Lecture: Enhancing Cataract Surgery Outcomes With Surgical Technologies & Techniques

>> Dr. Warrier: I’m not sure if it’s morning or evening. But it’s certainly evening where I am. Just wanted to welcome you all to this webinar. It’s the first one that I’ve presented and hopefully it’s directed at a broad range of my colleagues. And actually you’ll find this useful. The title is: Enhancing Cataract Surgery Outcomes With Surgical Technologies & Techniques. And specifically relates to 3D microscopy which I have now been using for almost 18 months to two years here in Brisbane, Australia. So, for those of you who aren’t familiar, Australia is somewhere down the bottom of the world. And I am located in Brisbane which is on the East Coast and the capital of the state of Queensland. We’re a growing city of about 2.5 million. And I guess our claim to fame in the next seven years or so will be hosting the Olympic Games. I think by that stage we should probably have over 3 million people. Not a huge city, but we’re not a small one, either. In terms of myself, I’m a general or anterior segment ophthalmologist. Do lots of cataract surgery and lots of glaucoma surgery. And work in a private practice in an area called Redlands, which is just outside of Brisbane. The public hospital they work at is called the Mater Hospital in Brisbane, itself. That’s where I do most of my teaching. Our practice has five ophthalmologists. And three full-time and now offer full scopes, including VRT service.
I wanted to show this little video which is I guess a promotional of our theater in the hospital across the road from us where we offer it. And I use a solid digital microscope. Does have binoculars, but we don’t actually use these, but we use 3D glasses. Its unique feature is it has a C-shaped arm. You don’t have to bend your neck and look past the binocular apparatus, but can look straight ahead. Two beautiful 30-inch screens, one attached to the scope itself and then free-standing 50-inch screen as well. So, why did we look to digital microscopy and what were we hoping for? Well, we were looking for better visualization, which as you all know makes surgery that much easier. We were looking for an improvement in ergonomics. And I guess this is something that has become more relevant to me as I have grown a bit older and been working for a bit longer. It has improved our workflow. And this, I think, is relevant to, shall I say, developed countries and under-resourced areas where you are struggling to meet demand. And anything that makes you more efficient is helpful. And then, obviously, from a teaching and education viewpoint, we were looking for something that would help with that. And that was looking for something that was more than just a recording platform. So, in terms of visualization, the scope itself has been extraordinary. And until you actually try one of these things, it’s just words. But the depth of focus, it’s truly amazing. So, what I found is that I hardly ever lose focus during a standard case. Once I set the scope up with my glasses on, the cornea, the spheroidal conjunctiva, the anterior chamber, even as far down as — is in focus. You can tweak with your foot pedal, but more often than not, it’s not necessary. The second thing is the field of view is also extraordinary. And I found this probably most relevant during the IA stage of surgery. Initially I thought I was imagining it, but after discussing this with other colleagues who have trialed this scope, my commentary that I felt that I was looking around the corner was not just in my head. So, in terms of ergonomics, the ability to sit straight and to look straight ahead without having to tilt the neck, without having your neck extended or flexed, and also the relaxation in the shoulders is significant. More so when you’re doing a full day operating. Especially so if you’re doing more than one day in a row of surgery. And for the youngsters out it had, you probably don’t understand what this means, but you will in time. And I guess the old adage physician myself comes into play where you are — it’s necessary for you to look after your own health in order to provide excellent care for your patients. So, this is a little video highlighting during surgery. You’ll note that the chair here supports most of the way up my back. And I’m really sitting back in a very relaxed position. Not hunched over the patient. And looking straight ahead whilst operating a comfortable distance away from me. And I’ll just play the video. Which is really just live performing — the lighting is not super-dark in the room. But you can see that I am resting back comfortably with my arms a little bit away from me. And this is a change from standard analog microscopes where you are often right up at the eye piece and your hands a little bit further down. So, this sort of relaxed position subpoena going to be extremely beneficial to my comfort whilst operating. And hopefully the accuracy of what I do. And especially towards the end of the day. I’m going to go to the next slide. There we go. So, you may ask why ergonomics? It wasn’t until I did a little bit of research into this that I was able to discover that there is a lot of literature out there about the issues faced by ophthalmologists. And most of this is related to back and neck pain. As you can see from these studies, and there are many more, most of the respondents reported a back or neck pain or both. And moving forward we see that at least a third of us have reported some pain whilst operating. And three quarters of these people have found that operating, especially towards the end of the day, makes this worse. So, again, in a young person’s agile body, it’s probably not such a big deal. But after 15, 20 years of high volume work, I think you’ll find that your life — not life expectancy — but shall we say “Work expectancy,” is reduced significantly. And that’s certainly been the case in our group. Amongst our cohort of surgeons utilizing this. In so far as one of my colleagues feels he’s probably added 5 to 10 years in terms of her operating working life. Certainly as a much more comfortable existence since switching to this technology. The workflow. Really, it’s the consistency from image-to-image and from case-to-case. It’s really easy to set up. The 55-inch monitor, it’s incredible. And the other thing that it allows is everybody in the room with the addition of glasses that we don’t have to wear, but doubled begin it’s a 3D scope. But the glasses on everybody is seeing what you’re seeing. Which is spectacular, but also allows your assistant staff or nursing staff to predict what’s going on. What you’re up to. And allows truly the ability for you to focus on what you’re doing and simply place your hand out and hopefully receiving the instrument that you’re awaiting. From a teaching and education perspective, the ability to teach without being right next to somebody, which often adds stress to the student or resident or registrar, is fantastic. So you can be a little bit away explaining what you’d like to impart without crowding the operating surgeon. We also have the ability to draw on the screen, pointing out where you’d like them to attempt maneuvers or things to touch/not touch/avoid, et cetera. Which is really the way of the future. The recording is of extremely high-quality and I will show you some cases shortly. And the next part of this is the ability to record in 3D, which I’m currently working through with the company as I speak. There aren’t many of these units currently in use worldwide, and we’re very fortunate to have one. But it has been life-changing for us and allowed us to hopefully offer fantastic surgery to our patients. So, I just want — excuse me — I just wanted to show you some examples of the surgery that we can perform. Using this scope. And then I’m going go through several cases with some tips about cataract surgery from routine cases to some more complex cases. I have based these videos on some of the questions that were sent in by some prospective attendees. And hopefully they are aimed at the right level.
So the red free surgery, I find this really useful as my go-to when there is sort of a dodgy red reflex with my surgery. I try to minimize how many steps I take and how many instruments I use. So, you can see that, you know, this black and white case, the contrast is still spectacular and you’re able to easily perform this without the image being in color. And I use this when the red reflex isn’t great and will often try this view first before resorting to something such as Trypan blue or vision blue as we call it here. You can see it’s easy to distinguish the cortex from the capsule. You can easily pick up the whisps. This is the single piece IOL in the bag. Hydration of the wound. Some intracameral antibiotic and a beautiful black and white case. So, this is what’s known as MIGS, which is minimally invasive glaucoma surgery. Many devices available now. My device of choice is the eye stent. And I thought I would show you the view that you get with a single use prism. Showing us the angle. And you can see blood in Schlemm’s canal quite clearly here. And I’ll play this video. Shows us the eye stent infinite, where you can see the trocar and delivery of the stent. And what’s very nice once we come back is to see a little puff of blood indicating we’re in the right spot. This is Preserflo glaucoma micro shunt which is now my go-to procedure and has replaced, in my hands, certainly, trabeculectomy. We use antimetabolite, but it has helped me provide a much more consistent result in terms of IOP lowering with a very, very high success rate at the moment. And I can’t see myself going back to standard trabeculectomy any time soon. The next step up from this obviously would be a glaucoma tube device. But it’s rare to have to progress to that in standard cases after using this device. And you can see how clear the image is using the digital microscopy. So, let’s play this video. And you can see as we extend this blade through the sclera, partial thickness and then stepped entry into the anterior chamber. All beautifully visible. And insertion of the micro shunt, which has a little winged flange to prevent it going too far into the anterior chamber. And here we can see aqueous beautifully flowing through the tube. This is a 10-0 nylon which I thread and stent the tube. And this is the finished product. So, it’s wonderful for sort of these extra ocular/glaucoma procedures. Many of you would be experts at small incision cataract surgery. Something that we do quite infrequently. But it is a lovely skill to have. And again, this microscope allows you to perform this quite comfortably as well. So, we can see that we’re in construction, which is really — in this case. I always use anterior chamber maintainer, especially when teaching this to our residents and registrars who are relatively unfamiliar with this, given that we use phaco 99% of the time. And the maintainer just keeps everything under control. Allows very safe delivery of the nucleus without applying pressure. And all in all, just adds a level of safety to something which is not performed very frequently quite well. And this is a more complex sort of case here. I just wanted to point out, this was a patient that had suffered trauma and we knew beforehand that there was weakness. But still planning to place a toric IOL in the bag down the track. And what you can see here is that I have fixed the capsule using Chang capsule hooks which have a rounded tip to them. And are longer than the standard iris hooks. The beauty of these hooks is they can help you fixate the bag with a far less likelihood of tearing. But also because of the extra length of the tip, once you insert them, they tend to extend to the equator of the bag. And you can see here where my cursor or pointer is that there’s at least sort of three to four clock hours of zonular dehiscence, and the bag sort of flopping over here. Play this video to highlight how it’s still this case and expand the bag. And it pushes it back. But you can see that it still wants to come over towards the center of the pupil, and I have added an extra Chang hook to fixate in the area where there was weakness. And we inflate the bag. The hook’s in place before taking the rest of the cortex out. And I’m just highlighting where I think the weakness is. So before attempting to remove the cortex, I place a capsular tensioner all the way around inside the bag, which just places it on tension. It’s nice to do this relatively slowly so that you don’t tear the bag. And once the cortex is out, this is a segment with an 8-0 cortex suture, which we then pull out through the sclera. And you can see that it was fixated here in the toric lens in the bag. Still only to give the patient excellent vision as well as bag stability. So, that was just a series of examples of the case types that can be done very safely with digital microscopy. We also have many vitrector cases and our colleague uses this with a heads up display and performs all range of VR surgery and vitrectomies and detachment and buckles, et cetera, on a regular basis. And really enjoys the scope. So, these are just some cataract surgery cases. Now these are actually a little bit older, not recorded on the digital scope. And from my point of view, I certainly notice the decrease in the quality of the recording. But that could be my bias. This is just a standard analog scope. That we’ll go through the cases and just highlight my techniques and what I think are important. I do use these videos to teach our trainees, register stars we call them in Australia. Residents is I think they’re known in many parts of the world. And I’ll just highlight what I think is important to safe and successful surgery. So, don’t use pre-op dilation. But I use an intracameral mix of cefazolin and lidocaine. Which gives pupil dilation. And kick my cannula in there and make a stepped wound. One of the questions — I’ll just pause that there — was how do you create a wound and avoid damaging Descemet as well? In my case, it’s a three-step wound, and I should never say never, but I never have any wound leaks with a step wound made at the limbus. In terms of the capsulorhexis, you can use the cystotome, but I continue with the speed and the accuracy. Start at the beginning, I apologize. Capsulorhexis here. And this technique is leading where I’m trying not to tear at my forceps tips are way in front of the flap. Release some of the visco. Hydrated section is simply done one side decompression and the other. And this is a primary chop technique, where you aim for the middle of the nucleus. And bring the chopper towards the phaco tip. This is a nice way of separating it with very little ultrasound power. And divide the half into quarters. And what I was attempting to do here is to move it so that you can grab the edge of the piece, which then brings it up. Still in the iris plane, but in the center, which is what I call the safe zone for cataract surgery. This is the capsule guard. Hand piece, which is a silicone tip. And you don’t need a split system at all, really. And can safely remove all the cortex through your main incisions. It’s just one less wound that you need to make. And given that the tip is silicone, very safe to do a capsule polish at the same time. It’s great for your trainees. I guess from a resource point of view, they are single-use so it’s probably not the most environmentally friendly way of operating. And again, just trying to highlight capsulorhexis by leading it around. And not tearing it. Grabbing near the edge. And using iris as my guide. Again, the stop technique from the edge. Down. You’ll notice that my phaco tip, I’m attempting to keep it towards the center. Not chasing the piece. I’m letting the piece come towards the phaco. And this is single piece IOL, which unfolds very neatly in the bag. Again, small pupil, a little bit of intracameral phenylephrine and lidocaine, and you get pupil dilation. Many people try to dilate this pupil more, but that’s plenty big to take out a cataract. And again, step wound, and capsulorhexis, when the pupil is a bit smaller, you simply follow the edge of the pupil. Trying to provide you with a lovely buffer. Hydrodissection one side, decompression on the other. And ensuring that it spins once you attempt phaco. Again, aiming for the center, in, split in half. Split in quarters now. And teasing that piece out trying to just keep your phaco around the center. The one thing with the small pupil is the iris can very easily get taught in your phaco tip. And so, you just have to be a little bit careful where your tip is before putting your foot down and engaging vacuum. And again, capsule guard, always start with your sub-incisional cortex first. Do the hard bits first. The rest of it is fairly easy. And then a polish. And cleaning the bag. IOL insertion. Fill the bag with your viscoelastic. And again, an IOL. And I like these pre-loaded IOLs because you can simply place them and nearly 90% of the time it will be in the bag without having to manipulate that again. So, again this is much larger pupil. And I wanted to show you sort of a grooving technique. It’s not really divide and conquer. But it’s a way of safely disassembling the nucleus by grooving down. So, the important thing to think about when doing phaco is what do I need to do? Or how deep do I need to go into phaco before I can safely crack? And this is the thing most people struggle with as we’re learning cataract surgery. And there are some metrics around this which I think it’s important to get your head around. So, if we assume that most cataracts in terms of lens thickness are 4.5 to 5 millimeters, you want to be at least three fifths of the way down. You want to be, realistically, 3 millimeters down, minimum, before attempting to crack. Obviously density does matter. But what really matters is width of your groove and depth of your groove. So, many people don’t actually think of this from a mathematical viewpoint and just assume that you can judge depth. Think it’s important when you are learning this to actually have a measurement. One way of working this out is to measure your phaco tip to the /x10/x02A. tip that is shown. You may notice that I show a fair bit of my phaco tip. I’ll just go back to that. And you’re looking here. I often leave at least 1.5 millimeters of tip out. And what it then means is if I groove down two to three times my tip length, I know that I’m past the 3 millimeters. The other thing that’s really important here is to look at the width of the groove. It has to be wider than this because of the sleeve. The sleeve, yes, it compresses. But with a dense nucleus, when you place your phaco tip down there and the groove is too narrow, you’re effectively putting posterior pressure on the lent and what you want to be putting is sideways pressure at the bottom of your groove. That’s how you divide the lens. So, when doing this, if I could just play this from here. And you can see I’m making it wide enough that I can place both instruments at base and just push sideways. It’s a very gentle procedure. And then what I’ve used is the Drysdale or the paddle, chop that using the neck of the instrument. It’s effectively a blunt instrument. A very safe and a great way to start your cataract journey. The other instruments I was using here are various types of choppers which have a pointy tip. And good for get book is dense nuclei. And here we have another polish. I wanted to highlight here is a ring. So, in terms of pupil expanders, the iris hook it probably less and less used nowadays. They are fiddly. They’re fantastic, but certainly in my hands, and from a teaching viewpoint nowadays here in Brisbane, we would use the ring far more often. I know there are various iterations invented by many of our brilliant colleagues. But I use this and this technique is a way of guaranteeing engagement every time. So, I do my distal first when the rest it comes out, there will be one on this side and one on that side. And I just engage one side. You can attempt to engage both. But what that involves is pressing down with the steel introducer. Which can damage the capsule. So, I find in order to avoid touching the capsule there, what I aim to do is engage one side. And I’ll let this play again. So, you’ll see off to the left. And then I have my second instrument coming out, ensuring that my sub-incisional one is engaged. And then come back through the main wound and engage the other side. So, that you will get it in every time. And now we come to removal. And again, this is a technique that if you utilize, you will be able to remove it every time without causing damage. There have been cases where the ring has caught the capsule, caught the iris. Scraped the cornea. And you can avoid all of these by this simple technique. So I place the lens in the bag. Just fill it up with a bit of visco, protect the endothelium. Disengage my sub one, the introducer is to the left, extend the arm. So, what was really important was that — and I’ll just go back to this — the introduce goes to the left and goes under this. You then extend the hook. And once it’s fully extended, you come over to the side and then — and the hook’s over the top of this circle — you retract the hook. Play it again, and you’ll see it then brings the ring back into a linear formation which you can then safely remove through the wound without engaging any other structures. Straight. And then out she goes. We see here a lovely white cataract. And one thing that I would ask you all to consider is obviously in your pre-op assessment, working out whether this is a cataract or a lens that is under tension. And obviously prior to the capsule, what I have done here is used the 27-gauge needle on a syringe and pierced and aspirated to try and relieve the tension to avoid what’s known as the Argentinian flag sign. Obviously, there are many ways of avoiding this. Some people advocate the preoperative YAG of the anterior capsule. And then the other people simply pierce the capsule with the phaco tip itself, which obviously creates a much larger wound with aspiration to try and decompress this. I’ve just used a needle here. Keep playing this. So, again, capsulorhexis. Starting to lead this around, which reduces your risk of losing the capsule. Obviously, if you’re concerned at all, stop and refill with viscoelastic just to flatten it out. And we get circular rhexis. What I wanted to highlight here is what I call teasing the lens apart. Often you’re required to do that in leathery cases, post-vitrectomy cataracts, for example. And what happens here is my right hand here with the phaco tip is engaged a piece, and this is effectively still. It is the left hand that tease this is piece apart. So, one hand is still, and the secondhand teases the piece apart. You just got to be patient and gentle. And operate at the base of the pieces. And again on the last piece here, I’ll place a blunt instrument underneath a phaco tip so that there isn’t suddenly surge capsular tensioner. Which I often use. In many cases. It keeps the capsule under tension and I find my position is really predictable. Also allows me the options of lens exchanges down the track should I wish to change people’s refractive outcomes. And I chase all of the wispy cortex pieces in these dense, traumatic cases. The last thing I want to do is puncture the bag. And if there is some PCO down the track, it is simple enough to perform a YAG capsulotomy, which is far better for the patient than busting the bag and having to do a vitrectomy and placing a lens in the sulcus. I’ll just move on now to the last few tips. So again, stabilize with the visco, stepped wound, pierce the capsule. Capsulorhexis. I guess the key to good surgery is not to rush, but to be smooth. And if you’re smooth, you’ll be efficient. So, I really wanted to show this grooving technique. What I’m trying to show is if it’s too narrow, you cannot get both instruments down there. So, this is a dense nucleus. So, I’m not making it very long. What’s really important is I am aiming for depth. Okay? So, I can place both instruments at the base and tease the lens apart. This is a really gentle maneuver. But you can see how wide that groove it. Again, we engage and use the neck to separate the piece. And engage the edge, which brings it up into the center. Spin this around. Engage. Very gentle. And before you know it, this is gone. Stepped wound. Piercing the capsule. And again. Just taking our time to finish our capsulorhexis, the hard compression to one side, decompress the other, spin the lens. Again, a nice, wide groove and concentrating on depth. I’m at the base, split. It is really a very gentle press. This is a chop, again. You can see it’s very, very simple to disassemble a nucleus if you use the right techniques. And the key to all of this is depth. Whether with the chopper or with a nice, deep, and wide groove. Doesn’t need to be long. The length is really not important. But you can see how efficiently we can disassemble and remove a nucleus with either a stop and chop or a straight chop technique. So, these were just some basic principles, I guess of phacoemulsification surgery. What I really wanted to highlight in the talk was the advent of digital microscopy and how it has certainly changed my life. Has improved my efficiency. I use it across a broad variety of cases. And I feel, certainly, that my visualization has improved, my ergonomics have improved, my efficiency, and, I guess, technical outcomes have improved as a surgeon. Obviously the margins are very small. We’re already operating, you know, across the world. Surgery from an ocular viewpoint is at a very, very high standard. All these minute improvements certainly I feel make our lives better and certainly our patients’ lives better. And I hope some of these simple techniques have been of use to you. So, in terms of Queensland, we’re known as the most relaxed place in Australia, and I just wanted to show you this little photo. It’s in Jest. I don’t usually have beer in the operating room. But I feel comfortable operating with one hand and with the other one resting on my armrest whilst doing I A and capsulorhexis. I hope you have enjoyed the talk. I think what we’ll do now is go some Q&A. Yeah. And thanks very much for your time. I think do I stop the share now? I’ll just go to some of these questions here. So, you have a question here about the video delay relative to real surgery? So, both of the screens are wired to the scope so there’s absolutely no delay whatsoever. It’s not a wireless connection. The large screen and the screen that’s attached to the microscope are wired. So, there’s absolutely zero delay. Another question is fogging a problem in terms of the eyeglasses due to the surgical mask? That’s an excellent, excellent question. So, the mask I use certainly to avoid this has sticky tape across the top. So, it’s actually a mask that as adhesive on the inside that I know many of my colleagues just place an adhesive tape over the top of the mask to prevent fogging. Very similar to what you would do if you were looking down binoculars. But certainly, no, I have had no problems. So another question here that we have is what type of anesthesia is used for cataract surgery? Certainly in my practice it is some IV sedation with anesthesia and a peribulbar, or topical case. I don’t love using topical cataract surgery. Mainly because of the amount of patient cooperation that’s required. And so, I tend to have my patients, you know, relatively sedated and certainly they appreciate not knowing anything about the surgery. And a block. But I do have some very, very experienced anesthetists who have been with me for the last sort of almost 12 to 13 years. So, over 20,000 cases and they are very experienced. So, I have no problem using blocks. How much time do we need to wait to prescribe prescription glasses after a cataract operation? Routinely we like to wait until the eye has healed and the surface has returned to normal. So, everything that we use in terms of pre-op sterilizations, either betadine or Hexidine solutions dry the eye out. And the post operative care with drops, even though we’re using preservative-free drops cause ocular surface issues. It’s better to wait for that to settle. So, four to six weeks before considering until glasses prescriptions. This question here beauty some pearls about phaco chop and get the firm grip. Again, this is the old concept of depth. And, you know, if you are putting that probe into the nucleus, you want to have the tip buried. And so, again, if you have at least 1.5mls of tip showing, that’s a fairly reasonable, I guess, spear tip that you can think of. Which impales the aqueous. And then you’ve got to have your vacuum high enough to hold that piece before attempting the chop. Most chopping fails because the tip is not deep enough. So, depth as in depth of the lens. But also, hasn’t been speared enough into the phaco piece. Pearls for dealing with small pupils. So, yes, if you have intracameral phenylephrine, that’s one, and phaco techniques, that’s quite traumatic. You get some bleeding, et cetera. Iris extenders such as the Malyugin or iris hooks, very useful. Just time consuming. And I find that if at least a 3 to 3.5 millimeter pupil, you can safely take out a cataract without doing anything to the iris. Using the techniques they just showed you. If you straight chop in the middle of that safe zone and you use the chopper, you can easily separate the nucleus into small pieces and deliver those through the pupil. And the most difficult part of the operation is definitely your irrigation aspiration at that point and that just takes a little bit of practice. I’ve got a question here about sharing some pearls and how to do capsulorhexis. So, obviously when you first start with a cystotome, that is the safest way to perform capsulorhexis. You pierce in the center, and if the cystotome is hooked, I would suggest that you move it to the left and pull the capsule towards you. So the hook is designed to pull. Now, what that does is create a flap which is then in a configuration for you to keep leading that around with your tip anticlockwise. So, if you’re sort of looking at the patient and you’ve pulled that flap towards you, then lead it anticlockwise. Now, if you wish to go into the other direction, I suggest that you use a straight needle. So, you pierce the lens and move it to the right and then push. So, a straight needle is very useful for pushing the capsule. You can then, you know, bend the tip, and again the flap can then be moved anti-clockwise. If you wish to go clockwise, it’s the other way. You would move to the left and push more, move to the right and then pull. And then you can do in a clockwise passion. Start with the capsulorhexis forceps and effectively what you’re doing is laying that flat on to the flat of the lens and leading it around. Once you’re comfortable doing this, I think the next step is to move to forceps. As I showed the video, the forceps are in the same plane as the lens, you’re leading and not pulling or tearing. You can tear, it’s far higher risk of losing the rhexis that way. How do you manage when it has the bowl? You’ve gotten rid of most of the nucleus if you have created a bowl. One technique is to use some viscoelastic just around the back of the bowl which then separates that bowl of nucleus from the capsule. You can then place a second instrument and flip that bowl up and take that remaining bowl that you’ve got behind. All you need to do is get one edge. It’s almost like a flipping maneuver. But you will need viscoelastic and implement second instrument to lift that up. I find that’s the easiest way. Rather than trying to separate the bowl itself. Using something sharp where by you can catch the capsule very easily. In terms of the Preserflos, we have an order now of my last 60 cases and on average my IOP is between 8 and 12 post operatively. So, they are really very low. Far lower than I’ve seen many published results. And I do have many videos. So, feel free to email me. Happy to share those. I do have a couple of videos on YouTube, I think. I need to update that. I’ve got a question here from South Africa. Yeah. So, you know, the use and appropriateness of different chop techniques, you just need to find one that you’re comfortable with. And don’t really vary too much from dividing with a Drysdale, which is that paddle or that non-sharp instrument and chopping using the neck of that. Or a sharp chopper and straight chopping. You need to just modify between a vertical and a horizontal chop depending on the density. Some cataracts are really dense and if you try and vertical chop, in other words, place the chopper straight into the nucleus, it’s too dense and all you end up doing is pushing the piece off your phaco tip. So, in those you need to actually go past the dense nucleus and get into the epinucleus. It’s almost a combination of a horizontal and vertical. You’re going around into the softer part of the nucleus and then bringing that tip towards your phaco tip. So, those are probably the three that I would find I can get nearly every cataract out and if it’s too dense, then I sort of revert to small incision cataract surgery to protect the endothelium. Yeah. So, what anesthesia do you perform in extreme axial length? My anesthetist would use — or do topical with sedation. So, what were the tip for the soft cataract that cannot be fragmented? There’s a couple of tips and more in the realm of the private cataract surgery that we do for refractive reasons. And so, again, a couple of techniques. One is the onion technique. Basically, this is a hydrodelineation where you delineate into multiple layers and take out each piece like you would an onion. And that works quite well. What I like to do given they’re so soft is simply hydrodissect and cleave as much of the cortex as they can and try to just lift up one edge. Once I’ve got one edge up, I base my phaco tip inside and move straight to my segment, which is the high vacuum setting. And with the blunt second instrument flip the whole thing up out of the bag. And it comes out very easily. This is a procedure that will take seconds. Yes. So, there’s a question about the digital microscope and using corrective glasses. Yeah, you simply place the 3D scope over the top of your prescription and away you go. And yeah. I’ve certainly — so the question is have you noticed a reduction in the frequency of intraoperative focus adjustments while wearing the 3D glasses? The answer is absolutely yes. The depth of field and the field of view have both meant that it is, you know, hardly use my foot pedal at all. I just set it up from the get go and can finish most cases. Do I routinely use intracameral antibiotics? I use it 100% of the time and our endoophthalmitis rates are probably less than 1 in 4,000. So practical tips for a novice surgeon starting phaco. We’ve all been there. Take your time. And think, you know, the biggest things that I’ve highlighted in terms of phaco is making sure you’ve got a good view. Obviously, with whatever technology you have available. And the second thing is understanding depth. Once you understand depth, that can be, as I said, using metrics and measurements or, you know, with time that will become experience. Then phaco becomes easy. A question here, in zonular weakness, how do you decide peri-operatively between using a standard CTR or a modified Cionni ring? I think that is depending on how much zonular weakness you have, and a lot of that you also decide intra-operatively. The case I showed you today, I put the standard CTR in to provide tension before attempting IA. And obviously, with the irrigation aspiration, you don’t — excuse me — pull towards the center as you would normally. But you pull sort inform a modified fashion after the size to try to minimize further tension on the zones. And once the CTR is in, sort of see how the bag is sitting. And if I feel like there’s still some drift away from the weak area, then I will top that up with the modified Cionni ring or the R-med segment. It’s one of those things, I think, look, if I’m there and I’m operating and I don’t want to come back, then I will just suture the segment to the sclera. Because the worst thing you can do is be in the eye operating and just say, look, I’ll leave the CTR in and post operatively you realize that the lens has drifted off and you have to go back in. Another question that we have is what is your recommendation for a novice surgeon to start heads up 3D? I think the answer is just dive into it. The learning curve is very quick. I wouldn’t bother with the binocular attachments. I would put on the 3D glasses and have a go. And you’ll find that before you know it, you’re very comfortable. I think you will find that children nowadays are all playing video games, certainly here in Australia, will pick this up quicker than us. I have another question here: Can I postpone nuclear rotation until performing the first groove? So, as to avoid any pressure on the zonules caused by one instrument rotation? Look, yes. I think the answer to that is that I like to rotate the lens after I have hydrated sector just to prove that it is mobile. Because the last thing you want to do is have to go back and repeat hydrodissection. So, I think what you can do is do a nice groove, split that into, you know, two and then rotate. And you can rotate with one instrument if you feel that the lens is mobile. But, you know, two instruments always produces less downward pressure and more rotation whilst operating. So, there’s a question here, is there any limit to nuclear density to do phaco? And I think the answer is yes. There’s nothing that a phaco cannot get through. The question is how much ultrasound do you think that cornea can take? Really we’re talking about endothelial dysfunction. I decide on this based on the preoperative corneal assessment to Fuchs dystrophy. How old is the patient? And how much ultrasound do I think I’m going to use? I guess that’s a question for experience. But, you know, not all white cataracts are dense. But certainly the brown ones moving to the black ones are very dense and so, I then decide between, you know, an extra capsular extraction such as a small incision, or phaco. And we’ve got a question here about how do I control the flow in Preserflo micro shunt to video hypotony and however do they clog? I stent all I my Preserflos with a 10-0 nylon, approximately an 18 to 20% reduction in the flow and certainly that will avoid hypotony. And that suture is not tied, but buried in the cornea, and I are remove that at a later date at the slit lab. I use a suture at the back to ensure that the Preserflo follows the contour of the plug, and this also helps me to avoid the phenols capsule block it up. And the third thing with the Preserflo, we use .04% of the mitomycin for 3 minutes to avoid adhesion in that area. But it is a far more — surgery than standard trabeculectomy in my hands. Got a question here about posterior pole cataracts and the technique being modified. I’m thinking you’re talking about posterior polar cataracts, with an associated capsular weakness. Certainly the most common technique is to be prepared for vitrectomy in these patients and warning the patients preoperatively. The second thing is not to perform full hydrodissection until the very, very end. The key is to advance the fluid up until that polar section, but not all the way around. And again the onion technique or hydrodelineation is what I would use to separate those inner layers of the lens, leaving the epinucleus and cortex and then slowly peeling all of that away until you’re left with only the polar segment. And then taking that out at the end. If you’re lucky, it may leave a small circular hole. If there is, you just need to put some viscoelastic to push any vitreous way, and often the lens in the bag quite safely. Sometimes the bag will break and you just have to be prepared for that. I am going to possibly sign out now, ladies and gentlemen, because it’s now well past midnight here in Australia. But I certainly hope that it was useful for you and thank you all very much for signing in from around the world. It’s wonderful to have such a fantastic technology where we can share knowledge with each other and I wish you all the very best. Thank you once again.