Lecture: Visualizing Cataract Surgery & Techniques: A Step-by-Step Surgical Walkthrough

>> All righty. Welcome everyone. We’re going to have a fun time today. We have some fun cataract cases to do together. Let me pull that up and we will start sharing it. There we go. We’re going to share right here. These are all interesting and challenging cataract cases and interactive Q&A is built in here and I will go through the answers with you. We’re going to go fast. There is no stopping here. In the bottom right of the screen there is a timer. The first case is a trauma mat certificate cataract with segmental zonular loss. There you see lot of the lens equator. Clearly there is a cataract. Clearly the lens is dislocated. What is your first step? Inject viscoelastic, inject trypan blue, inject triamcinolone, do something else or cry and regret that you agreed to do the case. Go ahead and vote here. You can inject trypan but if you do it now, what is going to happen? It’s going go into the vitreous cavity and you lose the red reflex. You can put viscoelastic to support the area but is there already vitreous there. And the answer you will be surprised to see is yes. A little low dose triamcinolone preservative free is the best bet here. Let me show you why. Take a look here. Look how much vitreous is present. A tremendous amount. You may not see this all the time. The triamcinolone is going to stain the outside of the vitreous and now doing a 23 gauge vitrectomy here, you can see once you move the vitreous, the nucleus looks deeper in the eye, farther back. Now, there is the viscoelastic and after the trypan, just a tiny bit painted on the surface. Don’t fill the AC. Just a little and now do the eye rhexis here. Certainly, there is significant zonular weakness because the whole area has to support it. If it’s able to get the rhexis done, if there is this much zonulopathy you need do a two-head technique. The forceps and then with the secondhand through the paracentesis to stabilize the capsular bag. Here you see how wrinkled the capsular bag is. That is common. There is no counter traction support here. We get the rhexis completed and it’s important to get it central and stabilized. How do you stabilize the capsular bag prior to phaco. Put an iris hook, use capsule hooks, should you put in a capsular tension ring. Use a capsular segment. Or just inject very viscoelastic. You want to do more than just viscoelastic. Your need to do something. Iris hooks are okay to stabilize the rhexis edge but better is probably to use capsule hooks to stabilize the capsule there. If you put a CTR in now, it can help but it’s not enough. And so you can go use a capsular segment with an iris hook and I will show you that technique here. Capsular segment is what we’re going to do. CTR is not enough. Here is a capsular segment going inside the eye. I goes under the rhexis but the central islet stays above the rhexis. This surgeon did not have any capsular — you can put in an iris hook through the islet. I would put the iris hook in with the hook facing up. Upside down, if you will. Now that is supporting the bag a lot. You can actually do a routine phaco. The phaco comes out easy, the lens nucleus is gone and the bag is stabilized. What is all the white stuff back there? That’s the triamcinolone. The doctor put in too much triamcinolone. It will go away. Here is the capsular ring, the CTR. Don’t get caught in the segment there. Having the CTR is helpful in the bag. What’s the choice for the eye well. We have a CTR in the bag and capsular suture in place. What next, a single piece in the bag, a three piece in the bag, a three piece in the sulcus, or a three-piece haptics and sulcus capture or Yamane intra-scleral haptic fixation? In this case I think any an is reasonable but you can put the single piece lens in the capsular bag here. The reason you can do that is, because you can already stabilize the capsular bag. Three piece in the bag is reasonable. Three piece in the sulcus, I wouldn’t put the lens totally in the sulcus. I wouldn’t go Yamane. You have a CTR and a segment. Here is a single piece going in the bag and we have to fixate that capsular segment. Here is a half groove and going inside, we use Gore-Tex. This is an off-label use. The needle being put there in the eye, the hollow bore to guide out the other suture needle. You can pull that through. Now you have it through the eye let and pass the other end of the Gore-Tex through and you can suture this and close this suture and you’ll be able to fixate this. The Gore-Tex will certainly last forever. You can use a Prolene suture but keep in mind that may not last quite as long. The Gore-Tex is anticipated to last for the patient’s life even if the patient is young. Getting 50 years out of a Gore-Tex suture is no problem. Make sure the segment is in the bag but the eye let is above the rhexis. When you suture this, not too tight. Just enough to get the eye well centered. Eye well beautifully centered here. Here is a slip knot. Get just the tension you want. Gore-Tex is slippery. So once you tie this, make sure the knots are square and bury the suture. And that’s important because you don’t want it to erode through. That knot has to be pushed into the sclera and you can close the conjunctiva and close the incision. The patient has a really, really nice outcome. Interesting case here and this is well within the realm of the cataract surgeon. Now a challenge casing, iris prolapse and zonular loss. What do you notice inside of the eye? A tube right. A C ton tube that you see visible. That is going to change fluidics. The pupil is not well dilated. It’s asymmetric. That lets you know there may be issues with iris prolapse later. Here is a chop technique. Obviously a very skilled surgeon doing a beautiful chop technique. And now removing the cataract is straightforward and you think it’s going to be an easy case, right? That is why you always have to keep your guard up. There is a lot of iris mobility during the case. That tells you something. Take the nucleus out and look at the iris, whoa. Just like that. What just happened with the iris and the pupil? A, nothing happened. Just plow ahead. Is it floppy I resistance syndrome. Chamber instability. Re-expand with IA infusion or I don’t know I was playing with my phone. There are chamber instability and zonular issues. You should worry, don’t just plow ahead because you will get into trouble here. This is going to be a very challenging situation. So it may expand with the infusion going inside the eye or maybe not. That’s the issue there. Don’t play on your phone. Now, going back to our picture here. The surgeon is not putting an iris hook but lifting um the iris. Look at the paracentesis, so much prolapse still. This is going to be a bad sign here. So this is a case where you want to put in the iris hooks right now. Now is the time to put them in. Don’t try to plow through the case. You can see — now look how much trouble you’re in. Sub incisionally there is so much iris prolapse and you see the lens bag equator. This is not the right way to put an iris back in the eye. What now? Viscoelastic and put the lens in? Ignore the prolapsed iris? Amputate or cut the prolapsed iris? Somehow get the iris back in the eye or I don’t know, I just want to cry. This is stressful, right. Very, very stressful case. Think about this, what do you want to do here? Let’s take a look. In this case, I think you definitely want to fix the iris, put it back in the eye. But the best way of doing that is through a new incision. Don’t just keep injecting viscoelastic, that is not going to solve the issue. You need to make another pair and sweep it back into the eye. You want the iris back inside the eye. Here is the extra para and we can sweep across and now the iris hooks. I like the sub incisional iris. Here is a capsular — going in the bag. That’s going to help stabilize. In this case there was not too much zonular loss, maybe 3 clock hours and that’s enough for a CT loan. A CTR loan is good for 3 or 4 clock hours: Once you have 6 clock hours you need to suture something in place. The one thing I recommend, put a suture in the main incision. You want a suture here. The reason you want that is because you may get more iris prolapse in the postop period. This is a case that you’re definitely going to encounter in your career. So look carefully. Surgeon is very experienced. Doing a beautiful job. Taking out the nucleus, nice chop technique. This surgeon has done thousands of surgeries. Sometimes when you’re so good you do a shortcut, let me try to vacuum and right here — no, didn’t get it. Maybe right there and right there, look at that. There is a hole. Right there. That’s not just a hole in the shell, that went through the bag. What do you do now? It’s not a real big deal, proceed with the case. That’s not the right answer. B, pull the phaco probe out of the eye immediately? That’s not a great answer here. If you pull the probe out, what happens you get vitreous prolapse. Keep the phaco probe and inject OVD. Inject triamcinolone is okay, too. But the important thing is put a little triamcinolone and keep the probe in the eye on position one with the infusion and then you inject the viscoelastic. Because you tamponade the hole in the capsule and keep the vitreous back. The surgeon comes out of the eye and just like that. But if you look back, you can see the capsular bag is wide open. Why is that? Because you pulled vitreous forward. Way too much vitreous prolapse. As the vitreous comes forward, the hole gets huge. The hole is small as the phaco tip. That’s one millimeter but it became huge because you pulled vitreous forward and the vitreous comes up and rips the hole larger. Now removing the cortex. Not my favorite. You had a vitrectomy. Here triamcinolone check and no ice resistance prolapse. So we can now plant a lens here. The vitrectomy was a good job and this is a complex case. This was not handled totally correctly. As a result it’s more challenging now. Here is a slightly larger incision. What’s the best lens, single piece lens in the bag. No. The bag is open you can’t do that. Single piece lens on the sulcus. No. You can never place a single piece lens in the sulcus. Three-piece lens in the sulcus is a reasonable option. Three piece with haptics in the sulcus and optic capture. Yes, that is better if you have an intact capsular reck surfactants. AC lens? I don’t think so because the anterior capsular is intact but you can put in a sulcus lens, the answer here is three piece with the sulcus or three piece with the haptics in the sulcus. That’s the best move here. As a result, this patient will do okay but again no single piece in the bag, never put a single piece in the sulcus. Here comes the three-piece lens. Remember the No. 7, trailing haptics like the capital letter L. Put the lens in. The haptics look like the letter S, S is stupid and I don’t want to be stupid, I want to be smart. Get the lens in and it’s nicely placed. Bringing the iris down now. You can see it’s a reasonable outcome peer. More triamcinolone to make sure no viscoelastic in the anterior chamber which is good. I recommend putting in a suture here in the main incision. Put a suture in the main incision and that helps prevent leaks postop like iris prolapse or if the AC shallows you can get vitreous prolapse around the edge of the optic. You want a suture here, 10-0 nylon here for sure. The para and that looks good. Now this one, this is the snap sign. You 100% should know this. Watch carefully. What happens right there? I’m going to play it again so you can see. Right there. What happened here? Look again, slow motion. The cannula should not be over the middle of the nucleus but right there, what happened? Think about it. What just happened here? Give you a hint. This patient has many, many intravitreal injections in the past. And maybe one of those intravitreal injections hit the posterior lens capsule. That could be an issue here. Now, there’s the nucleus, what happens, you go inside with the phaco probe and watch carefully what happens. Now, bye bye. There’s the nucleus. What happened? A, too much ultrasound trauma sonic power? No. That’s not it. A blow out of the posterior capsule. Yes. That’s the issue here. Because remember this patient has a lot of intravitreal injections when you put the cannula on the middle of the nucleus, you prevent the nucleus from coming up. That’s a problem. Too much pressure, it’s a weak capsule and it blows out. The patient moved too much. No. Not enough anesthesia. No. And bad protoplasm, no. The issue is blow out of the posterior capsule. That’s the issue here. When you see that snap sign, you have to remember that the capsule already is wide open. Now let’s talk about how do you clean this up. An anterior vitrectomy. Here is an anterior vitrectomy. Do not use the main incision. You can make two para. One hand has the infusion and the other has the vitreous cutter. A little triamcinolone and look at that vitreous. With the infusion you can see it. Take your time with the anterior vitrectomy. This is position one on the foot pedal and two is the cutter and three is aspiration. You want a high cut rate. As high as the machine goes. When you keep more time and put more triamcinolone and look how much vitreous prolapse there is at the main incision. Remember the triamcinolone is only going to stain the outside of the vitreous. Once you start doing vitrectomy, you have to stain again. Anti-vitrectomy is longer than you think it’s going to take. You have to completely clean the prolapse up. I’m a cataract couch, my teaching website is all free but I have videos on doing a proper vitrectomy. What are the additional postop risks for this patient? Endophthalmitis is ten times the risk. Cystoid macular edema is ten times the risk. Retinal break is ten times the risk. Patient is unhappy. Or all of the above? Remember this, the capsule there has a very, very important role. That role is creating a barrier. Keeping the vitreous back. The aqueous in the front part keeps turning over. 1 percent a minute. So 17 times a day you have new aqueous produced there. And this is a very important issue because you can wash out any contaminants. But, unfortunately, with the vitreous, if you get bacterial contamination of the vitreous you’re at higher risk of ophthalmitis. Here is the lens. Remember a No. 7 leading haptic, then that’s too far deep in the eye. Get that haptic out. Insert the lens on top of the iris and then position the haptics. There is another haptic going into the sulcus, good. Another one, very nicely done. If you have a good rhexis that is 5 mm you can do an optic capture and that is going to be stable. The optic is behind the reck surfactants and the haptics are in front. You have a nice outcome here. You want to check again to see there is no more vitreous prolapse and suture the main incision here. Again, the reason you need to suture, we have a complication, so you don’t have more issues. Bimanual IA using the vitrector, but you can go on IA settings and remove the viscoelastic and check. This is a patient that I did surgery in Beverly Hills in my private clinic. On the left is zonular loss. A traumatic cataract. Totally opaque. The top of the screen, there is probably about 3 or 4 clock loss. There is the triamcinolone, we learned about that. Surprise, no vitreous prolapse. Now what’s the next step? You put the triamcinolone in, no vitreous present. You want to inject trypan blue or put more triamcinolone, inject a cohesive viscoelastic, inject a dispersive viscoelastic or lament, why did I agree to do this very, very difficult case? It’s important as you get better and better as a surgeon to take on the bigger and more challenging cases because you want to have the challenges you want to grow your skills as a surgeon. Here, trypan blue dye you will need. Triamcinolone you already did. I would put viscoelastic. So yes, I would first put the viscoelastic so you done want the triamcinolone right now. You already did it. You don’t want the trypan to go the vitreous cavity. There is a barrier with the viscoelastic. Now, you can paint on a tiny bit, a few drops of trypan blue dye and rub it on with the cannula. That’s important. Don’t fill the whole anterior chamber with trypan. Do not. The case of zonulopathy here, you will have problems. The other free sister channel is retina rounds if you want to learn retina things. What do you want to make for the incision. Clear cornea phaco, a limbal incision for phaco, scleral tunnel for phaco, MSICS or ECCE incision with scissors. Don’t do ECCE with scissors. That is what was taught to me many years ago. It’s not a great procedure and those incisions never seal well. I actually in this case would not do phaco. Even though this is a Beverly Hills patient, I’m going to do MSICS and that’s going to be the best solution in this case. The reason is, you will see, this is a very dense nucleus. Now, making our incision, the patient, nice retro bulbar or block, do not do this topical. Sitting superior. A little cautery. Once that cautery is complete, we do the MSICS incision. You should learn how to do MSICS, it’s an elegant procedure. You can do a straight line or frown incision. Whatever you like. The incision should be nicely tunneled. So you can see how well tunneled it is. A shelfed incision is there and now the anterior chamber. I’m going to make my incision with the keratome and do a rhexis through the smaller incision before I widen it. Remember here for MSICS, you want a generous capsular rhexis at least 5 mm or 5 and a half or maybe 6. But nice generous rhexis. My forceps have marks at 2 and a half and 5 mm from the tip. As I tear the rhexis, I can understand the size immediately. There is the incision. There is the rhexis. Get the nucleus out of the bag. Gentle, gentle. Up out of the bag and I want the nucleus above the capsule and above the iris. There is the nuke. Viscoelastic on the cornea and underneath the lens to protect the bag. And now project the cornea. And we’ll enlarge the incision. To do MSICS, I will show you an easy way, I teach my American colleagues because in the U.S. very few surgeons now how to do MSICS unfortunately and I think you need to learn how to do it. I make an opposite para and push the nucleus out. Do not lift the nucleus towards the cornea ever. Put it here and I push it out and it comes right out of the eye and you can see how dense that nucleus is, wow. Crazy. Now, how will you stabilize the capsular bag? Put in capsule hooks right now? Use iris hooks because you don’t have capsule hooks? Use counter traction from a second instrument. Insert a CTR right now. Or it’s going to be fine, proceed with IA? Again, maybe you got three clock hours of zonular loss here. What are the options here? All of the above can be reasonable. And put in a CTR right now is okay but it makes removal of the cortex more challenging because the CTR can hold it in place. I think I like that answer. And I probably should have listened to you guys because in this case, I’m going to do the bimanual cortex removal here. I’m doing the areas of good zonular support first. I will wait for the weak area last. A CTR probably would have been a better idea at this point. Because as we’re doing all this manipulation, we may be getting a little vitreous prolapse through that one area. Now, you can see, yes, I should have put the CTR right here. It’s a good, about 3 or 4 clock hours. Here is a CTR going in. I like to dial it in with a Sinskey hook in the leading eyelid and boom, beautiful in the capsular bag and let that go. Fantastic. Now, we can finish cleaning this up. I did get a bit of vitreous prolapse, a little triamcinolone and I think I see something right there. Put a little more triamcinolone, yep, that piece is the vitreous. No problem, remove that with the vitrector. Don’t do vitrectomy unless you stabilize the bag first, do the CTR first. Now we can use the same two instruments but by manual IA. Now the lens choice here. Do you want to do a single piece acrylic in the bag? That is a reasonable option. Do you want to do three piece of the sulcus? I don’t think you need to do that. Want a three piece of haptics in the sulcus and optic capture. That’s a good idea. And AC lens, no. And no, not the Yamane. We stabilized the bag and the best choice is a single piece acrylic in the bag or a three piece in the bag. In this case, I’m going to agree with the 35 percent, the three-piece haptics and sulcus and optic capture. Remember to get the haptics 90 degrees away from the zonular loss. Here is the lens inside of the eye. And we rotate 90 degrees. The haptics are away from the area of the zonular loss. And I dial this in here, there is one. And for the other haptic, use a hook and place that under the sulcus, there. And now optic capture this and this is going to give great long-term stability. This lens is going nowhere. I like to suture the MSICS incisions. People often don’t but I do. Here are three sutures. 10-0 nylon. And suture just so I can sleep well. Rotate the knots and take out the viscoelastic from the anterior chamber and close the conjunctiva with a suture as well. This patient is going to have a beautiful, beautiful outcome here. Little triamcinolone just to check. Put preservative free moxifloxacin in as well. And a Vicryl suture to close the conjunctiva and at the end check for leaks. There is a fluorescein dye leakage test. The pressure is good. Postop day one, this looks fantastic and the patient is very, very happy. Case 7, a lens is stuck in the incision. Now what do you want to do? Watch carefully. It’s a young patient. The nucleus is very soft. All fluffy material. You don’t need the phaco probe. Just wash out. Cleaning up the cortex with the probe. That looks great. And then again, if you like retina, we have free retina videos, retina rounds.com. Everything I do is free. There is a free PDF book how to learn cataract surgery and 25-part curriculum. This is the wrong way. Don’t shove the lens and stop. Make the incision bigger. Don’t keep pushing. It’s difficult to watch this hurts my eyes. Now look, the lens is stuck in the incision. Now what is the next move? Use forceps and pull the lens out? Forceps and push the lens in? Want to enlarge the incision? Pull one haptic out to make some room or I’m not sure, still thinking. The lens is folded up. If you pull one haptic out of the taco fold maybe there will be more room. You can make your side port blade cut to the side of the incision and cut towards the eye. That will enlarge it. But what do you want to do here? Push the lens in the eye? Pull it out? Let’s see what the audience thinks. Enlarge. Probably a good answer. Let’s get that off the screen. There we go. This is the wrong way: Do not try to shove the lens in the eye. This surgeon is not giving up. Just wants to continue, continue, continue. The problem is what? If you keep continuing here, the issue you’re going to have is oh, god, it hurts to even look. The problem is you’re going to break the bag. There’s the lens in the eye and it went right through the capsule. Now what? The posterior capsule is broken. What do you do? Oh my goodness, right? That’s just terrible. Now what should we do? Think about it. You can’t leave that in there. The IOL is in the vitreous. Bring it up and leave it in the sulcus? No. Never ever ever put a single piece in the sulcus. Lift the IOL and anterior vitrectomy. Or explant the ILO or anterior vitrectomy and then a 3-piece vitrectomy or just cry now. This could have been an easy case. The cornea does not stretch. Don’t think you can stretch the incision and push the lens in. Doesn’t happen. I agree with the audience: You just have to get the lens out, anterior vitrectomy and three piece. Now the surgeon has to get the lens out of the eye. Here look how big the incision. You were worried about enlarging the incision, now it’s huge. We get the lens out. I like to twist it out and I have a video on how to do this. This surgeon is going to yank it out. Not a great idea but okay. Now you have to do anterior vitrectomy. The patient is going to do okay but we didn’t have to suffer through all of these issues and complications if we thought more carefully here. A case like this, you’re much better always enlarging the incision. Incisions do not stretch. I promise the cornea is not this big elastic thing that will stretch. It will not. In a case like this, just make the incision bigger. And now look, you have a huge incision anyway. Triamcinolone, and a three piece lens going in. This is in the sulcus and hopefully optic capture and the outcome can still be good but again, we didn’t need to suffer through all of this. It could have been a much much easier case here. Unfortunately, these are important lessons that we have to learn. It’s why we do these videos. I post a new video every day. We’re almost at 3,000 videos. A new one every day for 3,000 days in a row, I never missed a single day. Including today. Now bring the pupil down. Put a suture. That incision is way too big. Now look at this. This is not lens cortex. It’s not lens cortex. Here is an anonymous surgeon. What do you notice on the right side of the screen? You see the bag equator. You shouldn’t see that. There is an area of zonulopathy here. Try to move the cortex but you’re ripping the zonular support even more now. What’s the problem. Stop doing this. Don’t keep doing this. The issue is this surgeon is being too tenacious. You have to face reality and the reality is you have a lot of zonulopathy. Stop doing this and reinflate the AC and put viscoelastic and reevaluate. Don’t keep pulling on the cortex here. Look what happens. You’re not going to be able to separate the cortex from the bag because there is no counter traction and the area with no zonular support, the bag keeps ripping up. Look how wrinkled the bag is: Now 3 clock hours is 6 hours of zonular loss. Look how much the rhexis moved. How bad is this? A, I just witnessed a crime. You may as well yank the whole capsule now. Place a CTR, it will be fine. You will need scleral suture fixation of the bag. And time for Yamane. If you want to do CTR alone, the most is 3 or maybe 4 clock hours zonular loss. You cannot do 6 clock hour zonular loss. That is not CTR. You did witness a crime. I would not yank the whole bag out now. Yes, I agree, you need some scleral suture fixation of the bag. You want a CT R and CTS. Now the surgeon, any guesses? Another incision on the opposite side. Okay. And then what. Look at the shape of the rhexis. It became like more square sided. Like a letter D almost. Now a Simcoe, what are we doing? What are we doing here. No. This is not good. Now it’s a hot mess. You finally got the cortex out but now what? Now you for sure, look how decentered the rhexis is. You’re missing so much zonular support here, 6, 7, 8 clock hours of zonular loss here. What now? This is tough. This is viscoelastic to stabilize it. Okay. Now what? Think about it. This is tough now. You got the bag, the bag is there. Not supported. Do you want to put a CTR now and a single piece in the bag? That’s not going to be enough. Want to put a CTR and 3 piece haptic in the sulcus, optic capture? Again not enough to support. CTR and suture segment ring and IOL in the bag. Scleral fix stated IOL, you can do that or leave aphakic and come back later. That’s a reasonable option, too. If you’re unable to handle this case, you can leave the patient aphakic but come back soon. Have your colleague see the patient the next day and come back to the OR within a week, maybe 10 days. Otherwise, if you wait a month, the capsular bag is going to get fibrotic. Here, it’s the same case, we just changed the lighting. The surgeon is going to lever it alone and come back at a later date. They went back to the OR three days later with a colleague who helped. But a CT segment and sutured it to the sclera and put an IOL on the bag and the patient did okay. The patient left aphakic day one and went back to the OR after three days to resolve the issue and fix it and everything went just fine: You don’t have to solve everything at one time. The last final case in the last minute or two. What are you going to do now? Watch carefully. The surgeon is doing a routine case they thought but notice the bag is shallow. There is zonulopathy and fluid is going around the zonulopathy into Berger’s space. So the bag is shallowing. It’s getting too shallow. So now what? Try to clean this up a little bit. Okay. Put some viscoelastic in the eye and get the lens in. You put the viscoelastic in and you want a cohesive viscoelastic. The surgeon is not doing that. They’re putting HPMC which is a dispersive — that’s not a great choice. It’s not going to stay in the bag. It’s going to leak out. Too dispersive. Now the lens, three piece lens, put the cartridge in and look, wow. What about those wrinkles? What are those wrinkles? What is your next move? Inject viscoelastic, right. Inject the viscoelastic. Watch carefully. Not enough. Gone. Did you see what happened? Did you see that? The entire capsule got sucked into the injector. Look in slow motion. What a mistake, look at that. Because there is some negative pressure in the injector and positive pressure behind the bag, the whole bag is gone. Now you have to do the Yamane. You have to watch begin and you’ll have nightmares about this. What a crazy case here. I can’t even believe it. Hope you enjoyed these videos today and learned a lot. I want to thank you for participating, we’re happy to do the question and answer now. We can stop the share. All righty. Q&A. 17 questions. The first question, how did we get confidence for such complicated procedures as we are fresh graduates? Every day you’re going to learn a little more. This is your goal. The reason you have to learn every single day is because cataract surgery and ophthalmology, everything changes. The way you do it today is not how you’ll do it in ten years. What if triamcinolone goes posterior segment and blocks the reflex. The answer is put in less triamcinolone. And then okay. Now how to identify ZD with clock hours. Three or maybe 4 clock hours a CTR is enough. 5, 6, 7 clock hours you need to put in the ring and a suture. Vitrectomy settings. I cannot spoon feed you. You have to put in your own time and learn that. There is a ten-part series on how to choose the phaco settings. You took physics in school and you understand how flow works and pressure. It’s all explained there. I can’t spoon feed you, you have to do it yourself. How do you proceed once you know it’s a snap sign? Convert to MSICS right away. If you see a snap sign, the best bet in that case is do MSICS. We talked about snap sign. There is a video on cataract coach shows you exactly how to get the regular triamcinolone and use a filter and make it preservative free. We get the particles out of the triamcinolone in the filter and resuspend it in BSF and it’s fine. There is a video on cataract coach and you need to look that up yourself. Why not put a single piece of sulcus? It will 100% cause UGH, uveitis, glaucoma, and hyphema. The six pieces scrape the back of the iris. You damage the blood vessels and never, never, never put a single piece acrylic lens in the sulcus. If you only have that in the center, you’re wrong. You need a three piece lens and do that instead. That’s the reality and the truth. How many clock hours, we did this. Bilateral Fuchs with mature cataract. MSICS is okay. No phaco into the eye. We have videos on this. I can’t spoon feed you so much. You have to put in the effort to do a little research. Three piece haptics, think about it. If you put a three piece in the sulcus, the haptics, if you have a gap in the zonular support, the haptic can go through the support. If you put the three piece in the bag, then you can aim the haptic towards the area of zonular weakness and it can support the bag. But if the three piece is in the sulcus, the haptics should be 90 degrees away from the area of the zonular loss. If you put it in the same place the haptic can slip through the zonular loss. Can we wait — sure. The capsular bag is going to start to fibrous immediately. The you leave an eye phakic, you want to go back and operate within a week or ten days. Can you put an AC lens in. Yes. In big analysis it’s just about the same as suture fixated lens. That is okay. But remember, don’t enlarge the phaco corneal incision 6 mm for the lens. You need to make a tunnel for that. IOL dislodged into the vitreous cavity. You need to do a partial vitrectomy and remove the lens. ACL we talked about. Now, the night will be full of nightmares. Thank you. All righty. Can LRI help astigmatism. No. LRI is for less than one diopter. Easy game. Okay. Right. Why is there negative pressure in the injector? Maybe they didn’t have it fully filled with viscoelastic. The cartridge is a hollow tube. You have a plunger in the back but it opens. That acts as an exit point. So the AC shallowed. Anterior vitrectomy and pars plana, you have to check for entry side breaks and do it right. Why the cap sewer fall into the vitreous. Where was the negative pressure? What was the easiest exit path. The injector cartridge is a hollow tube. That’s the exit. It’s not going to go into the vitreous cavity. Best action on the last case. We saw the capsule wrinkling but the patient may not have been stable anyway. If you see the snap sign, stop. Don’t do more, the capsule is open. How to deal with complications when your confidence is lost. Thank you for asking these. We covered this in videos. I teach a little bit every day but safe hydrodissection. There is a video on it. A 25-part curriculum series. A 30 or 40 minute video once a week for 25 weeks or 6 months and goes through all of this. How to do the correct hydrodissection, how to do a rhexis. It’s there. There is a free PDF book. You see the videos and when the videos say cataract coach.com. You never put the effort in to go there. It’s all there. It’s free. You don’t even have to sign up. It’s free. We talked about how do you handle yourself after complications? Here is the trick. If a resident is doing a cataract case and has a complication and I come and take over. I’m very calm. Because I just look at it like I’m saving this patient’s eye. If I have a complication, I will stop, stabilize the eye, put viscoelastic and stop and take a breath. This patient was referred to me for me to fix this issue. How will I fix it. I stay calm. It’s in the mind. How do I convert phaco to MSICS. Make a proper MSICS incision. We talked about the last case already. If you have — move away, if you have a temporal phaco incision, go superior. How can you predict an impending nucleus drop. You start to see it. Deepening of the posterior chamber behind the iris. It starts to deepen. Why do you not go to the center of the cataract. If you go to the center, any fluid back there you don’t allow it to burp up. So I only cataract dissect to the left or the right. Never the middle. Would you prescribe glasses after surgery. Wait a month because the capsular bag has finished contracting and you have the final effective lens position. How do you get three piece haptics in the bag, you inject it in there. Can you put a three piece with a sulcus six months. Yes. Probably. If IOL is hanging half way to the vitreous, do you pull it out? That’s the catch. It may be entrapped with vitreous and you get a retinal tear. How to avoid the Chevron sign in phaco. You start out thin on the incision and change directions and that’s a terrible incision. There is a whole section on how to make incisions: I have a fancy OCT on the microscope and here is the best way of doing. That is all on cataract coach. For young surgeons, avoid the habit of asking to be spoon fed. You have to do some work yourself. What’s the best design of side port — there is no perfect design. Can you use iris hooks when the pupil is prolapsed. Yes. You can do that. I think we hammered them all out. Done. I want to say thank you to you guys. Appreciate it. All of these resources are there for free. Just have them. How do you shorten your surgery from 6 minutes to 10 minutes. Speed is not the goal. That’s a mistake. You don’t want to be faster, you want to be more efficient. You want to be safer in surgery. There is a video on cataract coach of me making a mistake. I put a video maybe 15 or 18 years ago and I thought I was so smart. I did a phaco in 3 minutes. It was so ugly. Now I take 6 minutes, 7 minutes, whatever, doesn’t matter. Do a beautiful job. You have to watch your own videos and you’ll see where am I wasting time and you’ll figure it out. If you want to be fast, you have to do phaco chop. Divide and concur makes no sense. CTR and PCO. Wait at least three months before the posterior capsulotomy. Robotic, yes. I did the world’s robotic last October. The videos are online. It’s coming. I have a financial interest. I’m part owner of that company. You have to use triamcinolone for PCR rupture. In the case of the bag sucked into the injector — maybe, maybe not. Hard to say. Robotic surgery, you can look it up online. It will make surgery more efficient and better. Let’s close the Q&A. We’re done. Any questions, don’t hesitate. CataractCoach.com. All the videos I showed you today are on CataractCoach.com. Be proactive. You learn if you want to learn. If you don’t want to learn, don’t be proactive. Avoid the desire to be spoon fed. No, go learn it yourself. It’s all out there. I want to say thank you, I appreciate it.