Live Surgical Demonstration: Basic and Advanced Phaco Techniques

[James] Hi there, good morning. My name’s Dr. James Lehmann, and welcome to our operating room. We’re coming to you live from San Antonio, Texas. And we’re going to be doing an ORBIS Webinar about cataract surgery, basic and advanced phaco techniques. Our moderator is Dr. Hunter Cherweck, I’m going to turn it over to him. He’s the Vice President of Clinical Services for ORBIS. While I get the first patient ready, he’ll go through the list of events and then we’ll get started pretty shortly here. Thank you.

[Hunter] Thank you, James, really appreciate you joining us live on Cybersight today. Really want to welcome the audience, especially those who asked questions beforehand. Before we begin with live surgery, I did want to remind everyone we have an excellent phaco course on the Cybersight website. I encourage all of you to go to the phaco course and complete it, because many of the questions that were asked about parameters, second instruments, management of a posterior capsular rupture, or PCR, are all on that course. The course is completely free, but you do need to register, just as you would for any course, for the phaco course.

Also, for those who are looking at their schedule, October 12-16, we have a very exciting 4-day symposia on simulation. Where a lot of that simulation training will be focused on phaco, as well as new techniques to practice skills. So I know many of you are looking at adopting or incorporating phaco into your practice, and I’m really excited by the symposia that we’re going to have next month. So please register, it’s October 12th through the 16th.

Our first patient that James, Dr. Lehmann, is going to be treating today, is a 60-year-old with a three plus NSC, three plus PSC, and is a high myope. Their pre-op refraction was -9 diopters of myopia, with some cylinder of astigmatism at 0.75 at 85. This patient had best corrected vision at 2100 and the patient received a pretreatment on the lens AR using femtosecond. I know one of the questions we received beforehand was discussing femtosecond laser, and I know Dr. Lehmann is going to talk about the advantages of this treatment. Especially with not only the construction of the continuous curvilinear capsulorhexis or the CCC, but how that may affect ELP or the lens position after surgery.

Dr. Lehmann will be demonstrating both fundamental techniques of divide and conquer, as well as how to look at best practices for polishing. I know a lot of you had questions about the parameters Dr. Lehmann uses for polishing the posterior capsule. We all know that polishing’s a wonderful technique to reduce the incidence of secondary cataract or posterior capsular opacification, and that’s something that Dr. Lehmann is going to talk about. So Dr. Lehmann’s going to do the first case today, where he’s going to demonstrate all the fundamentals of phaco in a three plus NSC PSC, that has received prior treatment with femtosecond laser. The advantages of that, are not only does it help with wound construction and the CCC, but it will also help with nucleus disassembly, so that you’ll have ideal viewing of how he’s going to disassemble this nucleus and remove it by phacoemulsification technique.

[James] So here we’re just taking a look. It’s a dense cataract and you can see the rhexis has already been made here. There’s also a little LRI here and here. And there’s a couple of subconj hemorrhages. Sometimes that happens with the suction ring from the laser. You may be wondering why, if I did the laser, I’m using a 15 degree blade right now. And that’s because sometimes some of the incisions can’t be made so posteriorly, and so we still do them manually for the paracentesis and for the keratome. This is some topical lidocaine, so it may sting a little, ma’am.

So this is lidocaine with epinephrine to help maintain pupil dilation during the case, if unpreserved. It goes by the name of Shugarcaine here in the US. I’m going to inject some Vision Blue, so you guys can see the rhexis a little bit better. Because you may not have such a detailed view through the stream. So we’re going to let that simmer a bit a few minutes here, a few seconds. And we’re going to rinse it out. Kind of lets you see those LRI’s a little better, right here and here. And then we’ll go ahead and use our disperser viscoelastic. So obviously, we use a disperser for this first part to help coat the endothelium so we don’t have cell damage during the surgery. And you can see the nice curvilinear capsulorhexis or capsulotomy there.

And then we’re going to use a Keratome. We’re going to go over wound construction during the lecture part, but basically, I like to do it at the limbus. And you want to get some of the vessels there so that you have a little bleeding. Then you want to make it as square as possible. See some bleeding from the vessels there, that tells you you have a good incision that will heal well.

Now, we’ve already made the capsulotomy, but we like to remove it here, with Utrada forceps. So that we can make sure that it was continuous. You can see here it’s really mobile in the anterior chamber. And we’ll remove that. You can see it’s here on the cornea. Now, one good thing about the Femto-Phaco, is that the hydrodissection part’s actually easier. That big distortion you see in the back there, that’s a air bubble. And so you’ve already done a lot of the pneumodissection, so we’re just going to do the hydrodissection right under the anterior capsule there. And you can see the lens come forward and some burping of viscoelastic. So we’re just going to tap down to try to release some of that excess fluid. It’s a fairly dense nucleus. I’m going to put a little more viscoelastic and you want to be able to confirm that it’s mobile. And so I’m going to try to rotate it a little bit and it looks like it rotates pretty freely there.

So now we’re going to start the phaco. And so of course we have different steps in phaco. First we’re going to sculpt. The first part, the sculpt, the laser has already cut through and made quadrants for us, so we don’t have to go down as far as we normally would with a normal phaco. So instead of having that 80% depth, we can go down maybe just 50%, and I’ll show you that. I’ll center this better. Put some VSS for me. Now I went into quadrant mode here and I’m just clearing up some viscoelastic there to improve the view. And then I’m going to start with my groove. I’m going to sculpt, which is obviously low vacuum and high-power, high-infusion. You can start to see the little slices that the laser made. And there’s an internal cylinder there. And then we’re going about 60% there, you can see. And then this is my second instrument, which is called a chopper. This is a horizontal chopper, you can see the tip is blunt. And we’re going to put that through our paracentesis and then we’re going to do a little bit of quadrant cracking here.

So you open that and you’re going to see some bubbles come forward. Those are there from the laser. And now we’re going to eat those up and we’re going to rotate 90 degrees. We’ll do the same right here. And for purposes of this video, trying to keep everything pretty straight forward, I’m going to go ahead and break up all the quadrants. But sometimes you can go ahead and take that first quadrant out, especially if the lens is not rotating so great. And taking that first one out can create space and also remove some epi-nucleus.

So you can see here, I don’t even have to crack it anymore or groove anymore. And then we just have this heminucleous here. Then I’m going to sculpt a little bit. And now I’m going to crack it, go down deep into the groove there. And you know the air escapes, you know you’re deep enough. But I want a little bit more.

So now we go into quadrant mode, which is obviously to move the quadrants here, and it’s always easier to remove the smallest quadrant first, so that would be this one. Now, I only remove quadrants, or I try to only remove quadrants, directly away from the phaco handpiece. So I don’t want to be grabbing here, I don’t want to be grabbing here, because you bring them out in a twisted way. And it can cause the capsule to toric or you could maybe bring up the capsule with your aspirations. Notice with this phaco handpiece, I’m going to rotate it so I can get the biggest amount of surface area covered. And then I go halfway down on the pedal, lift it up into the iris plane, and then begin to eat it. So now I wanted to go back down. So I’ll go back and go get it.

Instead of going and reaching it here, I’m going to rotate that and try another piece, because that little shelf on the anterior part is gone so that I always have something good to grab on to. Now I’m going to bring it up. And now I have moderate power, it’s not that dense there was a PC element to it. And I’m going to try to eat it in the iris plane, keep it centered in the eye, away from the iris. With minimal power, I use a burst mode so that it kind of keeps it dancing on the tip.

Now we’re going to get this quadrant and again I kind of lift it up, rotated out, trying to eat it in the iris plane. Maybe a little higher. You can tell in the center it’s attached to the other part. You can see a little denser here in the center, that white area there. And you can see now the lens is kind of freely mobile. I’m going to remove my second instrument to add stability to the chamber. Which people think, “Oh no, how are you going to protect the posterior capsule?” But with the new phaco machines, they have such good fluidics, that you’re actually doing a disservice by keeping another instrument in, causing water to leak out of the paracentesis. So I’m just going to lift that little part up there.
And then this last piece, I eat a little bit higher and not necessarily in the iris plain, because I do want to keep that posterior capsule from trampolining up. And I’m using that burst mode and just trying to keep dancing on the tip. And you can see, just patience. And now not much cortex, but you can see there’s a little part of some nuclear fragment that looks a little too dense to eat with just the I/A tips. So I’m going to put this instrument back in and try to nudge it into the center. And then put it back onto the tip here and eat that.

All right, so now I look around, everything looks okay. So I’m going to turn off my continuous infusion. And then I come out of the eye and no ris prolapse, so that’s nice. And now we’re going to switch to I/A, which I like to do with coaxial, I don’t think by manual. I’m not a big fan of it. I think you get more disturbing of the anterior chamber depth, it kind of bounces up and down. This has a more snug fit through the incision. And so you can see it stirs loose a little bit of cortical fibers over here.

And one trick, especially in blue eyes, is to go around with the I/A and make sure there’s no empty nucleus or little fragments hiding in the angle. Really not much cortex there. Can I see a push pull?

I’m going to move the iris around for you all to be able to see. So there’s some fragments here, there’s some cortex. I’m going under the iris there and I’m going to pull them to the middle here. And then I’m going to go into that polish mode like Dr. Truac was saying and get all of that stuff right there. And I’m kind of lifting it up and I’m going to go back into cortex. Now that it’s freely separated from the capsule, I can be a little more aggressive with the cortex mode. And bring it to the middle and eat it here.

You wouldn’t want to go just freely and start sucking with cortex. So again, a little polish mode here. You get some of those little fibers there. But most of that stuff can mostly stay. I’ll try to grab some over here and see how freely it wants to come.

It’s almost like a mature cataract that you don’t have much cortex to go and grab. And you can see the central part is clear there, so I’m going to leave that be. And then we’re going to inject the cohesive viscoelastic. And we really want to see that chamber deepen a lot, and we want to see the bag deepen too. So now I got a big, deep capsule we can put the lens in. It’s a one-piece hydrophobic acrylic lens. Clear, nice, good material, no glistenings, no chromatic aberration. And you can see my technician has loaded it excellent. And now I’m just going to use this thing called a push pull or a Kuglin, and I’m going to put it into the bag, and while it unfolds I’m going to kind of tap the optics here and get them to open up a little faster.

14.21 And then there we go. Now again, with the femto, it’s nice because you know you’ve got a five millimeter rhexis. I’m just going to just move the iris around so we can make sure we didn’t have anything hiding back in those parts. Okay. And now we’re going to do I/A and remove the remaining.

I’m not going too fast here because you can cause a lot of, if that lens, until it’s unfolded completely, if you’re too aggressive with the vacuuming it can sometimes make the lens bounce around and I’ve seen it flip. So removing all the viscoelastic. Okay, and we’re good. I turn off my infusion and then I’m going to hydrate my wound. And this is Moxifloxacin that I am injecting into the interior chamber, we like to do that on all our cataract cases. And this here is just hydration of our incision, you can see it whitening the stroma there.

And then we’re going to test the incision. And the way that I do that is just by injecting into the paracentesis here, seeing the chamber deepen, that’s a good sign. And then I’m going to go in with my cannula and tap down on that lens and get it to center in the bag better. And then now I’m goin to use strong burst, I’m looking to make sure there’s no leakage here. And then I’m going to touch on the eye, it’s still a little soft. And there we go. I touch now and it’s pretty firm and that’s what we want to leave it.

And so again, we did this with topical anesthesia. The patient’s really relaxed and sleeping, everything looks good. The lens is in the bag. There’s a little bit of some cortical material around the periphery. It’s a little tricky to get so we’re going to leave it and that should be fine.
So everything’s gone well. I’ll turn it back over to Hunter and then I’ll join you all again here in a second when I do the lecture. Thank you very much.

[Hunter] Well thank you, Doctor Lehmann, that was a beautiful demonstration. I think one of the key things to look at is his use of viscoelastic agents. Obviously, we use viscoelastics to protect the endothelium. During cataract surgery, we’re worried about three types of injury to the endothelium. Direct mechanical trauma from the lens coming up and hitting the endothelium, the energy from the phaco, so phaco trauma. And then, obviously, fluidic trauma, you don’t want to run a lot of fluid through the eye. That’s one of the things that I think you appreciated from Dr. Lehmann’s case was how little leakage he had from his wounds. Chamber stability really is controlled first by wound stability. Then we adjust parameters.

I was very impressed to see how nicely the chamber stayed full. And he used viscoelastics to protect the endothelium at the beginning of the case, and then to deepen that capsular bag so that the intraocular lens beautifully went in the bag, and slowly opened in a very controlled way.

I always remember viscoelastics, there’s three rules with cataract surgery. That the iris is always your enemy, viscoelastics are always your friend, but never leave your friend behind. And that’s why you saw Dr. Lehmann taking extra time to make sure all of that viscoelastic came out. So that there was never going to be a pressurized the next day. And that’s particularly important as you all start to use toric lenses so that you get maximum capsular contact with the intraocular lens. Dr. Lehmann are you ready for your lecture?

[James] Yeah, I’m ready for the lecture and I’ll answer a few questions that have come up on the chat. Dr. Regish Agerwall asked, “Do I regularly prefer dispersive viscoelastic?” In all our cases we use two viscoelastics, the dispersive for the first part doing the rhexis and then we’re going to put the bag in, we use a cohesive. There’s some combination ones that work great and you just need one. If you only had one, you probably would want a cohesive because it’s easier to remove. If you use a dispersive to fill the bag and then you put the lens in, and it’s very difficult to get all that dispersive out, and you can’t be sure where the lens position is in the bag. So if you only had one, go with a cohesive. But if you have two, that’s the best way.

And then Dr. Jesus Maticorena asks, “Do you remove the OBD from behind the IOL as routine practice?” When it’s a cohesive, you don’t necessarily have to, it will come up from behind. If it’s a dispersive, you definitely have to go behind and get it out. So generally I don’t have to do that. I can see the way that the chamber flattens and the way the lens kind of comes up, that’s there’s nothing behind it.

Next question is, what are the key points of Femto-Phaco and a highly myopic patient? So the main thing in a myopic patient is number one, there can be deepening of the chamber when you put an instrument in. As they get a capsulary block from the iris and you have to go and start an instrument under the edge of the iris and lift it up. So that’s number one.

Number two, IOL calculations can be hard in a very myopic eye, especially if they have steep K’s. Fortunately, lens powers in the myopes are generally very low. So if the effective lens position isn’t as critical as in a hyperopic eye. But those are the two main points. Also sealing the incision, you’re more likely to have to suture a wound on a patient that has a myopic eye, because they have a thin sclera and they have a floppy cornea.

Okay, Dr. Mortazi again. “How much moxifloxacin do you inject intracamerally?” I’ll have to get you the exact dosage, but we put about 0.2 cc’s. But the dosage of it is, I’d have to ask my nurses on that.

Dr. Long Dong Huong asks, “Why divide the nucleus not completely, can lead to posterior capsular tear.” Yeah, that’s true. Especially in the beginning, you want to make all four quadrants before you remove them. Because you’re right, if you get a hemi-nucleus and you pull it up, it can rotate and hit the back part.

“How to rotate an epinuclear sheet with one chopper?” By Dr. Davindra. In this situation I didn’t really have an epinucleus. You can make one by doing hydrodelineation in normal phaco. And it can be manipulated. But to me, that’s just extra steps. I prefer just doing hydrodissection and not hydrodelineation. If there happens to be an epinuclear sheet, you rotate it pretty much like you rotate a nucleus. Basically with a blunt instrument, you go out to the periphery and use toric to help there.

Dr. Aguilar again, “In flex, do we have to sculpt the lens fragments regularly?” Yes, you do have to sculpt a little bit. Because you have to be able to put your instruments in between to do the cracking. However you could do a stop and chop kind of, like the flax does the incisions, and you go in impale one quadrant, and then stick the chopper in and do that. That’s pretty fancy and I would love to do that. But I kind of keep things simple.

Dr. Sharma asked, “Do you practice horizontal and vertical chopping?” Normally, I only do divide and conquer. But in soft nuclei, I can chop the last heminuclous, but I don’t really do stop and chop. Because I’ve never been comfortable with putting instruments blindly behind the iris.

Dr. Tertag asked, “Do you use intracameral antibiotics?” Yes, we use Moxie. And Dr. Suresh Kumar Durwall is asking, “Is this surgery performed under topical anesthesia?” Yeah, that was topical anesthesia. The next one will be local because she was much more sensitive and not a very good patient. Which I’ll get into in the lecture.

So I’m going to cut over to the lecture right now and then we’ll come back to some questions at the end of the talk. Okay so again, I’m Dr. Lehmann, and this is our Phaco Surgical Steps and Intro to Femto-Phaco webinar. The objectives of this lecture are going to be to understand the steps involved in phaco, to understand the proper way to perform each step, and to gain an introduction to Femto-Phaco.

These are my disclosures. I’ve worked with ORBIS since 2005 when Dr. Cherweck and I were staff docs on the Flying Eye Hospital. And I’ve had the opportunity to be a volunteer faculty probably six or seven times since then. I also go with Sightlife to teach cornea in other countries. I’m a cornea and cataract doc.

We’re going to do a few questions before we get started with the lecture. So Lawrence, you can tee up the poll. So which method of prophylaxis has not been shown to reduce the incidence of postoperative endophthalmitis? Not been shown. Topical antibiotics, intracameral or Betadine prep? That’s correct. We all know intracameral antibiotics.

There’s a great study out of Araven, they looked at, I don’t know, 700 million eyes. And moxifloxacin was helpful, and then we know Betadine prep is helpful as well. Topical antibiotic, on the other hand, we just do because we do.

So what’s the ideal size of a capsulorhexis? It’s like Goldilocks. It can be too small, too big, or not important? All right, four to five millimeters. So everyone’s on the same page with that. Obviously, too big and IOL can come forward, too small and phaco’s too hard. So four to five is where we’re at.

Where in the eye should one perform phacoemulsification of nuclear quadrants? So basically, after you’ve divided and conquered, or chopped and whatever. And you want to eat the quadrants, where do you do it? In the bag, in the iris plane, in the anterior chamber, or in the vitreous gel? In the iris plane.

Man, my questions were too easy. Yeah, in the capsular bag is kind of dangerous because you can get the capsule. In the anterior chamber, you’re going to hurt the endothelium. The iris plane is kind of what you want to shoot for.

So phaco consists of these steps. Patient preparation, incision, rhexis, dissection, removal of the nucleus and cortex, insertion of the lens, and closure of the wound. And all these steps build on each other like a house of cards, so if you mess up the first step, all the other steps are harder. That’s why you have to master each step and do them well.

And that begins with patient preparation. I’m going to turn the volume down. So you’ll see in the video here, but basically the patient has to be comfortable and the surgeon has to be comfortable. So the patient needs, if they can do it without any IV sedation or just with the Valium, every country is different with that. If you do with a block, do with a block, if you can do it comfortably with topical, do it with that. But you need to find a comfort zone for you and for the patient.

The patient needs to be laying flat, the eye has to be nicely exposed, the lashes have to be out of the way. The eye has to be prepped with Betadine and I like the head to be tilted slightly to the surgeon, since I operate temporally. So that fluid falls out over the cheek so it’s not pooling in the medial canthal area. There’s a good view of the technician prepping the patient in that scenario.

Again, critical that you’re comfortable. Now, when I visited other countries, I noticed that the surgeons don’t take the time normally to get comfortable with the microscope prior to the surgery. The nurses come in and set it up and the surgeon just comes in and sits. I think it’s important before the surgery, before you’ve prep[ed the patient, to have the patient in the OR, sit down like you’re going to do the surgery, make sure that the height of your chair is correct, the pedal position, that your legs can fit underneath the head of the patient. That you’re not leaning too far forward or too far back, or crouching down to see the scope. All of these things are going to add up and cause problems if you don’t take care of them in the beginning. And the patient, like I said, needs to be comfortable and in a good position.

In terms of the incision, you can kind of get fancy with this, but the bottom line is to use a double bevel keratome, shoot for 2.6 to 2.8 millimeters. And do one motion in and out, where you’re not pushing down too hard, and you start at the limbus.

So some good form and some bad form. If you look right here, the first one shows good form. It starts at the limbus, where you see some little broken blood vessels like on my case. And it looks like a square, it doesn’t look like a tunnel. You want it temporal for many reasons, it’s further away from the visual access, it’s less astigmatic effect, and to me it’s more comfortable operating temporally than superiorly.

Now here’s poor form. Look at this incision, it’s too far anterior. That causes problems, it’s harder to seal, it looks ugly, and it makes it hard to do the phaco. Because when you start rotating the handpiece, you cause stria to radiate from the incision, causing you to have a poor view. It’s also harder to get subincisional cortex in that scenario.

By the way, I want to give props to Dr. Devgan for the slides, I did borrow them from him.

So again, good form is a square appearance with equal thickness of the roof and floor of the incision. Poor form is where you push too hard in the beginning and you get this chevron appearance that has a real shallow roof and a real thick floor.

And then the last thing, is you want to go straight in and straight out. You don’t want to enlarge the incision on the anterior, you don’t want to go in obliquely. And so in summary, if you look at this Part B here, a short tunnel is bad because it’s hard to seal. You want it to look as close to a square as you can, if it’s too much of a tunnel it’s restrictive, and it starts to interfere with your view.

So this is a video of some phaco incisions of my paracentesis. And that, you want it to be about one millimeter. Here I’m injecting Vision Blue, just basically to show how good you can see the width of the incisions better. I like to make it 1 to 1.5 millimeters. Now we’re filling the anterior chamber with viscoelastic. And then you’re going to see me make the wound here. I start at the limbus and in one move, I’m stabilizing the eye with my forceps.

I go in, and honestly, I could have stopped there, I went in too far. There’s no reason to go past that little mark right there. Again in slow motion here, you kind of go in. And you want it to be like a square, you don’t want it too long and not too short.

Okay, the next step is the capsulorhexis. We’ll start the video here. When you’re doing it manually, I like to start in the middle, and then a cystotome to start at the flap right here. Once I have a flap edge, then I start using capsulorhexis forceps, Atrada forceps. To me it’s better than with a needle. And then you can see me pulling around and I always grasp, and then regrasp in the same position every time. You don’t want to grab too close to the area of the tear because you’ll cause it to go out. And you don’t want to go too far, because then you can’t control it. It’s always about three millimeters away from the tear. And you just rotate around there.

Now hydrodissection, hold on, let me go back there. Hydrodissection is when you go right under the anterior capsule and inject fluid, you can see the nice fluid wave there. And then you blot down to keep the nucleus free and then you want to confirm. I’m going to go there again a little more, you want to confirm that you can rotate it. So I’m going to dig my cannula in and rotate it. That’s very critical, if you can rotate a nucleus you’re not going to have a hard time with the case. You’re going to be able to crack it and get those quadrants out.

So here’s just a little diagram about hydrodissection. This is where you want to be, just right under the anterior capsular leaflet. You don’t want to be in the nucleus because then you do the hydrodelineation, which is okay for soft nuclai. But it’s totally not necessary. I think it’s an extra step.

And then the divide and conquer. You know the technique is basically, you remove a little of the nucleus here in the center, so you have a good view. And then using the sculpt mode and the phaco machine, you create a tunnel, like a little crevice here in the middle of it. And how far deep did you want to go? You want to go to when you can start to see striations in the lens there. And that lets you know the right depth. So right there, you can see the reflection, you can see these little striations there, that’s how you know you’re about 80%. And then you can go in with your second instrument and crack it.

So again, when I was learning phaco, nobody taught me, hey how far deep should you go? I thought, do I need to get at close as I can to the posterior pole? Not necessarily. Once you start to see those perpendicular to your phaco tip striations, that tells you that you’re in the right depth to crack.

If you can’t crack it, if you put your instrument in and you can’t crack it, it’s because you’re not deep enough. And the first one always needs to be the deepest, the other one’s kind of go easier. So I like to make all four quadrants. Here, I just extend that first area, the little groove that I made, and now we have this hemi-nucleus there and we’re going to do the same thing that you saw on the video. So you guys get the divide and conquer stuff. And then we’re going to move on to.

A little sidebar here about Femto-Phaco. I didn’t show you what I was doing on these patients because it was hard to get the camera to give us a good picture. But this is what it looks like when it’s taking pictures. And then we’re programming it here. It’s centering on the eye and it starts its work. And you can see in this picture here.

We’re telling it how much astigmatism it has, it’s putting it into a nomogram and I’ll go into that in a little better detail. And then it begins the process here by doing the rhexis, you can see here going through the lens. And then the final thing and make sure those AK’s. In my opinion, I was not a believer of the Femto-Phaco, I had one of the first generation machines and it made life harder. But these newer machines are a lot better. And in my opinion, it can give you that consistent rhexis. It gives you a five millimeter rhexis that’s centered all the time.

The cool thing is, is that you can hook it up to your Pentacam and it can do iris registration for you, so that it can plan your AK’s and mark your toric lenses without you having to mark patients. It also creates those grooves and makes divide and conquer easier, it can do AK’s for low amounts of astigmatism, and it gets the IOL centered better. So it kind of simplifies some of the steps. It’s not good at making the incisions yet because it can’t make them so posterior, so I don’t use it for that. But otherwise I think it’s a benefit.

This is what it looks like when we’re using it. The patient is brought to a separate room. this isn’t the operating room, and nowadays the patient would have a mask, we have gloves, et cetera. But basically you put a little plastic speculum on the eye and then that uses a suction ring with only 15 millimeters of mercury. So it’s not real strong, it doesn’t hurt. And then you dock this glass and metal contraption on the eye and then we’re able to do the laser after that.

Here’s a video of a case last week with my technician. I’m planning the toric lens surgery. I’m just going to show you that again here. Because there’s kind of a cool part right here. So if you look at the Pentacam right here, It’s showing me a stigmatism here that’s already in sync with the computer, it does iris registration, I don’t have to mark the patient, and it’s going to put nubs, or little cutouts, in the capsule to show me where to orient that toric lens. And so it eliminates the need for marking patient and I think helps to eliminate the cyclotorsion problem.

And so here’s a little video of that. The case I did earlier this year and I’m trying to illustrate these little nubs, they’re hard to see because what they are is the rhexis has these little extensions here. So now I’m injecting a toric lens and as we all know, a toric lens has little markers on it that we have to line up on the toric access. So those are those little markers right here, those little dots. And so I have the little nubs and it’s hard to see in the video, but you can see it clearly under the microscope. Removing the viscoelastic, and now I’m strongly hydrating my wounds, and now I’m going to rotate this little guy so it’s right on those little nubs.

And it’s really nice. It eliminates parallax, it eliminates having to mark the patient in pre-op, and so I think that’s a big added value in Lensar and Femto. So I just wanted to stick that in there and we’re going to go back to the steps of phaco. I felt it’d fit in with the divide and conquer because it kind of helps with that step.

This has to do with cortex removal. Let’s go back there, sorry, a little video. And here we’re using I/A, now there’s different kinds of I/A tips. I use a metal I/A tip now. This is a silicone one where you can be a little more aggressive. But as we know, you basically catch a tag and bring it to the center and remove it. Sometimes it’s thicker than other times, sometimes it’s thinner. But the bottom line is keeping that tip away from the posterior capsule because we don’t want to cause a tear.

I think the last time I broke a capsule it was during this step, which by then you’re kind of thinking, man, I’m already out in the clear and it’s all easy now. But anyway, you can see here, this is pretty straightforward, this is not the hardest part of phaco to master. Really the hardest part is doing good quadrant removal and good rotation of the nuclei.

So we’ll skip over to the injection of the eye well. So we’re filling that cohesive viscoelastic to fill up the capsular bag and then we’re injecting the lens here. And I like to use these acrylic lenses but silicone lenses are great too. They have some really great injectors, I use a push pull rather than just a Sinskey, or a Kuglen, because it can do pushing and pulling, not just pushing. Then we center it up, make sure the haptics are freed off the optics. And basically remove the viscoelastic, and then hydrate the wounds. And again, I like to use the moxifloxacin to do that. So we’re almost done here guys. So in wound closure, you want to confirm at the end of the case, that the eye is firm.

And I wanted to say just some of the common mistakes for beginners are going to be these things. Number one is poor patient positioning. Like that head too far down, or extended, or rotated a way that makes it hard for you to have a good view. Making your phaco incision too long or too short is a common mistake. If it’s too short, you’re going to have iris prolapse and leakage, if it’s too long you’re going to have a distorted view. Making the rhexis too small is a common mistake when you’re learning because you’re nervous and you want to make a good rhexis. If the rhexis is too small, it’s hard to get the quadrants up and you end up causing problems. Another thing is incomplete hydrodissection. You need to be able to confirm that you can rotate the nucleus prior to starting with phaco. So after you do hydrodissection. get in the habit of blotting the lens, pushing it down, and then trying to rotate it. Number five would be starting too fancy phaco technique too soon. So divide and conquer is a good technique. It’s great to learn chopping and it’s cool to watch videos and all that, but master the basics first so you can always go back to them. And then the last thing that even experienced surgeons error with, is not keeping the eye in primary position. So especially when you’re doing a webinar, that eye needs to be centered the whole time. So that makes it easier to see what’s going on.

[Hunter] Thank you very much, Dr. Lehmann. That was an excellent case. And it gave great review. I think one of the things while Dr. Lehmann is getting ready. I just want to go over some of the key things that he said. Patient positioning is key. Not only having it parallel to the floor but at comfortable height. I can tell you, I’ve walked into hundreds of operating rooms around the world, and I see doctors hunched over like this, or their hands not stable. And that’s simply going to make a very long day and a very uncomfortable case.

It’s one of the first things is patient positioning. Make sure that the chin and the forehead are flat, and that you’re not distorted, or having the eye in an uncomfortable position ergonomically for you as a surgeon.

I think one of the things that Dr. Lehmann talked about was the importance of draping. I can tell you a lot of people skip the step of draping and have lashes in the way. We all know that’s where the bacteria are that are going to cause the endophthalmitis, then also it can create pooling, or create other problems that are going to affect the visualization during the case.

So although it seems like a small thing, draping is a very important step and something that you should take very seriously and not start until you have a good view and there’s no pooling or problems with the irrigation fluid.

James, Dr. Lehmann, makes the wounds look easy. I can tell you wound construction is one of the most important things to do, not only for chamber stability, but as you’re looking to start toric cases. If you have inconsistent wounds, you’re not going to have consistent refractive outcomes.

And I think he’s about to begin the last case. The last thing I’m going to say is, remember that first case was a high myope. And if your tunnel’s too long, you’re going to be distorting the wound trying to get the phaco tip down into a deep eye.

So this patient, as Dr. Lehmann said, was blocked. So we’re doing a local anesthesia, not topical. Where it’s a very, very dense lens, the patient’s refraction before surgery was -0.5 plus .25 at 178. So not a high refractive error and not a lot of astigmatism. Like the first patient, this patient is diabetic and has been pre-treated with a femtosecond laser.

[James] All right, everybody. Thanks again. We’re looking at the patient here and you can see it’s a mature cataract. I’m going to get started. You can see again the little hemorrhages from the femto. We had to mark her eye, most of the time the iris registration it’s great on the Lensar, but in this patient it wasn’t working. I think having to do with not being able to see the iris and in contrast with the lens, so we put marks and did one little AK here at 180.

But basically, it’s a mature cataract and these mature cataracts can come in two flavors. They can be soft and feathery or they can be dense. And when they have a little yellowish tint like this, you know they’re kind of dense. I’m going to start with my paracentesis wand and then obviously the mature cataracts can be tricky with doing the rhexis, it’s the hardest part. They want to run out and oftentimes there’s an imbalance in the pressure between high-pressure in the capsular bag, and then low pressure in the anterior chamber that causes Argentinian flag sign. So the femto works nicely in these cases.

I’m putting Vision Blue in here, just so you guys can visualize that it’s a complete capsulotomy and it also helps to maintain the orientation during the phaco. So I’m just rinsing it out here and we can kind of see some of the capsule there staying, and then we’re going to put in the viscoelastic, which is, of course, again to disperse it. And just like Dr. Cherweck said, this patient is blocked. She was very nervous and had a hard time maintaining her lids open so we didn’t want to make it any harder than it should be.

So I’ve cleared things up, you can see the rhexis, you can see the capsulotomy is good. And we’re going to make the main wound here and then I’ll go in with some Utrata forceps to remove it, So again, I stabilize the eye by closing the .12’s, and then going right at the limbus. And then one step going in, just to that mark, and then out. You can see the bleeding there at the wound, that’s what we like to see. And then we’re going to go in with the Utrata forceps and we want to make sure there’s no tags, that’s a main thing. So I’m going to go in and grab where it’s already up like that and then I’m going to just, you can see it being pulled there. And everything went nicely there. So we have a nice 360 rhexis and that’s tricky to grab that, and we’ll just remove that from the eye.

So now, the other thing that I learned when I was in residency, was that you do not have to do hydrodissection of a mature nucleus. That cortex has already been liquefied and so I’m not going to do any aggressive hydrodissection here, just a little bit. And then I’m going to be able to show you that you can rotate the lens fine, see?

So again, you can make a mistake o,f capsules can be really fibrale in mature lenses and so if you’re too aggressive with hydrodissection, unnecessarily, you can cause a blow out of the posterior capsule. I have the continuous flow and then you can see it again, I didn’t talk about it much, but here’s the phaco tip. I use a Kelman 45 degree, because to me it’s the easiest to cut with. There’s different kinds of phaco tips, you can have 30 degree, which is better for stop and chop. But you have to talk to your mentors, and learn about the different tips, and see what works for you.

I always put it in upside down so that I don’t jab the iris. And then I rotate it 180 degrees. And then, I’m just going to clean a little of this. I’m going to switch to quadrant. I’m going to remove a little of that cortex, just to kind of get an idea of where the truth depth of that lens begins. We clear that area where you made the rhexis in. Now I’m back in sculpt, I can’t really see where the femto did its work. But I’m just going to start with a groove right centrally. And I’m using only a moderate amount of pressure, doesn’t seem too deep yet. You can see the lens move, that tells you there’s not much cortex. But it doesn’t move too much, it’s not scary moving, like if it didn’t have good zonules. And then how far down do I want to go? Look, I’m starting to see a red reflex there, I’m going to focus down for you. Some striations, I think I’m pretty good there to be able to crack, so we’re going to give that a chance. If not I’ll go a little bit deeper.

I’m trying to keep that centered for you all. And it cracks pretty easily. And then I’m just going to move some of that liquefied stuff, and then see how easy it is to rotate. Remember, I didn’t even do any decent hydrodissection and it rotates easily.

So now I know the depth that I need to go for these. That’s the easy part. And once you have the first crack, you know how far down you have to go, basically as far as the first one. And so that looks about the same, you can see down there in the trench. And then again, we just crack that gently. And then again, notice when I do this movement with my hands, I rotate my right hand to get the tip out of the way. If I didn’t, guess where I’d be hitting and going over. So that’s a nice move to be able to do that rotation.

And rotating a nucleus is like opening a door. If you go up peripherally, it just takes a little bit of effort and it spins. If you try to do it centrally, you just push it to the side. You’re not using the torque that you need, so you got to go out peripherally to rotate a lens nicely. And here’s my groove from the first groove, so I just go back into that trench and there I’m at the right depth. Cracks nicely, rotate my hand, spinning it around another 45 degrees, 90 degrees, and then I’m going to go to this last hemi-nucleus.

And now if I had to remove these two quadrants, and then I just tried to do what I did there by doing a groove in the last one, it would be moving around all the time because there would be no other pieces trying to stabilize it. So especially beginning, do all your quadrants before you remove them, it’s just going to make life easier. So now I know they’re free, so I’m going to switch to quadrant mode and I’m going to rotate the tip of my phaco so that I can get the largest piece occluded. And now I’ll bring it up into the iris plane, bring the focus to that. And now I’m just going to eat it, really minimal power. Turned out it wasn’t as dense as it looked.

Then again, I’m not going to go grabbing stuff. The best thing to do, especially if you’re a beginning phaco, is to always move the piece directly across from you. That way you’re always doing the same move and you know how that little piece is going to come into the phaco tip. You’re not guessing it’s going to flip or anything. So I’m eating this a little higher than the iris plane. I’m guilty of that because I see that capsule doesn’t have any cortex protecting it. See, most mature cataracts don’t have any cortex, as we discussed, so just has a little blotchy stuff. Some VSS, please?

Now again, look what I’m doing. I’m not going and dragging this, and trying to bring it here or anything. I’m rotating the pieces around and I’m putting it across from me, before I go grab it. Now it’s attached to the middle there, that’s okay. And then we’re just going to be patient. I’m going to remove my second instrument. I’m phacoing the AC now more, eating that last piece, excuse me the third piece. And now I’m going to rotate and rotate my phaco tip and then gauge that corner of the lens right there. And now we’re in the AC. And again moderate power and I don’t really need to be protecting my capsule, as long as I’m up high and I don’t have that phaco tip pointing inferiorly.

See, it is just bouncing on the tip there, everything is going fine, just taking my time being patient. Now there’s some little stray fragments floating around. So that one’s right there. That one I should be able to eat with the I/A, but I’m just going to show you how to get a piece like that. So first, we’re going to get that one. Now here what you do is, you lower your phaco tip and now I’ll raise it, and just move that second instrument around. And kind of swing it around. It wants to keep coming there because there is some outflow there. So I’m just going to move the phaco tip and I’ll take it with the I/A.

Now you see some cortex but most of it’s on the posterior capsule, but we’re going to go in the anterior capsule and make sure there’s none that we can pull out easily. So that piece kind of got, so now I’m just eating it. A little trick I like to do, is kind of mash it at the base of my paracentesis where I know those endothelial cells aren’t happy anymore anyway, without having to stick a second instrument in. So I’m kind of doing gentle cortex removal. I don’t want that posterior capsule to trampoline. And this is really stringy, fibrotic stuff, it’s not like big, meaty cortex. So I’m just getting what I can get, without causing too much problems. Let’s get some of that. So I’m using very moderate vacuum here because if I use too much it could tear off.

So that’s pretty good. I’m not too concerned about it, I can polish so I can demonstrate if you wanted to go get some more. You can use the polish, which is low setting here. Just need to grab it like that. See how I’m grabbing this? But none of it’s in the middle there so it’s not really that consequential. Don’t want to spend too much time messing with it. Okay, so remove that.

You can see the capsule is clear here in the center. Here’s my cohesive viscoelastic. I’m going to augment the size of the capsule there, get my lens centered here, and then inject. And now using this Kuglen hook, just get that trailing haptic in the bag. Get it centered and then snap at the haptics here, make sure they’re not stuck. And then just a waiting game a little bit to let that thing expand. And this is the I/A handpiece with a viscoelastic setting, which is, just means a little more vacuum and a faster ramp up.

So here you can see the little movement in the anterior chamber of all the viscoelastic. This is a case where you could easily have a nuclear fragment hidden. She has a light iris and she has a little bit of an arcus. So I’m going around the angle and making sure there’s no fragments hidden there. I’ll go over here, at least to the side of the optic, so everything in the bag has come forward, I can see that. I’m just entering the lens and now I can kind of put the pedal to the metal and keep it here in the anterior chamber. And I don’t see much happening now, that tells me that a lot of the viscoelastic is gone. So I’ll get that lens a little more in the center and then I’m going to turn off the continuous irrigation and remove it. I can clearly see the back of the capsule, I clearly see that the optic has come forward. That shows me there’s no viscoelastic left.

This is the moxifloxacin that I’m going to put in my sideport incision. And then this is VSS on my 2.66 millimeter incision. I’m going to do the stromal hydration. Now I’m going to make sure that the lens sits back and that it’s completely covered by the rhexis that we made. I’m just gently injecting keeping the AC deep, so we’re nice and centered. Except I don’t like that haptic that hasn’t come unfolded yet. So I’m going to go in with my. There we go.

So now we know we’re in a good position here. I’ve got a 360 coverage of the rhexis, the haptics has expanded. Now I’m just going to fill the AC. I’m looking here at my wound to make sure there is no leakage. I feel like the eye’s firm, no, could be a little firmer. And that’s perfect. So I’m a little too firm, so I’m going to remove that. So we’re all done. I appreciate it and we’ll go take some questions. Thank you.

[Hunter] You know, thank you, Dr. Lehmann. One of the things I think you saw within this technique, was how he was very patient with the crack. When you’re grooving or sculpting that first groove, it’s like landing a plane. You want to come down and then back up. So you’re constantly sculpting and you want to be between the capsule or rhexis, you don’t want to be grooving under the capsule. You saw that Dr. Lehmann had a really nice depth where he started to see the red reflex and got both of those instruments very deep into the groove, so that when he applied that, the crack propagated along the entire length of the groove. So you saw that he had a really nice groove, that’s critical. And the mobility that he created is critical, so that as you move the quadrants around, it’s like eating a piece of pizza. You want to start at the point of the pizza and he had maximal occlusion with that 45 degrees Kelman tip.

Dr. Lehmann, they have some questions for you. I was just commenting on how nicely you had lens disassembly and movement inside the eye. And I think that was largely from both the fact that it was a white lens, but that you took your time and got the pieces lined up.

So thank you so much. Those were two beautiful demonstrations, you made them look easy. And certainly, it was nice to see how you can always do divide and conquer, even in the most challenging of cases. So yes, Dr.. Lehmann, are you ready for some questions that we have online?

[James] The first one by Dr. Lagow is, “Generally how do you know when to stop doing cortical clean up?” In those cases, there wasn’t really any cortex, there was just some remnant stuff. If they have cortex, you have to pretty much get all of it, if you’re pulling things off. Now if there’s some small subincisional cortex that you’re having a hard time getting and you think you’re going to tear the capsule getting to it, you can leave that. But it will get all fluffy and white and will cause some inflammation. So you try to want to remove all cortical material if you can. But in a case if it’s a mature cataract, or there’s not real cortex, leaving that fibrotic stuff in the periphery is not a big deal.

Dr. Fard asks, “Do you use a CTR for myopic patients?” I only use a CTR if there’s non-elastidy. And which you can tell during the case. Generally it’s helpful for two to six o’clock hours. I don’t use it routinely in myopic patients.

Dr. Kasheef asks, “What about small pupils in diabetics?” Yeah, those are no fun. You have to use a pupil ring for those. There’s different kinds, the Malyugin’s the most famous. Diamatrix makes one, or iris hooks if you don’t have any pupillary ring available.

Dr. Tertog asks, “In case of posterior polar cataract, what’s the technique?” You have to say three Hail Mary’s, no, I’m just kidding. What you do is, you need to do hydrodelineation in those and don’t try to rotate the nucleus or do hydrodissection. They’re generally soft, thankfully. So you remove as much as you can, leaving that little plaque there at the back for last. But the majority of the time you’re going to be safe and then sometimes when you take it off, the capsule will tear. So then you got to put a lens in the sulcus and do optic capture.

“What was the purpose,” Dr., I can’t read it because it’s in Cyrillic writing, Ana something or other. Komarob, something? “What was the purpose of introducing blue dye in the first operation?” It was just to show you all. I wouldn’t do it normally. It was so that you could see that the laser made a nice capsulotomy.

Dr. Shrestha asks, “How do you do a direct chop technique?” You have to have different parameters and you go in and impale the nucleus. And then put a chopper behind the equator and bring it to your gizmo. That’s a big technique, that could be a whole lecture in itself, so I’ll pass on that.

What phaco parameters? Like Dr. Cherweck said, I would go to the ORBIS website and look over some of those phaco lessons there. Dr. Gool asked, “Do you prefer aphakia or a zero power lens and high myope?” Always a lens, if you can put one in. It’s always good to keep two chambers in the eye. I think unless there’s glaucoma, and I mean, vitria is always coming forward. I wouldn’t want to leave a fibrotic capsule in place there.

“Do you recommend lens epithelial cell cleaning routinely?” That was by Dr. Faard. You can spend an hour on a phaco going and buying, cleaning the posterior aspect of the anterior capsule the whole time. But I think as long as the center part is clean, you’re good.

“Do you inject trypan blue with or without air?” You don’t need air, that’s an old way to do it. It doesn’t hurt the endothelium. We stain DMEX with it, right? And we do DMEX surgery. I mean it will hurt the endothelium, just like anything can, but not just for the little bit that we use.

Anonymous attendee, “I have a question about the settings of phaco in this case.” Again, I wish I had the overlay so you could see them, but we were not able to get that set up. It was making the video look wobbly. So I don’t have that info for you but the resources on the ORBIS website can be helpful.

We have a doc from Ethiopia here, “Thank you. Dr. Lehmann, for the presentation. Can you please compare temporal incision with superior temporal?” Either way is fine. To me, temporal is the most comfortable. Hospitals in a lot of countries don’t have stretchers or beds that’ll make it easy for the surgeon to sit temporally. I think that’s why most surgeons outside the US and Western Europe sit superiorly. But to me most surgeries, you have more room. The cornea is longer by 20% horizontally, so you just have a better view sitting temporally. And for DSEK and DMEK we sit temporally, again, it’s what you’re accustomed to.

Dr. Aguilar asks, “Sir, please guide about ideal sideport wound construction.” That’s iris plane in and out,1 to 1.5 millimeters.

“Can femto cut black heart cataract?” Dr. Ton. It can try, I don’t think it would do a great job but it can try.

Okay, Dr. Tuarey, “What phaco power are you using? Longitudinal or torsional?” I use the Johnson & Johnson machine, in this case, the White Star. And it uses torsional phaco. I also do the Kelman 45 degree tip. That’s what I like because sculpting is easy with it. And I think that the 30 degree tip, it grabs pieces too aggressively.

“What are your recommendations on groove depth?” So 80% when you start to see the striae, looking like this, that’s when you know you’re deep enough. With one and a half phaco tips.

Dr. Sherpa says, “Video not working.” All right, I think it was working. All right, next one.

“Do you consider preoperative specular microscopy in patient with dense brunescent cataract?” Eh, I don’t think so. They’re going to need the surgery in that case anyway. If you don’t see obvious you today, you can tell them, odds are, they’re going to do well. You can also consider doing a small incision cataracts surgery if it’s really dense. In a lot of developing countries, people have experience with that and so that’s going to be easier on the endothelium than phaco.

“Do I ever use my manual technique for removal of cortex?” I do not. Once in a while I will, but I don’t like it because the chamber gets shallow and deep. You can’t get enough inflow through that tiny little gizmo. So I never really liked it.

Dr. Aguilar, “Sir, is this Tekna sidewall?” Yes, it’s a was a ZC boo.

Dr. Ali, “Can we enlarge a capsulorhexis if we made it small?” Yes, but it’s tricky. You have to make a little nick into it and then rotate it around again.

“Sir, you had remove second instrument during last piece,is it safer?” I feel like with modern phaco machines, you’re safer removing the second instrument and keeping just the phaco tip in the eye, and not protecting the posterior capsule. Because when you’re protecting the posterior capsule, you’re pushing on the sideport incision, fluid is coming out of the eye, and you have more instability of the chamber.

I have to go, guys,so I’m not going to be able to answer all of these. But I’ll do maybe two or three more. “Do you have any hints of implantation of IOLs with slow unfolding behavior?” Yes, if you heat them, because the operating theatres are cold. So if you put them somewhere warm like a towel warmer or even next to something warm like under your arm, under the circulating nurse’s arm. You put it in a box like that, it’ll warm it up.

And then I think that’s all, so I appreciate your attention. I’m sorry if I didn’t get to all the questions. But any questions that I didn’t answer, you can go to the ORBIS website. They got awesome resources. So anything else, Dr. Cherweck?

[Hunter] No, I’d like to thank you for your time today, Dr. Lehmann. And we look forward to working with you again when we’re flying again. Again, I encourage all of the viewers to look at the Cybersight phaco courses. Look in the library for many of the phaco videos.

So again, I want to thank everyone for your time today. It was a great session, where again, I want to thank Dr. Lehmann for showing us both the fundamentals of phaco, as well as how to incorporate femtosecond laser into our practice. And it was really exciting to see how you’ve combined that practice to have optimal outcomes and make the surgeries look easy. Especially when that CCC was already done in a white cataract, where you’re not worried about the Argentinian flag sign or run outs. It kind of already de-stresses the situation beforehand.

[James] Thank you guys, I’m going to check out. Appreciate it.