re going to talk about are preparing the patient, making the incisions, doing the capsulorhexis, then performing hydrodissection, and then nucleus divide and conquer, removal of the cortex, and then implanting an IOL. And then lastly, sealing the incisions and then putting some intracameral antibiotics. These are the steps and we’re going to talk about half of them before I start a case. Here’s a video of a routine case in our center where the technician is prepping the eye and putting the drape on. You see I have the patient’s head taped and then we put betadine around the eye, covering the nose, down the cheek. And then they’re spreading the little plastic with a little bit of a drape support underneath so the patient’s not just mouth to that plastic. And then carefully the technician’s removing a little window there, making a slit across the palpebral fissure and then we’re going to put a nice speculum. The important things here in the US, most of us operate temporally. In different countries people operate differently, but I find that for phaco surgery, temporal is the most comfortable position. You want the patient comfortable so sometimes that can just be topical anesthetic. But it can also be a block if that’s your custom. If you don’t position the patient right, if they’re rolling their eyes back, if they have their neck arched, then you have a difficult view during the case, it prolongs the case and if you don’t have good visualization it increases the risk of you doing a complication during the surgery. Also if the patient’s not comfortable, they’re going to be complaining and moving and putting their hands up to their face during the case, which makes everything harder. In terms of anesthetic, the majority of cases we do are with topical anesthesia but with some IV sedation so the patient’s relaxed. But it’s okay to do them with a block, especially when you’re learning so that you have more comfort and better exposure. The first case I’m going to show here, I blocked the patient because the patient is going to, had a little hard time keeping his eye closed. Open, excuse me, he’s quite a squeezer. We did that. It’s also a very dense cataract and so I know that if I’m going to have a problem, it’s better to have the patient blocked. Lastly, you can’t ignore your own comfort. You need to be sitting with a straight back, you can’t have your neck bent over too much or you’re going to start getting neck and back injuries which are very common for ophthalmologists. And lastly, you have to do a good sterile prep, so the circulating nurse does that here in our center. And you have to do it with three betadine swabs, and go in a spiral fashion outside of the eyelashes. Talking about the incision, you’ll watch me in this first case. It’s a two plane, I like to use a double bevel knife, I like to go temporal and I do it in one motion. You make a little nick and then enter at the same time. And you’re shooting for a square incision. You can nick some blood vessels so that you know where the incisions are. First the paracentesis and also the main incision. What happens if the incision is made poorly? The first one here shows good form. This is where you have a rectangular type incision, it’s great for sealing, not too short, not too long. If you look below the surgeon started that incision too much anteriorly. And that causes poor sealing, it causes more astigmatic effect, and it also makes your job harder during surgery because you’re going striae away from the incision that makes things difficult to view. Here’s a side view of that, a good appearance of a square or almost rectangular little incision there is equal thickness of the roof and the floor of the incision. If you do it poorly and you push down too hard you get a real shallow roof and a real thick floor and that looks like a chevron from above. And then you want to go straight in and straight out. If you wiggle it or you go left too much you’re going to have too wide of an incision, you’re going to have too much astigmatic effect, or you’re going to have a leakage. If you make the incision too short like you see in the bottom there, you get poor sealing, if it’s too long, again, you get restriction of the movement of the phaco tip as well as difficulty visualizing the case. Here’s a video of me doing the main incisions on a patient. First, this is the paracentesis. The first patient we’re going to do today, this is his first eye. I did this surgery two weeks ago, very dense cataract. You can see me making my first wound there. Rinsing out the VisionBlue and then putting some viscoelastic in. I like to put viscoelastic in before I do my main wound otherwise my main wound sometimes turns out to be too long if it’s a softer eye. There I’m stabilizing the globe with the point one twos and entering. You see right here you can see the paracentesis and the main wound. Look at the locations. The main wound is basically temporal and then it’s about three clock hours, the wound for the second instrument. And I like to push the tips of the point one twos together to fixate the globe when I’m doing the main incision like that. Again, right there, bury the head and then one motion right there. For the capsulorhexis, this is a different case, obviously, very mild cataract. I like to score and then I start the capsulorhexis with the cystotome and then we use, I like to use Utrata forceps. And this is like walking a dog. You’ve got to be leading that in the next direction that you’re going to go. And this is definitely one of the harder skills to learn when you’re doing cataract surgery. Some helpful tips are to use Utrata forceps. The other thing is to fill the eye nice with viscoelastic so you flatten out the anterior capsule as much as possible. And you’re shooting for that round capsulorhexis. Here’s a more difficult case, this is a capsulorhexis in that same patient I was just showing you. In a mature cataract, sometimes there’s a lot of pressure inside the capsule. I always start my rhexis small in these cases and then spiral it out. You can see me, VisionBlue helps a lot, of course, but you can see me leading the rhexis here and then I’m not going to stop it, I’m going to keep going around on top and extend it nasally there to make it bigger. You still want a five or six millimeter rhexis on these cases. If it’s small then you have a hard time getting those big old nucleus pieces out because that’s what it’s going to be in this situation. There’s a mature cataract. And again, this is illustrating hydrodissection. Once we’ve done the capsulotomy, we want to insert a cannula right underneath the anterior capsular leaflet and inject fluid to free up the nucleus. Now, the key thing you don’t want to do in hydrodissection is flush too hard because then you get a lot of pressure coming out of the eye and you get iris prolapse. If you don’t flush enough you don’t get a good wave. Here’s an example of, just right under there you see that first wave and then that’s a nice wave right there. Then you know that that nucleus is free. And I like to even do a little more for demonstrating here and then rotate the nucleus myself prior to starting phaco so that I guarantee that that thing is mobile. So here I go and I’ll try to rotate a little. Now I know it’s freed up and then I’m not going to have problems later in the case. In a mature cataract, here’s a tip that you can take home. You don’t really have to do much hydrodissection. Those things are already free because the cortex has been pretty much liquified. I just put a little bitty because this was stuck to the anterior capsule there. I just free it up very little. You can see I can move it already just with that little amount of hydrodissection. With that we’re going to go ahead and go to the live surgery. I’m going to get draped up and we’re going to start here. You take over for a little bit, Hunter. [Hunter] Yeah, thank you Dr. Lehmann. Certainly there was a lot of great things that were said there. And I want to remind the entire audience there’s no small steps in phaco. A lot of times people will make a really quick wound or a really quick paracentesis and then the paracentesis leaks the entire procedure and you’ve got an unstable chamber, you’re constantly fighting a prior mistake. Also you saw James was always centered, always in focus. I find a lot of doctors will do the entire phaco case and never change their zoom or their magnification. Visualization is critical. You saw him use a lot of OVD. Don’t forget the D stands for device. Dr. Lehmann is going to be using OVD just like an instrument to move things around the eye, to fill the eye, to firm it up as he makes his wound. And the last thing I’m going to say before he starts his surgery, is you saw him do a beautiful hydrodissection and then that rotation. That rotation is going to free up more of the adhesions and make quadrant removal even easier as the pieces are already spinning freely. Dr. Lehmann, are you ready to hand over and start the case? [James] I’m ready to go, yeah. [Hunter] Perfect, over to you, sir. [James] Thank you. Okay guys, you can see here the patient has a mature cataract. In our surgery center we do a time out before every case to confirm the eye. We have a left eye prepped and then we have a 21 diopter lens. We confirm that. We normally do that before we sit down. But just because of the webinar here, we did it when I was sitting. Everybody have a good view, we can see, and we can hear me? [Hunter] Everything is crystal clear. [James] Sir, you’re doing okay? All right, I’m just asking the patient, he’s doing fine. We saw his other eye in the presentation. It was a very dense cataract. This is the same but there’s always two kinds of dense cataracts. One is soft and one is hard. The other one was like a rock and very leathery. This one, it looks like to me, that it may be one of those soft kind of mature cataracts but I may be rethinking that in a few steps here. Let’s make our paracentesis. Some surgeons look for a very prominent vessel to know where their paracentesis is or another trick is just to go and nick a vessel a little bit so that you get a little bit of bleeding like that and you can know where to go back so you don’t lose that. You also want to make that incision in the iris plane, not down. And then this is some lidocaine with epinephrine to help with dilation a little bit and then we’re going to do the VisionBlue next. This is the VisionBlue or Trypan to stain that capsule. And then you don’t have to put any air bubble or anything in there. I know I had that on the last case but that was just an accident because there was a bubble in the cannula. You just want to let it sit for a little bit. And then we’re going to rinse it out. This also helps mark your paracentesis, you’ll see after I withdraw this cannula that that paracentesis is nicely marked. And then just to be neat I want to get some of that here of the rest of the eye. You can see the paracentesis, it’s very easy to see there. Now we’re going to inject our viscoelastic and we use two different kinds. The first is a dispersive and last is a cohesive. I want to show you that there’s a little plastic safety thing here on the viscoelastic cannula. If you don’t have that you need to hold it at the neck here so that when you inject the little syringe cannula part doesn’t go flying through the front part of the eye. This has a safety mechanism so I don’t have to stress about that. And so when I inject this, I go all the way across the eye and then I start injecting and you’ll see it’ll start clearing away the rest of that Trypan Blue and that little bubble I had there. Now we have a nice, deep chamber. Now we’re going to make the main wound. I’m sitting temporally like I said. And then I close the tips of the point one two, inserting in my paracentesis, and I’m going to go right at the limbus. I’m going to put a little entrance there and then a nice single move and I got a nice rectangular, almost square incision. Now we’re talking about the rhexis. This is a delicate part in the mature cataract. What I’m going to do is I’m going to start small because sometimes there’s some pressure in here and it’s going to want to go out a little bit. I make a nick, I go across, and I’m starting kind of small. Now this looks like it’s going to be a dense cataract, not the soft kind. The soft kind you’ll see a lot of cortex, fluffy stuff come out. But we’ll still start out small here. I’m grabbing the little leaflet I made and I’m kind of dragging it here. You can see I’m always one step ahead. I’m wanting it to go left but I’m already pulling down. You see? Now I’m wanting it to go down and I’m already pulling right. You have to be one step ahead of the rhexis. And you want to start small because these have a tendency to want to run out. You want to be about two millimeters from where the tear is engaged. And then keep on going, keep on going, now I’m going to do that little spiral thing like I showed you in the video. So now I’m spiraling it and then we got a nice, about a five millimeter rhexis, pretty well-centered. And now here’s that part about that hydrodissection. You don’t always have to hydrodissect a mature cataract. I’m just going to put a little bit of fluid there. You can see stuff moving a little bit, kind of stuck down. Just see if we can spin it around a little bit. It’s not moving great, I’m going to put a little bit of fluid. Now we’ll try to turn it. There we go, we’re able to turn it. See, just with that little bit of hydrodissection. Now I got the phaco. Now let’s just look quickly at the phaco tip I’m using. It’s called a Kelman tip or a 45 tip. I’m using the Johnson & Johnson phaco machine. You can see that’s a 45 tip with a little bit of oval ostium there. And it’s 45 degrees. I like that because it cuts very nicely. Let’s put it on dense setting, Sylvia. I have two settings on my phaco machine. One is standard and one is dense. [Sylvia] Okay. [James] I’ll center the camera here guys, in a sec. Let me know if it’s centered nicely. [Hunter] Yep, we have a pretty good, James. [James] I’m on divide and conquer here, I’m just going to make a central groove. You see I’m clearing a little bit of space in the same size as the rhexis. And then I’m kind of clearing some. It’s cutting okay, it’s not the most dense cataract in the world, but it’s still fairly dense. Now what size groove am I doing here? This is about one phaco tip. You can go one and a half if you want. I can make that a little bigger here. That improves your visualization, gives you a little better. I’m going to clear a little viscoelastic there to improve y’alls view. And then I’m going to keep going. I’m only using phaco power on the way down. And I want to see the edge of that groove. And how far deep do I go? This is a good question. You really won’t see a red reflex in this situation. But you go down until you start seeing a change. You can see that that looks slightly different down there at the bottom of that. If you start to see little lines going perpendicular to your phaco tip, you know you’re in the right depth. I think I’m at the right depth there, I’m just going to go a little more here centrally. I think I’m about 80%. I’m going to put in my second instrument which is just a horizontal chopper. You can see it’s blunt at the tip. Go through my paracentesis. And then I’m going to try to crack. So we got a good crack there. You see that. Now I’m going to eat some of that. You can look at the depth. You look, maybe we’re at about 80% right there. So that’s good. Now I’m going to rotate. That helps to guide you on the next grooves because you know what the depth is. We’re going to start at the top here, that’s a real… We’re going to go down to that same depth. Okay. We’re good, we’re almost at that same depth. Now it’s easy to get that next piece. Then I just keep on moving. Now I’m moving to the next quadrant. Very methodical, no excessive movements. Now we’re just going to do the same. Really getting the first crack is the hardest part. I’m at the right depth, here’s a little fragment, I’m going to get that out. That’s just a little debris blocking our view. Now you can see I’m at the same depth. Crack that bad boy like that. There you go. Now we’re going to rotate again. These are the last heminucleus there. And I’m not taking any of the quadrants out, you can do that if you want. It saves a step, but in a mature cataract I like to get it all in the four quadrants like that. Now we know we have the quadrants free but they’re kind of locked in like little puzzle pieces. But I know this one, here to my left, is totally free. I’m switching to peristaltic quadrant mode and then I’m turning the phaco tip 90 degrees like that and then I’m putting it to completely occlude the ostium of the phaco tip, and then now I’m not increasing my vacuum, I’m just pulling out that little piece. And you can see it’s stuck there, no, here it comes. It’s freed up and then I’m just going to push on the pedal, 80%, get it up a little bit. See I’m right in the plane of the iris, maybe slightly superior to it. And I’m not really moving the phaco tip. You have the right settings on your machine and the little guy will just dance on the tip there. Now we have this piece that I can get. It still looks like it’s attached a little bit. Instead of trying to do an awkward movement like this, I’m going to move it where it’s directly across from me. And now I can put the phaco tip all the way into the groove and just break it a little bit more apart. That one’s still stuck, I’ll try this piece. That looks better. So I’ll take this one out. Peristaltic quadrant still. I’m going to bring this guy up. They may be attached down at the very base of the cataract. And see how I’m not really moving the tip much? Even my second instrument I don’t have to move too much. But I use my second instrument, I’m stuck in this position, I’m going to push the piece away again and then come back to it with my phaco tip. I’m just doing a medium amount of power here and nothing, I’m not flooring it, I don’t want to see too much movement, too much stuff happening. I like this piece, I’m going to push it back. I only go and grab things that are across the chamber from me. I don’t go trying to grab here, I don’t go trying to grab there. Just across the chamber. I’m going to lift that little piece up, eating in the iris plane. It’s kind of attached to that last piece so it’s going to come up as I’m eating this quadrant. And now, how do I get this one? I’ll stop phacoing, I’ll move my second instrument and I’ll throw it back in front of it like that. Not twist my phaco tip around and try to do gymnastics with it. And then here we’ve got the same thing. Just this last little piece and then modern phaco machines you don’t have that post occlusion surge like you used to have where you’re getting that last piece and then everything comes forward. But now you can see we’ve gotten the cataract, great red reflex and just minimal cortex, minimal cortex. I’ll remove this, turn off the continuous irrigation and now we’re going to put the I/A on just for those last little cortical fragments there. Little cortical debris. [Phaco machine] Continuous irrigation on. [James] Now this is the I/A handpiece. I’m going to go around and remove some of the dispersive viscoelastic, especially in this area of arcus where little pieces, you see that little piece was hiding right there. You’ve got to go in that area to make sure you get all the little fragments that causes post op inflammation. And then just the stuff that wants to come out, like this, that’s easy peasy. Go get that stuff. You don’t have to go vacuum in the capsule, the central part of the capsule’s clear. Just these little cortical remnants that are there. And this will just help with cleaning up that capsule. But I don’t need to go subincisionally and get much here, maybe a little bit of that cortical debris. It’s kind of hard to get, there you go. We can get it maybe once the IOL’s in, that’s another choice. You just want to grab the capsule there. But then it moved away so we’ll go ahead and put the lens in. I’ll get the viscoelastic. Now this is a cohesive viscoelastic, it doesn’t have that protection over the cannula. I’m grabbing it here so that it doesn’t go shooting around. We’re filling the hole from part of the eye now expanding the capsule. And then this is just a one piece acrylic lens. It’s a Johnson & Johnson AAB00. And of course this cataract was so dense we had to use ultrasound, but normally we would use just a normal biometry. And then I use, this is called a push/pull. People use different instruments for this, but I like this. And then basically we’re just going to push down and you’ll see that it will tuck itself into the capsule. Now I’m centering it, and then I’m just going to make sure this haptic’s not stuck on the optic, so I just do that. Now we’re good. Now looking at that size of that rhexis it was probably more in the four millimeter range. Could be a little bit bigger. Now we’re going to remove the viscoelastic. Our setting’s on just called Visco, that just means it’s going to have high amount of vacuum. And look, I just stay here in the middle of the eye, I don’t need to go chasing stuff just quite yet. We get that, we make sure all the viscoelastic’s removed around the IOL, push gently on it. Now I’m going again in this area near the angle to make sure there’s no nuclear fragments. And it looks good. Nothing’s coming. I’m getting constant flow there. Now we’re done and now we’re going to do hydration of the wounds. My first medicine, that’s this one. This is dexamethasone with moxifloxacin and then this is just BSS. With the smaller TB syringe, I’m going to go in, inject some of that antibiotic and steroid, and then use the rest of it to do some stromal hydration of my paracentesis there. And then I’m going to close my wound with stromal hydration. First I go on the right side of the lip, you want to see that whitening of the stroma. And then I go on the left side of the lip. You want to see that whitening. And then I go into the roof of the incision and you want to see some whitening there. Thank you guys for the case there, Steph. All right, sir, everything went well, okay. Thank you. [Hunter] First of all, beautiful case. You demonstrating everything nice and controlled. One question we had was what is your opinion about doing bimanual I/A? I know you did the cortex removal coaxial I/A. What are your thoughts on bimanual? [James] I have used bimanual when I’ve traveled to different places. I find the chamber isn’t as stable because you can’t get enough inflow through the size of the ostium on the bimanual. I feel like there’s a lot of ups and downs with the chamber. I never really liked it. Some surgeons love it, if you got it and you’re good and you have good machines, there’s nothing wrong with it. It’s easier, sometimes, to go get that subincisional stuff with bimanual. It’s just I never really had a need for it. The coaxial works nicely. [Hunter] I think that that’s just surgeon comfort. I don’t think one’s better than the other. This is what’s best in your hands. Another question was do you prefer continuous irrigation? [James] I do, yeah. The original phaco machines, they didn’t have that option. If you’re over the age of about 55, those surgeons never knew how to, that there was continuous irrigation. I love it. Before I go in the eye, I kick to the right on my pedal and it starts to flow in. Then I don’t have to keep my foot in the position one. In the old days, position one was fluid, position two was vacuum, and position three was phaco and vacuum. I like the continuous a lot, yeah. [Hunter] And I know you’re going to be getting your lecture ready because you want to demonstrate the next. One quick question that we had was what type of mydriatic do you use before surgery? The iris is always your enemy during cataract surgery and OVD is always your friend. With the mydriatic, how did you get that nice pupil so wide? What did you give preoperatively? [James] We give Mydriacyl and phenylephrine 2.5% and 1%. We do three rounds six minutes apart. This patient was blocked so blocked patients they dilate even more. So that’s why it was a nice, round pupil. If that doesn’t work, in some patients we’ll use 10% phenylephrine if their blood pressure is not high. [Hunter] Dr. Lehmann, I know you have slides. So we can certainly go to those when you’re ready. We also have a few more questions. Had a great question from Armenia about how do you prevent posterior capsule injury. How do you prevent a rupture of the posterior capsule? Staying in control, using OVDs, staying in a safe plane. What are some of the tricks you’d recommend for avoiding an injury to the posterior capsule when you’re starting phaco surgery? [James] I think the number one thing is you have to be able to freely rotate the nucleus. If you can demonstrate that you can rotate it before you start divide and conquer, You have a much lower chance. I see people tear the capsule because they’re pushing too hard to do the divide and conquer because they can’t rotate the lens nicely. If they’re rotating and they’re just forcing it, you can tear the capsule that way. I actually rarely ever see anybody eat it with the phaco tip. That’s rare to see somebody eat the posterior capsule with the phaco tip. But that’s another way you can do it. That’s why you want to eat the quadrants in the iris plane and not in the capsular bag. With that I can do a few slides. [Hunter] Yeah, when you’re ready with your slides. I think it’s a great question from Armenia because I think everyone is always worried about a posterior capsule rupture and it goes back to planning. You’re not going to continue the operation until you get good rotation. You’re not going to continue and try to do quadrant removal until you get a good crack and you get the pieces freely mobile. And so certainly I think you demonstrated a lot of safe techniques, especially where you’re applying your phaco energy. I’m going to hand it over to you, Dr. Lehmann, to finish your slides while we wait for the second patient to be prepared for the next surgical demonstration. [James] We’ll go back to the slides here. We watched a little bit of divide and conquer. On this slide you’re seeing me clear an area that’s about a millimeter or two deep and then I’m making that central groove. What I want you to get out of this video is the depth. You’re going to see me go and then stop. And then when I stop, I’m looking at that red reflex and I’m seeing I’m not down far enough. And how do I know? Because once you see those little lines, those little bands that are there, that tells me I’m at the right depth. Nobody ever taught me that when I was in phaco, when I was a resident. But I find that that’s a good way to know you’re about 80% depth. And you’ll see that on all cataracts except mature ones. And so once you do that, you can do that fracturing. And then once you’ve done the first fracture, the other ones are easier. So there we go. And then this is that last part and so you guys watched this. Remember how I said you always go across the chamber to get that nuclear fragment. You don’t want to be rotating that tip and stick it in funny positions and stuff, you want to always go across the chamber there. See how I moved that piece and then I get it. I don’t go try to grab it straight over in that area. And then this is just removal of those nuclear fragments. The last piece. Sometimes they talk about using your second instrument to protect the posterior capsule. I think with modern phaco machines that’s not needed. In fact, you can remove it and it’s oftentimes more stable just with the phaco tip only in the eye. Here’s a difficult divide and conquer. This was the right eye of that patient you just saw me do cataract surgery on. I did this two weeks ago. And you see I can’t crack it. You see I’m trying to crack it? This one was even worse, this cataract was even worse than the one I just did. The one I did was dense but it was doable. This one, the first eye, every time I went to try to crack it, it just wouldn’t. The base, the plate of it wouldn’t crack. It was very leathery. And I could rotate it. If I can’t crack it in the first go around, then I rotate 90 degrees, and then I try a second part. There I was able to get a crack. But it kept having a hard time judging the distance. And even here I can’t separate that leathery plate stuff there. This is where things get dicey and you can tear the capsule by stretching too much where you do the openings there. I still have trouble trying to get that last little quadrant free. Finally I think I’m able to free it up and then I go into the quadrant mode and I’m going to try to withdraw it here. See me struggling. Let me see here. Now we’re going to go try to remove it. With my left hand I’m holding back that part that it’s attached to hoping it can peel up. I freed up one quadrant. Once you free up a quadrant, you’re good. But I couldn’t crack the other one. I had to bring a whole heminucleus up into the AC and then I started just doing phaco fragmentation chopping technique. That was a lot harder one than this one I just did. And then was fortunately able to not tear the capsule and get a lens in and everything. Again, the take home point on this is you got to get up at least one quadrant. And then once you’ve done that if you can’t break it anymore, bring that whole thing up like a lollipop in the AC, even put in extra viscoelastic, this is what I did in this case. And then use that horizontal chopper to break it up into pieces if you can’t crack it. These are going to be cataracts, these are things that I’ve seen when I’ve traveled to Africa or to Central America, patients with very severe, leathery cataracts. Those are really the hardest ones. Cortex removal. A take home tip on this is to have the chamber nice and deep and then you can tweak your settings on your phaco machine to make this very easy, where you can tease it and eat it at the same time. When I first started doing phaco, I would always go get the subincisional cortex first because that’s the hardest one to get and you’re most likely to get the capsule in that scenario. When you’re learning, it’s almost better to do the first part getting subincisionally, which is not what I’m demonstrating here but do what I say and not what I do. Once you go the subincisional part, if you do that first you have a much less likely chance you’re going to pop the capsule. We removed all the cortex there. And then the last step is insertion of the IOL There’s not much to this except you need to hold the IOL inserter if you’re right handed with your right hand like a pencil and then twist the corkscrew with your left. Then use that second instrument to dial it into the bag and then free the haptics up. Remove the rest of the cohesive viscoelastic like you just saw, and then seal up those incisions. I like to do that stromal hydration. And if there’s leakage, don’t hesitate in putting a suture in. There’s nothing wrong with that and you just take it out at a week. There’s that part. And again, we like the moxifloxacin with dexamethasone. Some common mistakes for beginners is the poor patient positioning. Remember I talked about that. If the patient’s head is too tilted like chin down or chin up, then you have poor visualization and you won’t do a great job on the case. If you make your incision too long or too short, you have problems. If it’s too short, your wound leaks. If it’s too long, you got too much astigmatic correction or you have distortion of your view during the phaco case. If you make the rhexis too small the case is much, much harder trying to get pieces out. Rather make it too big than too small until you get comfortable making that five millimeter rhexis. Incomplete hydrodissection. Remember, you need to demonstrate that you can rotate that nucleus before you move onto the divide and conquer step. And then don’t get too fancy too soon. I would say you need to get 100 to 200 cases under your belt, divide and conquer, before you go and try the more advanced techniques. And the last thing is keeping the eye in primary position like Hunter was talking about. If you move the eye around too much, you’re going to make your life hard because you won’t be able to visualize what you need to be seeing. A few pro tips for y’all. When you’re making your paracentesis, nick the blood vessels going in at the limbus so that you know where your paracentesis is. When I used to staff cataract cases, the number one thing trainees would do, they could never find their paracentesis, nick the vessels. Hold the collar of the cannula when you’re doing the OVD injection so that it doesn’t go flying across the AC. Try to make that main wound a square or slightly less than a square. And in a mature cataract, start with a smaller capsulorhexis. Like I demonstrated in the last case, you don’t necessarily need to hydrodissect mature cataracts. When I was a second year resident, I’ll always remember this case. I had a mature cataract and I forcefully injected the hydrodissection and the nucleus just went boomp. I didn’t even get a chance to do the case, it fell to the back of the eye. They have fryable capsules so you do not want to be aggressive with hydrodissection. And the last tip I’ll leave you with, I’ll call it Lehmann’s Rule. You want to make that central groove until you see the little stripes that go horizontal and that tells you you’re at 80%. We already did these questions, you were good the first time, I don’t think we have to go over those. I’ll just show the last slide and give thanks here. I want to thank you all for your attention and we’ll turn to more questions now. [Hunter] Yeah, Dr. Lehmann, one of the first questions. You mentioned this in your pre survey question. At the end of the case you were using dexamethasone with antibiotic. How do you prepare that? How is your staff preparing that combined injection for you and how are you giving that? [James] We have to get, in the US, we can’t split the doses or anything. We get it already premixed and shipped to us. If you’re preparing the moxifloxacin on your own, you can either use Vigamox derivative that’s been verified to be okay, and you basically dilute it into just a cannula for each case. But you do still need to dilute it somewhat. I don’t have the paperwork to tell me the exact dilution. [Hunter] Let’s follow that up, we can answer that question offline. But yeah, I just want to make sure people know that they need to prepare these. This was in a compounding pharmacy. [James] Yeah, ours was sent to us already in a little ampule for the case. [Hunter] Exactly. It’s done under sterile conditions and this is something that you really need to get right and make sure your nursing and technician team know. [James] That’s correct. [Hunter] One of the questions that was asked, you had beautiful chamber stability that’s because your wounds and your paracentesis were so nicely done. The question is, what if you use a 20 or 21 gauge irrigation and a 23 gauge aspiration for chamber stability during bimanual I/A or during I/A. You were saying how during bimanual I/A sometimes there is a mismatch of inflow and outtake. Have you ever heard or would you recommend trying to mismatch intentionally the two ports? [James] No, I haven’t tried that it sounds like something that would be worth trying. You do have the different incision sizes though and then you can’t switch them around. It kind of defeats the- [Hunter] Exactly. I would be concerned about leakage and also you have to really be a master surgeon to be innovating like this and I think that goes back to your first point, you don’t innovate until you get comfortable with the fundamentals and you’re really rock solid with your technique. I’m sure what Dr. Amin is recommending here is fantastic in their hands, but I think when you’re learning to try to do a mismatch in a bit of a Frankenstein design for I/A would be very difficult for a learning doctor. Again, one of the questions you talked about is why are you using the injection of dexamethasone and antibiotic and not the drops? And I think you talked about this at the beginning of the lecture about why the intracameral or how you’re delivering antibiotics has been proven to have better efficacy in preventing endophthalmitis. Could you comment more on that? [James] Right. Drops haven’t been shown to prevent infection but intracameral injections have been, specifically moxifloxacin like I was mentioning at the Aravind Eye Health System in Southern India. That pretty much in the US most surgeons have gone to some sort of intracameral antibiotics. And then the dexamethasone to just make the eye less inflamed, happier on post op day one. [Hunter] There’s a question from an anonymous attendee about what is the visual acuity to ascertain the maturity of a cataract? And really that’s more of a clinical diagnosis and while Dr. Lehmann is operating, I’ll try to send a link. The LOCS score, how brunescent, how brown in that cataract? There is no cut off or a visual acuity to define maturity, it’s more by the grade. And certainly you can have a soft cataract which I see Dr. Gomer Azera has asked about. You can have a soft cataract like a posterior subcapsular cataract and that can cause severe vision loss in patients. Really it’s hard to ascertain the maturity of a cataract based on its visual acuity, it’s more by the clinical appearance. I saw there’s a great question and Dr. Lehmann’s probably going to answer this again about where does he prefer to make the main incision. He often does it temporally, that helps relax the normal astigmatism that most patients have but also with patients with a high brow, that gives you better access. Again, the two things no matter if you’re doing orthopedic surgery or ophthalmic surgery, you want visualization and exposure. You always want to keep in focus and you always want to have the best possible exposure. And so that’s why Dr. Lehmann goes temporally. I think Dr. Muhammed, I just want to make sure you know, certainly you want to stay comfortable, Dr. Lehmann talked about that, that the surgeon has to be comfortable to do great surgery. But often the temporal incision is the way to go for better access and also it does create a little bit more relaxation of an astigmatism. Dr. Lehmann, I see you’ve got this next patient ready. We’re in perfect focus. Can you hear us okay? [James] Yeah, I can hear you, can everybody hear me? [Hunter] Loud and clear, sir. [James] I may speak in Spanish a little bit, the patient’s Spanish speaking I’m just going to ask how he’s doing and if everything’s okay, all right? (speaking Spanish) This patient is monocular, has a pretty bad cataract in this eye. And he opted to start with the laser. We have already done the laser fragmentation. I just wanted to show you all this, kind of to contrast a typical cataract surgery and talk about some differences here. As you can tell, there’s a pattern there, it’s like a target with some cylinders. This allows me to break it up a little easier. You also see a pattern of an air bubble in the back there. A lot of hydrodissection is already done. It’s like a numodissection, it’s done by the laser. And that makes it a little easier to do that next step. And then on the cornea there are some arcuate incisions to help with his astigmatism. This patient, as I was saying, is monocular and he was very nearsighted. And we chose to leave him slightly nearsighted still because he is going to be monocular. We want him to wear protective eyewear. We’re going to leave him around minus two, that’s the idea. This is done under topical anesthesia. (Speaking Spanish) All right. I’m just fixating the eye with a Q-tip and then I’m going to go in my typical position here. I’m going to try to nick a vessel like I talked about. A little wider so you can see the nicked incision right there. He moved a little bit, a little wider incision but totally fine. And then we’re going to inject, this is lidocaine to help with pain. (Speaking Spanish) I know he’s going to feel a little burning, I like to tell him. And then that’s the lidocaine with epinephrine, commonly called Shugarcaine. This is the viscoelastic, the dispersive. And I’m going to fill the AC with that. And then I’ll use Utratas, okay, Addie? Now we’re going to fixate the globe again and go temporally here, bury the tip right there a little bit. And then in. You can see that, no problem. And then we’re going to use the Utrata forceps, I’ll get focused in here a little better for y’all. You can see the cap is kind of free floating right there. And then I’m just going to remove it from the eye, there we go. And now we’re going to do some, there’s a little debris here on the cornea, I’m going to wash that away so y’all get a better view. And then we’re going to do some… We’re going to do the hydrodissection now. And you’ll see that I just have to put very little under that anterior capsule leaflet. And then I push down and the bubble’s going to come. That tells me I’m pretty much freed up already. I’ll rotate around for you guys, let’s say a little bit more. And then push down, okay. He has a really dense central cataract but the cortex is pretty loose. But you can see there I’m able to rotate it slightly. I’ll show you. You can always go back and hydrodissect more if you have to. And that’s a good tip to do. Here’s another tip, you want the phaco tip exposed about that much and then I’m going to go above the eye and just rinse the eye a little bit and that allows you to get some of the oily surface film off. And I’ll get you nice and centered here. Now, I’m going to my second foot position and I’m just going to remove these bubbles and then a little bit of that cortical debris to help clear up the view a little bit. Now you see a bubble over here, you see that central line. I’m going to follow that central line and so you can see it’s already been prefractured with the laser. I’m about 80% there. I’m going to put my second instrument in. You can see I can freely rotate it. The reason I was having a hard time doing it with the cannula because I was digging into the cortex. I did the little fragmentation there, that’s good. Remove this extra stuff. And look how easily that breaks apart there. We’re going to go back to where we were, this is 180 degrees from where we started. Break this last little guy. I don’t think I went deep enough there in the middle. Pretty dense right there, there we go. Get that last piece, there we go. And then we’re going to go across here, do that last quadrant. Again, it’s a dense cataract in the middle but it’s fluffy on the outside. I got to go right through the center there. That’s great, nice depth, you can see the line. Insert both instruments, crack, refine. Now, removing the pieces, rotate the phaco tip 90 degrees, align it exactly across the chamber for you. Go to peristaltic quadrant, bury the tip, now I’m not sucking anymore I’m pulling it up. Now it’s freed up in the iris plane here, I’m removing that piece. And then I don’t go grab it here, remember, I’m going to rotate it around. Look at that. Now I’m going to grab it because it’s safer. Then I’m going to come back, I’m not trying to grab it over there, I’m rotating it around and then I’ll grab it. It’s connected to that other little piece so they’ll both come up together here shortly. I’m going to get close to the iris here, so I’ve got to be careful. I’m not going to eat it, I’m just going to pull the rest of it up here to the middle. And then I’m not really moving my phaco tip, it’s just nice eating all that. I’m going to remove my second instrument. Rock solid chamber, everything’s good. We’re fine. There’s that little piece there I need to get. I’m going to put my second instrument in, go under the phaco tip, throw it out into the central part of the eye there so that I can grab it and then we’re done. We’re going to do I/A. [Phaco machine] Continuous irrigation on. [James] Inserting my second instrument. Here’s a little tip, if you’re trying to get a little bit of nuclear fragment and you can’t eat it with the I/A, put your second instrument in and kind of smush it into the ostium of the I/A and you’re able to eat it that way. All right. Just a little more sticky capsule, so let’s do what I have talked about. Let’s try to get the subincisional stuff first. Sometimes people have really sticky cortex. There we go. Bring it up a little bit. It’s real sticky, here it comes, slowly, slowly. There it comes. Okay. Just have to be patient. And you try to bring it to the middle and eat it that way. Tug on it, bring it to the middle and then absorb it. Sometimes the capsule comes easy like in that last case, excuse me, the cortex comes easy like in the last case. And sometimes it can be very tenacious and not want to come. Let’s see over here. There we go, almost there, guys. Getting this last piece. Got any questions you want me to answer, Hunter, while I’m doing this? [Hunter] No, this is fantastic. One of the questions that people were asking about were any tips or tricks you have for soft nuclei where you go in and it’s just like mashed potatoes and you’re trying to get a soft but intumescent lens out. Do you have any tips or tricks there? [James] I like to hydrodissect those and flip them out of the capsule completely. Because you can’t really fracture them, you can’t really do divide and conquer on those very easily. I like to do pretty aggressive hydrodissection and since they’re so soft they prolapse themselves out of the capsule into the anterior chamber and then you can eat them. I got all that cortex and now I’m just getting some little remnants here. All right. I’m going to put in the cohesive viscoelastic, those are just some cortical remnants on the cornea there. I’ll wash them off here. And then okay now we’re inserting the lens. Also a single piece acrylic lens. Insert it straight into the capsule there. Remove that, use a second instrument to spin it into the bag. Basically just push posteriorly. Make sure it’s good and then free up those haptics. Once you see those haptics moving you’re good. Now I/A again with a little higher vacuum setting. [Phaco machine] Continuous irrigation on. [James] And now we just remove that cohesive viscoelastic all around the lens there. There’s a little piece of cortex lingering over there. I’ll move the lens towards it and I’ll go under it, see if I can get it. Looks like it’s gone. And now just removing all the cohesive from the anterior chamber. [Hunter] Dr. Lehmann, why are you removing the OVD from the anterior chamber at the end of the case and could you talk again about those little chips or those little fragments and why you search for those so carefully? [James] Right. You’ve got to be diligent about removing the OVD because otherwise they have pretty high pressure. It takes awhile to clear the OVD from the anterior chamber. And those little pieces, they’ll cause persistent inflammation or corneal edema. And in eyes with pretty dense arcus, they can hide in sneaky places mostly inferiorly. And here I’m just filling the AC, checking the pressure. I want to do a little more stromal hydration here on the anterior lip of my incision. And then I’m injecting, I want to leave the eye pretty firm at the end of the case. Let me see some more BSS, right here, thank you. You can see all that whitening around there, that’s fine, that goes away in a day or so. I touch it and I feel like the eye is firm so then I know our good spot. Should be good pressure there, so we’re pretty much done with this. [Hunter] A lot of people have asked, I know we had that great question from Armenia about that posterior capsule, but you as a cornea surgeon, what are some things you do to protect the endothelium? Dr. Terrafay is asking how do you prevent rubbing of the corneal endothelium during the manipulation of the nucleus? [James] First thing is to always use a dispersive viscoelastic during phaco. Cohesives are fine, but they don’t protect the endothelium, they come out of the eye pretty fast. If you use a dispersive, it’s going to be healthier for your endothelium. Surgically, you just have to be able to see in stereo and get comfortable in space and know where you are using landmarks and just experience. You don’t want to phaco too close to the endothelium. And if you are, you can always add more dispersive viscoelastic during the case if you have to. [Hunter] Like you said, the viscoelastics are always your friend and knowing where you are in three dimensions, staying in that safe iris plane is critical. Another thing that you demonstrated on the first case and also in your lecture, was the orange peel technique. And Dr. Tarek Mohamed is asking how can I enlarge a small rhexis? Maybe you can just talk about, as you’re either intentionally having a small rhexis because it’s a dense nuclei and you’re worried about a run out, or other things, how can you enlarge a small rhexis in the middle of a surgery? [James] If you’ve already started, it’s a spiral technique. But if you’ve made a rhexis and it’s too small, then it’s harder. What you have to do is you have to go in and cut and free up a leaflet so that you’ve got a lip. And then you regrab with Utratas on each side of that cut, and enlarge it. But it’s tricky. You can sometimes get into trouble with that. But that’s what you have to do. If you have two small of a rhexis and you’re like, I can’t operate on a two millimeter rhexis, then you have to go across the chamber, make a little snip with some Vannas or some intraocular scissors. And then you grab each side of those leaflet and separately, one at a time, and then you peel it back in circumferentially so that you can enlarge that rhexis. [Hunter] Great question from Dr. Dhaba. He’s asking if there’s anything wrong with a superior incision? I know that a lot of people like the superior or superotemporal. Is there anything wrong or why do you choose the temporal position? Why do you like that temporal side chair? [James] The cornea, as we know, it’s got a wider horizontal than vertical diameter so when you operate horizontally, temporally, you induce less astigmatism and you’ve got more room. The problem with superior, is you’re up in your operating space. You’ve much closer to the center of the cornea so visualization is worse. And if people have steep brows you’re coming in too steep of an angle, you can’t come in like this. Like I said, sometimes beds and ORs aren’t set up in other countries to do temporal surgery. I’ve run into that. If you’re used to operating superiorly you can be a great superior surgeon. It’s just that honestly, temporal is easier. We just have always started that way. [Hunter] I think it goes back to what you started your lecture with. It’s about comfort and ergodynamics. Are you going to be comfortable if the patient has a high brow because you don’t want to be switching, you like to set your routine and continue to do that. And so you can do superior but there are going to be cases where you’re probably going to have to switch because the brow or the patient is so skinny or their eye is so sunken, it’s going to be hard to access. Great question from an anonymous attendee. Do you routinely give acetazolamide after a case and what is your routine post op care? How often do you see them, what type of drops do you give them, what is your routine care, and do you include acetazolamide? [James] No, we don’t give acetazolamide. Sometimes after PKs I do, but after routine cataract surgery, we see them the next day. I guess if you weren’t seeing them the next day, because they live far away or something and you’re seeing them in a week, I could see the logic of giving some acetazolamide to every patient. But no, our routine is to see them the day after surgery. And then if they’re doing great, we do the other eye a week later. If they’re not doing great, then we see them in a week and we do the other eye two weeks later. If they’re 20/40 or better on post op day one, we go ahead and do the other eye a week later. If they’re worse than that, we see them one more time and do the other eye two weeks later. [Hunter] I love that. One question that Dr. Rasan Muhamed had. Is there increased risk of infection if you have a temporal incision? I know they’ve shown that with blebs if you have an inferior bleb, there’s a higher rate of endophthalmitis. But if you’re looking at infections, is the location of the wound more important or is the structural stability, the lack of leakage, what is really important for preventing endophthalmitis with your incisions, Dr. Lehmann? [James] You pretty much have to avoid a wound leak. You’re going to get an infection if you have a leak. I don’t know of any study that looked at temporal versus superior phaco incisions in terms of endophthalmitis. But like I said, if you’re comfortable and you have good results operating superiorly, there’s not a problem with it. I just feel it’s much more comfortable to operate temporally. [Hunter] And again this is going back to what you said. What works best in your hands, what are you most comfortable? But if the surgeon’s not comfortable and the surgeon can’t see, it’s not going to be an ideal surgery. One of the questions that Dr. Amin Zeckreft is asking is when do you prescribe acetazolamide? Is the patient with long-standing glaucoma, a patient who had a high pressure or they may have some OVD? When do you prescribe acetazolamide? Is it a patient where you’re worried about post op spikes or pressures? [James] I think that if you have a tear in the posterior capsule, giving acetazolamide afterwards is a good idea because a lot of them have high pressures. Because when you have a tear in the posterior capsule, you’re putting in extra OVD to manage vitreous prolapse and you’re going to put a lens in. Sometimes you can’t take all that viscoelastic out because it’s behind the lens now. If you’ve had a rupture in the posterior capsule and they don’t have allergies, give them 500 of Diamox after surgery. After PKs, a lot of doctors routinely give acetazolamide as well. Not DMEKs and DSEKs, but PKs. I think in routine cataract surgery it’s overkill but for a complication or for a PK I think it’s reasonable. [Hunter] And just a few more quick questions, how are you for time, Dr. Lehmann, I know you have other patients. [James] Unfortunately, I have clinic. Okay, let’s do one more question, how about that? [Hunter] Okay. We have a question from Greece. For your lens injector, what was your IOL type and what was the injector, is that all one standard package or is that something that you use custom? [James] A lot of companies have gone to the preloaded lenses. We still have our technicians fold the lens. It’s a one piece acrylic lens and then they are taught how to put it in the cartridge and then fold it and then they hand it to me and it’s ready to go. We confirm the power at the beginning of the case but the technician loads the lens. [Hunter] I’ll answer, there’s a few other questions remaining. But I want to thank you, not only for always you do for our mission at Orbis, but I think this is the first time on a live surgery you’ve heard the word “bad boy.” Thank you for talking about that “bad boy” cataract, okay. Thank you, Dr. Lehmann, we’ll be seeing you- [James] Thanks, Hunter. Thank you, Orbis friends, you all have a good day. Thank you. [Hunter] Very quickly I think we have a few more quick questions. One is from Dr. Shivankarsin. Certainly when you’re looking at what type of nucleus disassembly technique, you can use many different techniques: stop and chop, divide and conquer. I think what Dr. Lehmann tried to stress today is that the divide and conquer is always a great way to start learning phaco. And the nice thing about that technique is you’re really in control, you make a great crack, and then you break out the quadrant. Certainly as you advance your skills and experience, you can start changing to stop and chop or direct chop techniques, but I think for someone who has just beginning their phaco journey, certainly divide and conquer is a good technique. Thank you for that question. Certainly there were challenges when you’re trying to separate the nucleus after grooving. The most important thing is having the wall be very vertical, about a phaco tip and a half across and at the right depth. I think you heard Dr. Lehmann say you really want that groove or that trench about 80% depth. And if your instruments are not in the bottom and you’re not pushing them this way, and you’re high, you’re actually pushing the plate back together. I would say the most important thing when you’re separating the nucleus after grooving, is making sure you have a good groove. If you’re not comfortable with the groove you’ve made, take a moment, put in some OVD, rotate the lens 180 degrees and trench some more in the other direction. Again, as Dr. Lehmann said, you’re very rarely going to punch through the groove and hit the capsule. More damage is done because you’re not getting a good separation. I would say that if you’re really looking at how to best separate the nucleus, really think about your architecture. Are you 80% depth, are you having vertical walls, and are your instruments at the bottom of your trench pushing this way so that the pieces separate? Certainly that’s a great question that someone anonymously asked. There is a question about postoperative IOP. And certainly that can be managed like Dr. Lehmann said with oral medicines like acetazolamide but also that can be topically. I think what you saw, and Dr. Lehmann demonstrated in both his cases, the number one cause of a high intraocular pressure or IOP after surgery is retained or leftover OVD. Remember, in every cataract surgery, the iris is always your enemy, the OVD is always your friend, but never leave your friend behind. And it’s definitely worth a little extra time with your I/A to make sure you’ve got all the OVD out from behind the lens and there’s none of those little chips or little fragments, especially, in patients with arcus in the angle. But certainly I think you’ll find if you do a good wash out and remove all the OVD, you’ll prevent pressure spikes. Certainly I think we have talked about the hydroimplantation. I appreciate this, it sounds like another question from Greece. Hydroimplantation is certainly possible, I would say that is not recommended for people who are just starting their phaco journey. OVD is so safe, it is such a better way to implant a lens. I would say certainly you will see doctors doing hydroimplantation, I would not recommend that for anyone who is just starting phaco and certainly OVDs are the way to go. Don’t forget the OVDs also protect your endothelium whereas BSS plus or the different irrigating fluids often will stun or also injure the corneal endothelium. I love the question that Dr. Vitalli Mann asked. Certainly in a complicated patient where there’s a posterior capsular rupture, or concerns about uveitis, or concerns about cystoid macular edema you can use either a steroid plus an NSAID or an NSAID, a non-steroidal anti-inflammatory drug. Dr. Vitalli, I would say certainly many doctors use both a steroid and a nonsteroidal drug. Dr. Lehmann simply uses the steroid. I certainly want to thank everyone for the lectures. I think there’s one question from Dr. Golamezra. In your experience, you use two stab incisions, 90 degrees apart from the main wound to help with cortical cleanup. Certainly if that works well for you and you’re getting great results, absolutely continue that. That’s what a lot of the bimanual surgeons do. Certainly like we’ve talked about, visualization and access are key. If you are using a main wound and then two side ports for your I/A or cortical cleanup, and you’re getting great results, please continue. Certainly bimanual is a wonderful technique and it’s just what you’re comfortable with. I definitely think Dr. Shah is asking a very difficult question about posterior polar cataracts. I think this is the situation where you may want to avoid a hydrodissection because that could pop the adhesion to the posterior capsular bag and look at more hydrodelineation within the lens substance. And basically these cases will have posterior capsular ruptures no matter how perfect the surgeon may be just because of their structural weakness. You do not want to do aggressive hydrodissection, you may want to think about hydrodelineation. You’re going to try to remove as much of the nucleus substance as possible so that as you go and try to remove that last remaining polar cataract plaque, if you do break the bag you don’t have a lot of drop lens material which is everyone’s greatest fear. I think we’ve answered most of the questions and certainly I put in the chat and I’m going to, for those who were late to join, if you look in the chat, Lawrence and the Cybersight team have put together some amazing books and some lectures and materials including an e-course, a Cybersight e-course, on phaco. If you look in that chat, all of those resources are free to you as Cybersight team members. And so certainly if you have questions you can always reach us through an e-consultation, just like some of the doctors are asking about polar cataracts. That’s the beauty of Cybersight, you can ask for e-consults at any time. Again, I definitely want to thank everyone for a wonderful webinar. Dr. Lehmann did a great job and I hope I was able to answer some of these questions. But I hope everyone enjoys the rest of their day and they’re able to take one or two of the tips or tricks that Dr. Lehmann showed today and take them back to help their patients. Again, I just want to say thank you to everyone and we look forward to seeing you at our next Cybersight webinar.