Lecture: Using Simulation to Conquer the CCC

One of the most difficult steps of phacoemulsification to master is the creation of the continuous curvilinear capsulorhexis or “CCC” as pioneered by Howard Gimbel, MD, MPH, FRCSC. Occurring prior to the use of the phaco probe within the eye, the successful creation of a CCC is vital to the safety of the procedure and the long-term stability of the lens implant within the eye. With recent advances in simulation models and techniques, it is now possible for surgeons to understand and practice the fundamental technique of CCC before ever attempting this procedure during an actual case. While these simulation models can help develop competency in CCC, it is also now possible to create greater levels of difficulty (including creating posterior pressure and a more shallow anterior chamber) as well as practicing rescue maneuvers which can also be practiced to redirect a tear that is running out. This webinar is designed for cataract surgeons wanted to improve their CCC techniques as well as for cataract trainers who are wanting to learn new, safe methods of teaching this critical skill to others.

Lecturer: Dr. Stuart Stoll, MD, Founder & President, insEYEt, LLC, California, USA


DR STOLL: Welcome, everyone. Good morning. I’m coming to you from Beverly Hills, California. It’s 7:00 in the morning. I don’t know what time it is for all of you, but welcome to this Cybersight webinar. Today we’re talking about using simulation models to conquer the CCC. So here’s my financial disclosure. I did create a company all around ophthalmic simulation models. One of the models is SimuloRhexis. So there’s more information on that later. I’m a general ophthalmologist in California since 2001, my focus is on cataract and refractive surgery, and this whole simulation and developing teaching methods came about because after my fellowship in Georgetown, I had the opportunity to do a LASIK fellowship with Dr. Howard Gimbel up in Canada. It was an amazing experience, I learned a lot about LASIK, but I didn’t get to do any cataract or intraocular surgery, because I was a US citizen and they wouldn’t allow me to do any cataracts. So I got to watch him and learn from him, but I didn’t do any surgeries, so my skills at surgery were only at a resident level. And then I started a practice in Beverly Hills, and it’s a challenging place to be. Expectations are very high, my surgical volume was low, initially, and it was a challenge getting back into intraocular surgery. In particular I struggled with capsulotomy. I remember those days. And it was not fun. I had to find ways to practice techniques to rapidly improve my skills, and one of my friends at the time showed me some plastic film we got at the Hallmark Store, a gift shop, we used that to tear capsules, and I refined that, made it better and more realistic, and today we have this whole line of ophthalmic surgical training models called SimulEYE, and it flattens the learning curve. It helps me, it helps other people, and it turned into a whole business. So let’s jump into a polling question here. My understanding of CCC creation and management is: Excellent, just okay, or what’s a CCC? Take a moment and enter your response. I would just like to get a sense of who the audience is here. I’m guessing these are mostly surgeons in training, at the beginning of their learning curve. Going through things. Hopefully who we have a lot, that’s tuned in today. And I hope this will bring up some valuable insight. Excellent is 6%, just okay is 81%, and what’s a CCC is 13%. Sounds like we’ve got the right audience here. We’re targeting younger or newer surgeons, people just starting the CCC. So what is the CCC? Let’s talk about the background. It stands for continuous curvilinear capsulorrhexis, with the most important term being curvilinear. Rhexis means to tear, so it’s a continuous curvilinear tear in the anterior capsule. We’ll go over why that’s so important. But this came about over many years, through contributions from Dr. Thomas Neuhann and Dr. Shimizu, but it’s largely attributed to Dr. Gimbel, who I did my fellowship with, and he presented the continuous tear capsulotomy in 1985 at the American Intraocular Implant Society Film Festival. I would encourage you to read about the history of how he developed this technique, and go see his chalkboard explanations, which are fantastic, how he explains the forces and why the capsule tears the way it does, and we’ll show that in our videos as well, in a little bit different format. So key steps to prepare for the CCC. You have to understand the anatomy of the anterior chamber, the lens capsule, and the zonules, because they’re all interacting together when we’re doing the capsulotomy. You have to achieve optimal visualization of the capsule. Understand that a lot of scopes have a red reflex lighting system that enhances the red reflex, or if you can’t get a good red reflex, for whatever reason, you have to use a capsule stain like Trypan blue. You have to see what you’re doing and control the capsulotomy. You have to have familiarity with the cystotome and the forceps, and viscoelastic is your friend. You have to know where to grasp the capsule and the optimal clock hours to start, stop, and regrasp the capsule. You have to tear the capsule with control and understand the difference between shearing force and tearing or ripping forces. You have to have contingency plans for complicated scenarios, like the rescue technique, if you have a small rhexis, if there’s posterior pressure and the rhexis is running out. You have to know how to manage those, and you can practice those with different scenarios. And how do you practice? You don’t want to practice on your patients. It’s true that as we operate we get greater proficiency, and that’s really how you become a master surgeon, over years of doing cases and learning from your mistakes, but you can practice a lot with models now, prior to your initial cases, so you should feel confident and prepared going in to them. With CCC creation, you’re not gonna learn it all here on a webinar, of course. You have to go to many sources, go to your mentors who are teaching these surgeries, go to lectures, go to meetings, and check out many videos. There are surgical videos by experts online that you can find on YouTube and EyeTube. And a fantastic source is CataractCoach.com. I encourage you to go there. He’s a fantastic teacher and has contributed a lot through that website. There are multiple scenarios to practice, and we should practice using simulation. There’s no reason not to practice ahead of your cases. Just a little bit about my evolution as a surgeon and trainer and inventor and really an entrepreneur in this, is we all go through this evolution as a surgeon, from beginning to more advanced mastery of techniques, but in that process, because I struggled, and because I created teaching tools for myself, I shared those with others and tried to help others as well, and found that it really kind of took off. And so I became an inventor, just by default. And then as there was more of a need for those inventions, I became an entrepreneur and developed a whole business around it. So SimuloRhexis was the first of the SimulEYE line of ophthalmic surgical training models, and that led to a whole other line of helping surgeons with things. We did a talk on MIGS earlier in the year, where we showed simulation on models for MIGS, and that’s had a tremendous benefit, even experienced surgeons, getting them to do their first cases on models. We’ve refined these models over many years of hands on experience working with residents. The models are great, because they’re easily accessible, they’re portable, they’re lightweight, you can use them in the OR with your own instruments, and it’s never going to be exact human tissue, but it accurately mimics the feel and action of the human capsule for CCC. And the goal is to provide a platform, where you can get experience. You can understand angles, you can understand where you’re supposed to approach and how you’re supposed to do things, without being in the actual OR with the patients. So the thing that we’re gonna be talking about today is the SimuloRhexis kit. There are available refills, so you can practice multiple times, multiple attempts at making the CCC, and you have the ability to increase the level of difficulty. You can practice simple things like making incisions, you can practice the full rhexis, and you can practice more difficult scenarios. Creating posterior pressure, shallowing the anterior chamber, rescuing the capsule if it’s starting to run out and get away from you. Here are some early prototypes. I think you can see my cursor. These guys on the side — I had a revelation of using a suction cup to support the eye and allow eye movements. That came from seeing one of my son’s toys he was playing with when he was little. I thought — why not use a suction cup? It gives us stability but also rotation and eye movements. I went across my office to the drugstore and got candies, toy things from the vending machine, for 50 cents, and I opened them up and made caps and put the films over them. This was my platform to work on, and on the left here is another version of that, where I used the Dremel to cut parts and make it. This is part of the invention process. That turned into a more robust model here, That we used for TrueVision 3D, as they were showing their technology at the shows. We got fantastic feedback on this. It helped for a number of years for people to practice in 3D without looking through the microscope. And people asked where did you get this eye? Where did it come from? We knew there was a need, so we decided to make more of a platform, and on the left are some actual prototypes. This is when 3D printing was not as robust as it is now, but we could create models, cut metal, started doing injection molding, and once I had a platform, we could create so many other different types of eyes for different things, and that’s how this whole process developed. And fast-forward — I’ve basically become an expert in simulation for ophthalmic surgery. I never set out to do that, but that’s where we are now, and I’m really pleased that it’s having an impact on the ophthalmic community for training. You can see some of the models in action. This on the left here. This is one of the core programs that was sponsored by Alcon for many years. It’s been renamed, but basically they would bring residents in two or three times a year, all across the country, and I would go there to help teach, and in the process of teaching, we would use the models, and we would get feedback and refine models, and each year we got better and better. The feedback was fantastic, but there were always ways to improve, until finally we have a much more developed product. It comes in a kit, there’s refillable films, but basically I just want you to see what it is that we’re gonna be showing the videos on, that it is just a model that is very small and portable. And if you want more information, you can go to our website. There’s a video showing how to set up the model and features and things like that. But we’re not gonna get into all of that here today. So why the need for simulation? Well, CCC is arguably the most difficult step in cataract surgery. For beginning surgeons, including myself, when you’re there, and you’ve got to create that CCC, and get it completed, your heart rate is up, and you know that it’s an important step. Why is it important? Well, it’s vital to the safety of the procedure. During the surgery, intraocularly, and also the stability of the lens implant in the eye. It happens early in the procedure. It’s one of the early steps that we do. So complications with the CCC can cascade and lead to a significant downhill effect, where you get intraoperative challenges, vitreous loss, inability to place an intraocular lens where you want to, all these complications that can affect patient safety and visual outcome. So it’s really important to nail the capsulotomy to ensure a great case. The CCC is more important than ever now. These new ATIOLs require perfect and precise capsulotomies. The toric, multifocal, EDOF, pseudoaccommodating and accommodating lenses that are coming out. These require an intact capsule, a precisely placed capsulotomy of appropriate size, 5 or 5.5 millimeters. It’s important that FLACS or femto laser assisted cataract surgery, is being adopted. CCC is a major component of this expensive technology, but surgeons including myself are adopting them, because it’s like cheating, basically. You buzz the capsule with the laser, you’ve got a great capsulotomy ready to go, you pull off the anterior capsule, the lens is chopped into quadrants or sextants, and you take them out, because it’s really like cheating. But you have to have your skills down. Even if you have access to a femto laser for cataract, you have to have your skills down. There are gonna be times where you can’t use those lasers. The pupil is too small, or many of us are just not gonna have access to those. Or in the beginning, I was a very early adopter of FLACS, and it was actually more challenging doing surgery with the laser, because we would have tags, and things where you pull on the capsule wrong, and you would have a weak spot and it would run out. That’s largely been resolved, but as an early adopter, we had to know how to manage those issues. So when practicing CCC with simulation models, you can practice all the different steps. You can practice entering and exiting the incision, and filling the eye with viscoelastic. You can practice moving smoothly within the incision. We’re gonna talk about oar lock, versus pushing on the incision. You want to practice not distorting the incision, because you don’t want to lose viscoelastic. You can practice initiating the flap and then completing the CCC, and doing that with the cystotome, or forceps. And you want to practice the rescue technique, and other challenging scenarios. And we’re gonna show video clips, break it down and show video clips as we go along here. So let’s jump into another polling question. Before my first cataract surgery, I practiced with models, I practiced on animal eyes, I practiced with human cadaver eyes, or I didn’t practice on anything. I’ll tell you my own experience. We had a few wet labs during my residency, where different companies came in, and brought some pig eyes for us, we tried to do capsulotomies, we would sit there and struggle with the capsule, because it was very rubbery, the view was very difficult, you would get the phaco probe in the eye, and the capsule was very soft. I didn’t get much out of it. If anything, I maybe got some bad habits out of it. We didn’t have electronic stimulation like they have now, and they certainly didn’t have the models available back then. Before my first cataract surgery, I practiced with models. That’s great. I practiced on animal eyes. That’s very common. It’s interesting. A lot of people practiced on animal eyes, and I think that’s been a standard of care, with pig eyes especially, but honestly, they’re just kind of gross. And they’re just not realistic. Human cadaver eyes — I practiced on those with some of the early MIGS cases, because that’s what Glaukos came in. That was not the best experience. I think in this day and age, it’s not acceptable to not practice on anything. Another option we didn’t put up here is you could get grapes or you could get tomatoes, and you can practice doing capsulotomies on that. And that will actually work. It’s better than nothing. But with models now becoming more and more available, if you don’t have access to them yourself, go to your institutions, wherever you’re training, and encourage them to say: Let’s reach out. Let’s get some models in here. Let’s build up a better training program for ourselves. So the practice options — human cadaver, animal eyes. Many limitations, including cost, availability, sterility, safety, ability to use in the OR, and they’re just not pleasant. Preserved tissue is not realistic. Once it’s preserved you’re not getting the benefit you think you are. The pig eye anterior capsule is much more rubbery. It creates bad habits. You’re not gonna understand the proper tearing forces if you do capsulotomies on pig eyes. The model eyes make sense. You can do them outside the OR with the magnifying lamp, but it’s best in the OR with your scope and chair and instruments. You can do them multiple times and create various scenarios. So the advantage of simulation with models is: Like I said, you practice in your own OR with your own chair and own instruments. That’s an advantage over some of the digital systems, where the instruments are not that realistic, and you’re not getting yourself depth of field and focus and hand positioning as you would in the actual OR. So with the models, you can practice the body and hand position, you can optimize your approach angles. You’re working on your actual scopes. You can learn how to focus, how to zoom your scope. You can adjust your lighting. On the models you’re not gonna get an actual red reflex, but you can play with the scope and say… Here is my red reflex button. It brings in that light and it will enhance the red reflex. You can work on stereo vision and gauge depth within the eye. You can practice multiple times in an environment where there are no mistakes and no stress. So I think simulation models are becoming the gold standard in training. Especially for the CCC, it’s extremely helpful for surgeons before surgery. This has been validated by feedback I’ve gotten for many years, working with experienced and novice surgeons, that these models provide a training platform to practice in this non-stressful setting, so you can make adjustments and gain confidence. There’s no penalty for mistakes, you can try out different techniques, and the repetition allows for muscle memory, which is so important. You can gain confidence and experience before you work on patients. So you can make incisions. It’s not an incision trainer, but you can practice with the keratome. We’ll show you… Line it up, get the angle, nice and flat, smooth, dimple down, and create the single or biplane incision. You can do that multiple places around the eye. The eye is not gonna collapse. You can do that over and over again. We can fill the eye with viscoelastic. As a right-handed surgeon, I would fill the eye with the left hand, left hand paracentesis. But I can work on not hitting the iris, not hitting the capsule. On another attempt, I can go for the right hand paracentesis. And we haven’t touched the eye yet. We can just keep going in and out and doing these things. Same thing. We can practice entering and exiting the main incision. You see the cystotome. We rotate to go in, not affect the cornea, the endothelium, make sure we’re careful not to hit the iris or the capsule. So we’re rotating and then we get in centrally where the light reflex is back to center, rotate back down, and we’ll be ready to initiate our capsulotomy. We can do that multiple times. We haven’t even broken the capsule. There’s nothing to reset. Just do it over and over again. Here’s entering with the forceps. Same thing. Enter, rotate to the side, rotate, turn… And that can be done over and over again, without even initiating a tear yet. So let’s talk about oar lock pivoting versus pushing and distorting. It’s really, really, really important to pivot in the incision, like an oar in a lock that rotates in that position. So where is the pivot point? It’s at the incision. You don’t want to push on the incision. You want to slide in and out and pivot, so you’re not distorting the incision. If you push on that incision, you’re gonna move the eye away from you, and you’re also gonna cause loss of viscoelastic, which is gonna shallow the chamber and dome the anterior capsule, and now your capsule is gonna want to run downhill and out of control. So with the eye movement, what you’ll think is: Gosh, why is that patient looking around? They’ve been so good and all of a sudden right when I need them to hold still and I’m trying to go over here and do something and grab the capsule, now the patient is moving. They’re not moving. You’re moving their eye. You’re pushing on the incision, lifting up or pushing to the side. So let’s watch that here. Here we are in the incision. Notice when the tip goes to the right, the back of the instrument goes to the left. We’re sliding in and out. There is no distortion. We’re sliding around. We can attack any area in the eye. If we don’t, if we pivot, we hit the side. Obviously we’re exaggerating here, but if you hit the side, you’re gonna move the eye. Back to pivoting. You see minimal eye movements and there’s no loss of viscoelastic. But if we push down on the incision, see the bubbles go out, distorting, or we’re gonna see some air bubbles. So you have to stay sliding in and out, stay in multiple planes, stay in one position. And we can practice movements inside the eye without even creating a CCC. Here we are. We haven’t pierced the capsule. We’re just pretending. We’re grabbing the clock hours. This is after we’ve done this. We know where our attack is. Go back and just practice. Tips to the right, back to the left, grab where you think 2:00 is, maybe, go around, and keep practicing the muscle memory maneuvers, until you get it down. So let’s talk about initiating the tear with the cystotome. First you have to understand what the cystotome is. It’s usually a 27-gauge needle, and it’s prebent when it’s a cystotome, but you can bend your own needle. You can bend the tip so the needle is pointing downward, and put another bend in it to make it easy to get in and out of the eye. The bevel is 2 millimeters, and that’s important, because you can use that as an internal ruler. Sometimes you’ve got a widely dilated pupil, and it’s hard to gauge. I want to shoot for 5 or 5.5 millimeters. You’ve got an internal ruler, if you understand that the bevel is 2 millimeters from the tip to the very back of the bevel. And you have to understand that the tip of the cystotome — there’s the point, but there’s the edge of the needle. And the edge is what cuts. That’s the cutting edge. And if you move that edge laterally, you’re gonna create a precise, predictable cut in the capsule. If you just pierce the capsule and pull straight down, you’re gonna create an opening that’s a little bit unpredictable. So you want to pierce and go laterally with the cystotome. Either way, wherever you’re comfortable. I think most people would go to the left, if you’re a right-handed surgeon, and bring it down. But as you pull down, that’s what’s gonna create the flap. Let’s watch this in a minute. Here’s the cystotome on the left, my capsulotomy forceps on the right. And what you’ll notice about the forceps is they have hash marks on them. That’s a tool we’ll talk about later, useful for measuring. But you can see from the tip to the second hash mark, that’s 2 millimeters. I lined it up with the tip of the cystotome, and you can see that’s 2 millimeters to the bevel. So let’s watch the video. That’s the cystotome needle, that’s the side, that’s the cutting edge, right along there. That’s what we want to use to cut the capsule predictably. So we’re gonna initiate the tear with the cystotome, right in the center, light reflex is there, we’re gonna poke in and drag directly horizontally. And look at that nice precise tear. It’s cutting the capsule. And then we start to pull back down towards the incision, and that’s what’s gonna lift the flap. So let’s watch that one more time. Pierce in, go exactly horizontally, nice tear, and then when you get to where you want to, pull down. And again, we can use that bevel as a 2 millimeter indicator inside the eye. So here’s another version. We’re gonna go a little bit more on a curve. This was creating a little bit more of a tongue. So it’s up and over, but still using the cutting side of the cystotome. And here it is again. Another example. Pierce in, arcing over, and then pulling down. And it’s that pulling down that’s gonna start to lift the tongue of the capsule up. And look at how nicely positioned that is, when we can just go in and grab that with forceps, and continue on our way. So one last initiation and tear. And pulling down. There we go. Ready to go around. So you can do the CCC only with the cystotome. It’s an older technique, but it’s safe if there’s patient movement. We’re gonna show a little bit of that. We’ve initiated, we’ve pulled down here, and we’re just gonna stay with the cystotome. We’ve got the capsule folded over on itself, there’s the double capsule now, and we’re just walking it around. Very safely — if the patient were to move, we’re not holding the capsule, and everything continues great there. You need to use various forceps. Try them all. See what works best for you. I like ones that have measurement marks on them. Once you get your system down, you can use the same tool every time. Measure, probably initiate with your forceps, and eventually you won’t have a need for the cystotome. So here’s using forceps. We’re gonna start here, initiate with the forceps, leave a nice flap there, grab it, pull down, now we’re in the 6:00 position, leave the capsule in an optimal place, regrasp it, tips out to the side, and that’s using the forceps. Fantastic control. We can reposition the capsule where we need to and continue on. Look at how we’re leaving the capsule and then continuing on. So the capsulotomy forceps that I use have measurement marks. If I have a widely dilated pupil or a small pupil, I can see: Where do I need to be? I can use my measurement marks. It might be hard to see, but there are 6 hash marks on there. I like to aim for 5 to 5.5 millimeters. This is showing the measurement marks. We’ve already initiated, and now we’re gonna see where we’re going. You can use the measurement marks, stop at any point and use those measurement marks. There we are. Let’s see another one. So here we’re gonna initiate. Now we’re gonna go a different way. Bring it up and around, trying a different technique. Maybe we like that better. This is not how I choose to do it, but some people like this. You can see it does leave the capsule in a nice position to go in there and grab it very easily. Get the forceps on either side of the capsule, and start your capsulotomy. And oh, let’s stop and measure. See what we’re gonna be aiming for as we go around. Are we big enough? Do we need to extend as we go along? You can initiate with forceps. These forceps are designed to initiate the capsulotomy. So we’re gonna pull down to 6:00, grab, and away we go. It’s more efficient. You’ve saved a step. There’s no need for the cystotome. But practice on the models and get comfortable with it. I don’t think you want to practice a different maneuver the first time with your patient. You need to know where to grasp. I call it getting a grasp. You need to know where to grasp the flap for control, safety, and efficiency, and it’s all based on the point of propagation. If you’re too close to that point, it’s less safe, because small movements are gonna cause unwanted tearing. If you’re farther away you have less control and you’re less efficient. So you want to grasp appropriately so you can get around your capsule in three grabs. You can grab it ten times, nobody cares, but as you become a more advanced surgeon, you’re gonna be more skilled and you want to become efficient. The best clock hour locations to grasp, if you’re a right-handed surgeon initiating to the left and going counterclockwise, you want to regrasp at 6:00, 2:00, and 10:00. And those are great clock hours, because of the approach angles. And you can leave the capsule in an easy position, to regrasp it. So let’s see that here. So here we’re up around the 2:00. We’ve positioned the capsule, folded it over, positioning it nicely, we want to grasp… Didn’t like something there. Came out, maybe put in some viscoelastic. That’s too far. That’s too close. Right about there. Then we can regrasp and fold it over and get it on tension and come around. So not too close, not too far. Just an optimal position. You have to know where the tear is going. Once you get the capsule folded over onto itself, it shows you the exact curvature that will be torn, and the tips of the forceps should trace the outline of where the tear will go. That’s super important. And with a small pupil, you can tear the capsule outside the pupil border. You won’t be able to see the propagation point, but you know you’re under control because of what you’re doing. This is gonna show folding the capsule over. And once that capsule is folded over, the tear just follows exactly along behind it. So I’m gonna try to show you that again here. So here, look. Two important things. Follow the tips. Look at where the tips of the forceps are. The tips are tracing where I want that capsule to open. See how the tips stay open? Too many people go inward too much. You want to stay out, follow the tips, look at where they are. They’re tracing exactly the path of the opening. And also, as the capsule is folded over, you can see right here… I’ll stop it. As the capsule is folded over, you can see exactly that this curvature mimics this curvature. And that’s where it’s gonna continue to open. So those two things. When you get the capsule folded over, and you’re tracing the tear with your tips — it’s really the key here. The other important thing is tension off versus tension on. Tension off to manipulate the flap — so if you’re holding the capsule with your forceps tips, you bring the tips down towards the point of propagation, and that takes the tension off, and you can safely manipulate the flap. Tension on is when you’re ready to propagate the tear. So let’s see that. Here we go. We’re gonna initiate the capsule opening with the cystotome. Bring it down. The cystotome works best on these models. It’s a little bit harder to initiate with certain capsulotomy forceps. That’s why most of these videos you’ll see us initiate with the cystotome. Okay, so we’re gonna stop here and regrasp. And what you’ll see is… As we bring the tips down towards the point of propagation, now we’re tension on, now we’re ready to run. We’ll pull it around. The tips are tracing where we want to go. The capsule is unfolding. We’re keeping it down. We’re not pulling up on the capsule. We’re pulling up on the plane. Now we’re gonna reposition, around that 2:00 position. It’s easy to regrasp. Not too close, tips towards the point of propagation, and now I can move it without tearing anything. Here we go around a little bit more. We’re tension on now, we’re opening the capsule, tips are staying out, tracing the point, capsule is folded over, we got to the 10:00 position. Reposition the capsule. Get it in a nice position to grasp. I’m gonna grasp a little bit too far back, but just for demonstration, we’re going to bring those tips right down towards the point of propagation. Look how much I can maneuver that capsule, and nothing is happening. There’s no tear. We’re gonna go tension on. It’s like train cars that are coupled. You put the tension on, and then things are gonna move. Because I grasp so far away, things are gonna move, and we drive those forceps tips up the other direction. There’s a huge lesson there. Let me show you these. Get to right here. Here we are. This is tension off. Look at all that manipulation. Because the forceps tips are near the point of propagation. But once we go tension on, we fold it over, right there, tension is on, and any further movement is gonna create propagation of the tear like that. Remember, viscoelastic is your friend. You’re gonna fill the anterior chamber to create visco to make space. Remember what life was like before viscoelastic? You can clear the capsule, manipulate the flap. It’s definitely your friend. Here’s a case where we had too small a rhexis. We regrasp it, I’ve gotten down into the cortex. Fluffed it up. It’s hard to see. Take a second. Put some viscoelastic in. Clear your view, and then continue on around. And make sure you can always see. It’s a little bit hard to see right there. I can’t see the point of propagation. More Viscoat. Clear up that view. Regrasp and continue on doing your work. So viscoelastic is cheap. It’s a lot less expensive than vitreous loss. Right? Shearing versus tearing. What do we mean by this? So there are different types of forces. And they act differently. I’m just gonna show you with a piece of paper here. This is a shearing force. And that’s what we’re typically doing, when we’re tearing the capsule. But sometimes we pull the capsule differently, in a different fashion, this way. And you can see that’s a different type of force. That’s a tearing or ripping force. And look at how I can control the tear differently. So I can shear and I can drive it where I want it to go this way, or I can tear and rip. And that’s super important as we get into these next slides, in talking about the Little rescue technique. The Little capsulorrhexis tearout rescue is attributed to Brian Little. I would encourage you to look this up. It’s easily available online, it’s a PDF, and these are three of the most important pages you wish you had read when the capsule starts to tear outward. I learned by reading his article and watching a video, and later that week I had to use it, and I was so glad I had read this. So the key to this is you have to recognize early and stop. The further out it goes, the harder it is to fix things. You want to fill the AC completely with viscoelastic. Remember, it’s your friend. And you have to understand: The force applied to the capsule is reversed in direction, but maintained in the plane of the anterior capsule. We pull in the opposite direction, but we’re not lifting up on the capsule. We’re staying in the same plane of the anterior capsule. If you want to, make another paracentesis for optimal angle of approach. Unfold the capsule using viscoelastic or forceps. The cystotome may cause further tearing. And apply traction backwards, the opposite direction where you would normally be going, and as you go radially, that’s gonna initiate the tear, the ripping or tearing force. The tear will propagate to the center of the capsule. Once it’s rescued, the flap can be folded over and continue as normal. This is CataractCoach.com a fabulous teacher, Uday Devgan.

>> We can grab it, pull back towards the forceps in this direction, and rescue it, and we can bring it back in, make the rhexis normal again. That’s a neat technique! And thank you, Brian Little, the person who described this technique. Watch in slow motion. We have a run-out capsulorrhexis, small eye, shallow AC. We grab the capsule here, the part that’s flipped over, and now we pull backwards, towards our incision, pull towards the instrument, the forceps, that will allow this tear to come back inward. So right now, we’re right at the pupil margin. It could go toward the zonules. We pull inwards. Watch carefully. It will tear towards the center of the eye. This Little technique is very useful, and all surgeons should certainly know how to do it. Now, once it’s a normal position, flip back over and continue the rhexis normally. The slow motion video really tells the story. If you need to, go back to the video and watch it again.

DR STOLL: Share. Are we back up? Hopefully you guys can see me. Okay. I need to get my talk up here again. Sorry about the technical difficulty there. Not sure what happened exactly. I’ll find the talk again. We’ll get back on course here. Sorry about that, everyone. So at least we got through Dr. Devgan’s video before it crashed. And let me just find where we were. Almost there. Okay. Here we go. Okay. Sorry again about that. So we just saw Dr. Devgan’s great video, and hopefully you also saw things like tension on versus off, manipulating the flap. What you didn’t see is putting the viscoelastic, and remember that’s a critically important step, but let’s compare now that presentation with what we can do on the models, and how similar it is and how valuable it can be to practice this. Here’s our Little rescue technique. You can see the capsule is starting to run. And recognizing it early…

DR STOLL: Okay, I’m gonna just bring up my presentation here. View slideshow… I’m gonna try this one more time, everyone. Okay. So here we are, back with a Little rescue technique. Notice that the tear is running out. We’re gonna recognize it early. We’re gonna fold the capsule back over. This would be a great time to put viscoelastic in. We’re gonna get that capsule in position. So that we can do the tear. So now we’re gonna pull back. See, there’s no tension on the capsule. We can move all the way around. We have control. There’s the move pulling back circumferentially, and then as you come radially, you start to see the rescue. It doesn’t have to be a big aggressive maneuver. It’s not fast. It just has to be effective enough to accomplish what you want. Filling with visco, unfolding the capsule, pulling back circumferentially, and then pulling more radially. As you pull radially, that’s what creates the rescue tear. Let’s watch another example here. And I’m glad to see that we’re still continuing on here. So here we’re opening up the capsule. Maybe we’ve got a small tear here. We’re gonna open up the capsule. Let’s grab with forceps. And watch the tips of the forceps. They’re going around. And maybe there’s some loss of viscoelastic. Maybe there’s some posterior pressure. Things to be going okay so far. We’re gonna regrasp, we’re gonna reposition the capsule, and look at where those tips are going. That is wrong, right? We didn’t trace the outline. The tips went out and caused it to intentionally run out there. Watch that again. Watch the tips of the forceps. They should be going here. Look where they went. So look where the tear went. Stop, pull it back, pull circumferentially, and then as you pull radially, that’s what creates the tear. We’re going to go in here and grab. Now you’ll see it tear a little bit, but no big deal. We can just grab again. And it’s that radial maneuver, after your circumferential, that creates it. And then flip back over. Here’s another rescue coming up. That’s a really tough angle, isn’t it? That’s a difficult angle. Might have to create a paracentesis, go in a different side port, and now we can grab it at the proper angle, and we can grab the capsule and continue on more easily. And one last time. Finish it off. Let’s look at this again. Here’s another example. Again, we’re gonna initiate with the cystotome. Actually, no, this time it’s with the forceps. We’re gonna initiate with the forceps at 6:00, and bring this around. Everything looks like it’s going great. We’re getting a nice capsulotomy. Regrasp. And then what’s going on? Tips went wrong. Now you have to rescue it. Pull back and radially… That’s the maneuver. Let’s look at that again. Let’s stop here. So when we say pull circumferentially back the other way, normally you’re pulling this way. So circumferentially back is this angle. You put the tension on, and then as you pull it radially, that’s what creates that ripping, tearing maneuver. Watch it here. Bam. There’s the rescue. Fold it over with no tension and continue on. Oops. I didn’t mean to advance that. So let’s go one more time on that same one here. So I’m gonna jump ahead. Here we are. We rescued it. Nice rescue. Let’s watch the rest of this video and see what happens. So now… We’re gonna continue along. Right? Tension is off. Now tension is on. Continuing around. Struggling a little bit. Oh, what just happened there? My goodness! So let’s back up and see what happened there. It’s a subtle mistake, but watch what happens. So as we continue on the tear here, we’re almost finished. The finish line is right there. Well, what happened is there was lifting up of the capsule. So we pulled it up, as opposed to keeping it folded over. And moving it around circumferentially. We’re lifting up on the capsule, and bam, it just caused a sudden maneuver. So now you’ve got to stop and fix that. What are we gonna do to fix that? Reposition the capsule, this would be a great time to reinflate with viscoelastic, deepen the chamber, flatten the curve, and we’re gonna come in from a different approach angle. Once we grasp, it’s almost like an immediate rescue maneuver. That immediate radial tear. Bam, saves it and continues on. Fantastic save and optimize your approach for the final finish there. And there you go. Here’s one last demonstration of the Little rescue technique. And we’re bringing it around. Regrasping. Walking it out. And rescuing. There it is. So what if we have increased posterior pressure? We’re gonna show how you can simulate that on the model, because it’s almost like you’re doing a continuous rescue during the whole CCC procedure. What I mean by that is: You’re gonna be pulling more radially at certain times, as you’re propagating the tear. Here we go. Everything is under control. Initiated the capsule, flipped it over, got great control, we’re gonna regrasp here, tension off versus tension on, there’s off, there’s on, tips are out. Everything is just going perfectly. What could possibly happen? We’re gonna stop and we’re gonna make this more difficult. We’re gonna take the model, increase the posterior pressure, by twisting it and dialing up the pressure behind the capsule, it’s gonna shallow the chamber and dome the capsule, and now it’s gonna run downhill. There’s viscoelastic to clear the bubble, visco is our friend, and you’ll see now as we start to continue on in the normal fashion, it’s gonna want to unzip and open up to the outside. Watch the tips. At various times, we’re gonna pull more radially. See it opening up as I’m leading it? We’re gonna try to rescue it a little bit here, rescue it and get it back under control, there’s the radial maneuver, and look at where I’m pulling. I’m pulling radially to propagate the tear. Not leading the tear. Not out in front of it. If I do, it starts to run. I have to pull radially to get it under control. It’s like a continuous rescue maneuver, because you’re pulling radially. It’s not just for a moment to redirect it. When there’s increased pressure, you can keep it going around that way. Let’s talk about the baby rhexis. It sounds cute, but it’s not. It creates intraoperative challenges, like the removal of the nucleus and cortex, postoperatively, it can create phimosis and create problems with the ATIOLs. You want to reinitiate and make it larger. If you can get through the case safely, you may want to wait, because there’s less risk when you’re at the end of the case. So we’re going to initiate again, move it around here, get through that part quickly. Everything looks great, right? Not really. Look how small we are. Maybe this is intentional. It’s a case of an intumescent white cataract, and we’re gonna do a double rhexis, a baby rhexis and then a bigger rhexis, but it’s very common for beginning surgeons to end up with a beginning rhexis. We’re so concerned about letting it run out that we stay small. We don’t keep our forceps tips where they need to be, and end up with this baby rhexis. We think we did a great job, it’s continuous, perfect, centered, but it’s not. This is a big problem. Go back in with a 27-gauge Vannas scissors, regrasp it, fold it over — look at this control. Now the tips are out where we need them to be. We’re gonna reposition, regrasp, tension on, continue around, pivoting in the incision, leaving the capsule where we want it. All the things you’re using to your advantage now. You’re putting everything together. Viscoelastic, fill, clear the view, grasp it. The only thing we could have done better here is finish from outside to in. You’ll see a little nub at the very end. Watch. Right there. If we had gone a little bit wider at the end, you always want to finish from outside to in, to incorporate all that stuff in there. Only a couple more here. Let’s say we’ve got a decentered rhexis. Now you can reinitiate just with the cystotome if you want. Get that flap flipped over. It’s a good rhexis, a little bit small, but decentered. Let’s fix it. Reinitiate, grasp it, bring the tips out, this is maybe larger than we normally would want, but this is practice. Reposition, get comfortable, add visco, get rid of your bubbles, flatten the anterior capsule, tension is off, tension is on, fold it over, carry it around, tips stay out, tracing exactly where you want it to go, and you’re gonna have a beautiful rhexis there. Now we’re gonna finish it up, and this time we’re gonna finish from out to in. It doesn’t matter how many times you regrasp. Look at that control that you can obtain. That’s a great rhexis. You can have a great case with that. Here’s another one, where you can spiral outward. The case is of a white intumescent cataract with increased posterior pressure. One technique is that you’re gonna start small and then spiral outward. So we’re initiating with the cystotome, flipping it over, there’s pressure, we’re careful. We don’t want the dreaded Argentinean flag sign, when the capsule splits and you have the white and the blue on either side. That’s the Argentinean flag. This is one technique among many. CataractCoach.com has some great tips on that. But you can see we’re getting continuously bigger as we go. Immense control, capsule flipped over, tension on, and we’re gonna get bigger and bigger as we go here. We’re not gonna let the capsule run, even though we dialed up the pressure, and there’s a lot of pressure behind this. And you can see we’re just getting bigger and bigger, tracing the tips exactly where we want that capsule to go. Fold the flap over, get the tension back on, stay wide now, as you want to come around bigger. And so if you use models to get to this level of control, and stability, and technique, and understanding of tearing forces, and where you need to be with your tips, and where you need to be pulling, and how you can rescue, and maneuver things, imagine how comfortable you’re gonna be, going into your cases. And this will translate over into all sorts of other intraocular maneuvers, if you get your comfort level down with these types of maneuvers. So that’s the last video to show. The main takeaway here is: Practice, practice, practice. There’s really no excuse in this day and age not to practice. Here’s showing the practice that I did, just for making these videos! It’s a simple setup. I’m in my own OR. Here’s my phaco machine, my microscope. I pull over a side table, grab some instruments and viscoelastic. We save some visco, sometimes, at the end of cases. If I know I need to use some, we use any viscoelastic that got opened but didn’t get used. It’s gonna get thrown away. We’ll grab that. You can use other sources. Here’s 22 tears. They’re not perfect, but they’re perfect training. They’re continuous, curvilinear, well centered. And I was using three different models here, to keep things set up and moving along. It doesn’t require a lot of setup or a lot of time. You spend an hour or two doing this, and you’re gonna gain a lot of ground. Do that a few times over the course of the month and it’s gonna be amazing. Record yourself. Record your practice attempts. You can learn from even your practice attempts on models. Find your mistakes, where it went wrong, and fix it. If you want to be like Ike, use simulation… >> To take the pressure off.

DR STOLL: Exactly, take the pressure off. Here’s a quick word from Dr. Gimbel, who I am so indebted to. A great teacher and mentor. Because of what I learned from him, and because of that experience is what developed me into the surgeon I am and the experience of developing the model. So I just want to play a quick word from him.

>> Hello. I’m Dr. Howard Gimbel. I would like to speak to you about an important teaching aid to help master the technique of a continuous curvilinear capsulorrhexis. I’m pleased that the CCC technique has become integral in modern cataract surgery. The teaching model developed by Dr. Stoll and his colleagues is a simple yet effective method to help master this crucial step in cataract surgery. I would encourage all of you that desire greater proficiency in the OR to utilize this tool to become more confident and effective cataract surgeons.

DR STOLL: So, you know, my mentor. What an amazing doctor and person. Dr. Gimbel, thank you for your endorsement of the work we’re doing. So special thanks to Dr. Gimbel, my dear friend Dr. Nicole Fram, also for Dr. Devgan for letting us use his videos, on CataractCoach.com, and thank you to Cybersight. Again, I apologize for the technical difficulties. And thank you for your time. I think we’re gonna take some questions now. And see if there are some up there. Is it safe to finish the last hour of capsulorrhexis by Vannas scissors? I suppose under some circumstances. Say you’ve got a capsule you can’t tear safely — you might want to go around the other way, or incorporate that fibrous plaque into the capsulotomy. And that’s what you have to do, that’s what you have to do. You can use the scissors and cut or reinitiate and cut through, if it’s really that fibrous. It’s not an ideal choice, but if that’s what you need to do, that’s what you can do. Here’s a question. Does the product ship to South Africa? We’re working with a distributor who can help us get things where they need to go. Hopefully we can partner with Orbis and get things out around the world. Because the goal is to get people trained. How can we get SimulEYE in developing countries? Same answer. We’re working on that. I’m a small company. We have a big footprint now, because we working with a lot of the companies, so if you have access to some of the big surgical companies like Alcon, Bausch and Lomb, Johnson & Johnson, I work with all those companies. We can get kits to them and they can get it out to you. That’s how we’ve gotten them around the US and Europe. We would love to get into developing countries. We are working on that. Any discounts available for government or academic institutes? I don’t want to get too much into that stuff, but just contact us. Is it available for international purchase? It is available for international purchase. What are the best capsulorrhexis forceps to use as beginners? Try them all. That’s my best advice. Try them all. There are different ones. I really would encourage you to get something that has hash marks on them, and that way you can see — you can judge. I like the ones that I use — they’re from MST, Microsurgical Technologies. I have no financial interest there, but they make great instruments. For how long can a simulator be used? Ours doesn’t have much of a shelf life problem. It can sit around for months. The polymer clay might start to dry out, after three to six months, but that’s pretty easily attainable. You can get more. And you can put it on the shelf and revisit it a month later, or after you’ve had some experience. You can come back to it and practice and say: I’ve been going clockwise all this time, but I see everybody else go counterclockwise. I didn’t want to try that on my patients. Try it on a simulation, an electronic simulation, or a tomato or a grape or a SimulEYE. I think you’re gonna find that there’s a reason that many people do it a certain way. Maybe that’s not the best way for you, but you might find that it is, and it’s best to try it outside of using it on your patients. I think I got through most of those. What is the recommended number of films to order for practice? The kit comes with ten films. Then you can get refill kits. Those come with ten films. But remember, you can do so much practice even before you puncture that capsule. Getting your positioning, muscle memory, sliding in and out of the incision, not tearing the capsule. Just doing all those other things, you can gain so much practice, just from that. So the kit comes with ten and you can go from there. More information on the website, if you guys want more information there. I think that’s all the questions we have now. So thank you again, all, for your time. Sorry about the technical difficulties. I think we recovered okay, though, and got through it. Good luck with all of your training. And just keep practicing, and you’ll get there. All right. Have a great day, everyone.

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September 27, 2019

Last Updated: October 31, 2022

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