 Well, good afternoon and thank you so much for coming and I apologize. There was a small Misunderstanding about this lecture this morning, but I'm so happy that this could be organized for noon and thank you again for coming So Lisa I said does not really require an introduction, but I'll do it in any way So she's a very well-known Interior segment surgeon and she's now retired from her private practice But she's still very active in research and giving ideas And we are very happy that she's an adjunct faculty here at the moron So she's going to present something that's very interesting and important for us because she came This weekend to work with us in the lab this afternoon in a related subject So this is going to be a perfect background for that. Thank you very much Thank you so much. It's really a pleasure to be here Thank you so much to Elaine and others for making this come to fruition today It's been such a pleasure to be associated with you the last Important labs that Liliana and I did together became the nightest of my talks on complication management and avoidance and I'm looking forward to talking to you about a new subject here very which I think is very very important and to me Will be the future of medicine. I have disclosures. I am a consultant to menosis, which will be Important to this talk. The smart vision lab is irrelevant to the talk I'm going to try to convince you to abandon the bag I'll introduce my new surgical technique of scleral bicop capsuleotomy capture that I'm calling SBCC and To my knowledge, no one has ever recommended this as any routine procedure And I'll explain how I came to it and why I'm working to see if this is the right way to go Keep in mind being a great surgeon isn't just acquiring skills and having good hands But it's also having good judgment to know when not to jump on a bandwagon and neither to eat its dust now as you know when we operate there's a breakdown of the blood aqueous barrier and Healing response that involves the lens epithelial cells with proliferation Which is what we're mainly concerned with because we just take for granted the transformation proliferation of course leads to elchonics pearls and the typical PCO that we use Yag laser spore And then there can be fibroblasts and myoblasts that occur that actually lead to the Opacities and rigidities and then wrinkles and contraction that we see that we have often thought there's not much to do about And we're used to seeing these things over time and of course This is the phymosis that often leads to bag lens subluxation and needs early treatment and By and large it's thought that this is a normal perfect eye This eye is 2020 and although maybe they could have blown away that flight floater for them Whenever we do a Yag laser for secondary cataract, which as you know would be a hundred percent in children if we didn't do enter a vitrectomy and vitrector rexis But good 20 to 30 percent arguably probably more if people live long enough and as we do earlier surgery We'll find this out so many people undergo PCO and need a Yag laser Which is thought to be kind of very benign because it's quick and easy and painless But on the other hand we do always or virtually always break the anterior hyloid Which is actually our protection between the posterior segment and the anterior segment Which protects the macula and the retina Now I'm going to try to convince you regardless of whether you're interested in these future concepts to master the posterior capsular rexis and There are various reasons to do that in order to reduce PCO obviously But to convert an unstable accidental tear into a continuous tear that allows us to continue to bag and plant It's a very important skill Because a tear well that isn't finishing outside of where it began with any force can tear out To allow the immediate visual rehabilitation in unpolishable plaques You know we have we usually wait till the blood retinal barrier is restored It's six weeks to three months usually patients have to wait three months since that's the global period for payment before going ahead with the Yag laser and and they have to suffer a decreased vision in the interim and When general anesthesia is required for people who can't sit for a Yag mentally handicapped people or physically Distorted bodies that won't fit into the Yag laser and then I think it's an important technique Which people don't keep in mind nearly enough for optic capture for subluxated lenses We have a membrane or posterior capsule or an anterior capsule that can be converted in some way to a large enough continuous opening to be able to Optic capture then we don't need to suture to the iris which usually Leads to some low-grade chronic inflammation, and we don't have to do a major vitrectomy in order to scleral fixate Now here's an example of a patient a case where And I turn them all down. So sorry about that. I'll just have to do it again I saved it and everything but at any rate I'm happy to give this To you these videos. I can also substitute with the voiceover or if you'd like them later And it's a routine case I always support the anterior chamber when removing the INA and I saw a clear area here And I'm exploring it by putting OVD through that apparent hole Which obviously is a hole because you can see the viscote just fall down into the vitreous if you had 3d You know through the microscope it'd be very obvious. So I'm quickly Putting more OVD into the sulcus and I'm taking a little edge. Sometimes you need to use a Avanus to make an edge although that's rare And I'm going to convert this small tear as round as it looks it will not hold up to forces to a true continuous curvilinear capsular exis and We can do that nicely If there's already vitreous prolapse through there Then we have to deal with that vitreous first preferably with irrigation Anterior and a pars planar approach to bring the vitreous home and not enlarge the opening and there are many videos on that It's a course that I teach at many many of the meetings and actually abe viscavita has one of the nicest Videos through a SCRS showing how important it is to consider learning to do a proper pars planar approach At any rate here. We are it's not really rocket science though You see that the forces have to be more centripetal Because the anterior capsule is about 14 to 16 microns thick and the posterior capsule is in the range of five microns of Thickness and of course behind that is the anterior hyloid like the yolk of a like the membrane on a yolk from egg Very fragile and there is a space delimited by Weigert's ligament The posterior zonials all around called burger space between the anterior hyloid and the posterior capsule And so you can see we were able to save the day and place our one-piece Toric lens in the bag and rotate it properly And then you just have to be sure that you don't allow the chamber to collapse and that you keep it Down as a nice barrier to keep the hyloid from breaking when you finish Which is why I use the acetyl choline that you might have seen bring the people down now here's an example of obviously very mature cataract and Using tri-pan we've made a nice anterior capsular rexus have another whole lecture. I'd love to talk to you sometime for an hour about my Circumferential cross-action shop disassembly technique for very brunessant lenses such as this is that that tan Gooey bruness and variety, but they get black as well and sometimes the tan ones are even more leathery and more difficult And we won't concentrate on that But what you'll see here is that once I've completed the Faco and of course there's even a calcific Rim at the periphery and once we've completed that nicely I'm using my terry squeegee and you can see that this plaque Absolutely will not polish off and I feel that it's the bag is very It was very extended extensible So I've added a CTR to make it a little more taut in order to make it practical to be able to do the posterior capsular rexus and I'm putting OVD into the sulcus just to flatten the anterior and posterior Leaves I left this bubble in because you don't want to bubble in your you know in your Syringe when you do this ideally and the idea is to take a 30 gauge Bevel up needle not a cystatome which could poke down enough in order to break the hyaloid But rather lift it off make a little tear and then put the OVD through to define burger space And in this case because of the fibrosis we go two directions And I decide not to opt to capture which I'll talk about later in this case because of the fibrosis and not being absolutely certain of the perfect Continuousness of this particular rexus in this case But a patient like this instead of seeing 2050 or 2060 for three months will be 2020 on day one and So we've saved them the early YAG laser capsulotomy and all of the potential consequences of that Which as you know include particularly in my hopes the increased risk of retinal terror detachment and possibly CME and in diabetic Retinopathy we allow all of our compounds to move forward and back and in glaucoma There's some good evidence that it's the vitriol elements that Are toxic to the Trabeculum that increases the pressure sometimes not just as a pressure spike, but actually a long term after YAG laser and glaucoma patients So we've managed to complete this and then we're going to blow up the spare tire Basically, which is the bag because now we have a posterior rexus in an anterior rexus blow up the Spare tire the sulcus with OVD so that we can implant a lens and we could opt to capture a one-piece into burger space That's posterior optic capture, but three pieces are better when we intend to optic capture And certainly critical if we're going to put it in the sulcus and optic capture through the anterior capsule Since we never want a one-piece lens in the sulcus And you can see that this ends up very lovely. We've supported the chamber and this patient can be 2020 the next day Now there's lots of literature about posterior optic capture and It goes back to probably 1996 when gimbal first described this Certainly passing on a menopachy or two of the biggest proponents of posterior capsular rexus with what he calls Manipachi calls posterior button-holing and Perhaps we would add what would you say to Groot and noi hand perhaps to this list, but these are the big relevant articles and Basically the question is why should we do that? What if we just do a posterior capsular rexus? Will it always avoid visual axis obscuration? Absolutely not in children. We still have a very high percentage because of the vitreous being Pretty solid and the anterior high-loid gives a scaffolding for it to grow over and adults it even maybe two to seven percent of PCO despite posterior capsule capsular rexus itself This is a very nice picture that actually shows Burger space between the anterior high-loid and the posterior capsule. It's menopachy's picture and We have an earlier history a different way of doing this but Dr. Stegman in South Africa who mainly does a lot of pediatric trauma has just done slit capsulatomies and then optic captured But that means you've got to be really careful not to place any forces on that that might cause it to wrap around And we don't really consider that sufficiently stable though He has quite a bit of literature showing that five to twelve years out It's both stable and has a clear visual axis still I think we should strive for continuous rexus if we're looking to have all surgeons of all capacities and abilities to do a technique Now here is a case that I've done and You'll suffer through for four minutes Pediatric case always I don't like to use a tri-pan blue for the anterior capsule in pediatric cases Although it does make it less elastic and a little easier to deal with it does make a permanent molecular change And who knows that what that'll mean 50 60 years from now So I think it's quite possible to do a decent capsular rexus anterior capsular rexus without and I'll take time to measure Because anytime I'm going to deal with the posterior capsule It's really important that you have a well-sized and reasonably centered anterior capsulatomy since that's our backdoor option Should we have a complication in doing our posterior capsule or exis we can always Sulk us implant an anterior optic capture and So that's why I wouldn't attempt a posterior rexus in most cases if I don't have an appropriate Anterior capsule rexus the posterior capsule rexus can be quite forgiving in terms of its size and its And its Centration because when you place a lens in the bag or the sulcus for that matter an optic capture posteriorly into burger space It's not the capsular rexus that's centering the lens It's the haptics that are sitting in the bag or the sulcus that are centering that lens And so it can be fairly forgiving, but you can't make it too small or it's possible to break it So here and I'm a little slow dr. Menopachi feels that it's a hundred and fifty case learning curve to be really Facilate doing a posterior capsular rexus. I made it up to 80 I did all of our pediatric cataracts, which weren't that many my husband's pediatric Ophthalmologist and we thought we were the ideal team where I worked as his technician He actually you know followed the patient decided when and if they needed surgery and then followed them immediately afterwards and Even the newer pediatric ophthalmologist who joined our group Asked me to do anyone that needed an implant because these eyes are so quiet as opposed to Doing an anterior of a track to me or leaving them a faking, you know the recent infant a fakia study involve posterior vitreorexus and an anterior of a track to me capsule rexus and and anterior of a track to me and with or without an implant and They found that they had similar ultimate visual outcomes But more interventions with the ones within plants at early ages because of fibrosis and sublexation and inflammation and problems But all pediatric cataracts Have something like or congenital cataracts have something like a 15 to 20 percent risk of consecutive open-angle glaucoma Which is the truly once we get over amblyopia the truly vision-threatening problem and Stegman at least believes as do I that it's because we do something routinely in children That's considered a complication in adults and that is an anterior vitrectomy and that allowing those vitreal elements Access to the immature trabeculum makes for that high rate of glaucoma now some of these eyes may have just immature trabeculum I'm not including Anterior segment dysmorphic angles. I'm talking about normal-looking eyes with just congenital cataracts. So Posture optic capture and here what you're seeing is that I'm pushing the the poles of the optic having completed the capsule Arexus filling burger space through the small opening and I'm pushing on the poles 90 degrees apart 90 degrees away from the optic haptic junction in order to capture the optic into burger space below the posterior capsule And you'll see in a moment. I I'm doing lots of irrigation so that when I come out it won't collapse and just any by the way any OVD visco elastic that's left behind the implant with an open posterior capsule will not cause Capsular distention syndrome nor will it cause a pressure rise because it doesn't have access if you're hermetically Sealing it into the posterior segment. It doesn't have access to the trabeculum So of course you're still going to remove any OVD and I wanted to stop it here So you could really see just a little bit different than that So you can really see the capture and you can see here the cat eye appearance of the posterior capsulotomy from haptic optic junction to optic junction and then the intact capsule arexus which is undisturbed and Round here that you can just barely see and that's what we're looking for for posterior optic buttonhole And when we do this we find that the eyes are exceedingly quiet that the visual axis remains clear throughout life actually Now here is a beautiful Video from Maria Jose Tassiana in Brussels and it's intraoperative OCT so you're going to watch as she Violates the posterior capsule here. Here's the anterior hyloid and you'll watch as she goes and makes that that stab opening and pulls it around to make a little a little curvilinear tag and then takes the OVD and Puts it through the opening to push back and you see how burgers came I mean how anterior hyloid came forward But now she's got this little this little cannula and you see how she's pushing it backwards out of the way So that you end up with a fairly and you can barely see the hyloid here But you end up pushing the hyloid back with your OVD making a nice bubble of OVD and you have a fairly Convex posterior capsule and now she's going to grab the capsule and she's going to make this continuous circular curvilinear posterior capsular rexus and You can watch that happen on OCT and She is probably one of the world's masters at this Especially in pediatric cases and her goal is to make the anterior and the posterior Capsular rexus both perfectly centered perfectly sized and symmetric because she has a lens called the bag in the in the lens Which is not FDA approved and something that I found very fascinating that we'll see a little bit later in this presentation as well so here is a menopachies picture of a button-hold Lens in an adult and you can see there's just a little bit of opacity of the anterior capsule, but no real fibrosis He is extremely meticulous in scraping and polishing lens epithelial cells off the anterior capsule flap as well as doing the posterior capsule OREXUS and you can see how clear and beautiful that looks well Is it safe to do this menopachies added to the literature immeasurably and I actually went to study with him in order to learn this technique some years ago and he has Paradise studies of with and without capsular rexus with and without optic capture and so on and in fact There's no increase in CME. There's no increase in intraocular pressure and no increase in RD In fact, I'm thinking that when we get to enough numbers, we're going to see a much lower rate of eye of retinal detachment because we're Stabilizing the vitreous base and preserving the hyaloid for life Hmm now here's an example of one that went awry in one of my early series and I was hoping Sorry, I was hoping to To use the same lens that he uses which was a Hoya lens and I was told that that would be the case And perhaps I was just a little chicken on the size of my posterior capsular rexus at any rate It turned out to be rather a stiff lens He chooses a lens that has a very 90-degree optic haptic junction because that's the only place that our material our lens material is going to touch lens epithelial cells Which is what creates the transformation of these cells to fibroblasts and and myoblasts and so here I'm trying to optic capture and I realize at some point that as I'm trying to get the Proximal pole captured that I have broken the posterior capsule here And so I no longer have a continuous capsule you'll see after a bit here And so thinking quickly all I had to do was forward capture forward of the anterior capsular rexus Because I don't have a stable lens if it's in the bag But I don't have an intact and reliable posterior capsule and there's always the chance of subluxation later And so here I'm sort of digging underneath cantilevering over the edge of the anterior rexus in order to bring that Pull up out of the bag and then bringing the other pole up out of the bag into onto the Surface of the anterior capsule rexus so that the haptics are still in the bag But now the optic is reverse captured forward of the anterior capsule rexus And this is a technique by the way They can be used if say you put in a one-piece lens in the bag and then suddenly on removing OVD or something you break the capsule You can reverse optic capture rather than have to exchange a lens in the middle of things And I've added tree essence just to be sure that no vitreous prolapse And that's always a good idea whenever you're at risk for that and there was none in this patient did just as Beautifully as far as I could tell as if I had actually managed the procedure of putting it posterior So we have two back door outs in case of complication, and that's one of the beauties of this technique now Pediatric buttonhole avoids vitrectomy and I have six years experience as I said with small numbers But I got abevisavita who sees tons of pediatric cataracts to please please try the buttonhole technique because he had been involved in the a fakia pediatric a fakia study and And finally because of his particularly because he had ephemto laser and I'll show you that he decided to do a series and when I saw Him last as a personal communication in the last askers He had done 50 and he said they were the best eyes that he had seen in all the series that he had done Now let's get to that bag in the lens And so the typical thing of course is that we put our lens in the bag right with an anterior capsule or exosin and intact Posterior capsule but really testing you on designed a lens that doesn't actually have haptics the haptic is simply a collar button So there's two like parts of your haptic is kind of a base for the optic with a collar button around so that the two edges of the Capsula rex's the anterior and posterior fit right into that collar button So that's why she calls it the bag in the bag in the lens rather than the lens in the bag And she has some startlingly wonderful outcomes The only thing is it must be perfectly centered because centration depends entirely not on the zonules or on the bag itself But on the centration of the two capsula rex's and it must be perfectly centered and they're not FDA approved But look at her data between 1999 and 2006 and this hasn't caught on like wildfire. I think mainly because it's so technically difficult to do She did 300 eyes and they included babies and children and uveitis and diabetes and all the worst cases and her PCC closure rate 0% not only that but on pathology you can see the Cells these are the lens epithelial cells on the capsule with a regular lens in the bag and look at what the capsule looks like For the bag in the lens. It's devoid of these transformed fibrotic cells And look at these post-op results now Lilliana has seen some of these eyes postoperatively and seen that they do often have a summering's ring that remains questured out in the equator and really kind of shocked Maria Jose because she wasn't seeing them when you dilate the pupil and But the point is that they're sequestered And don't have that and that antigenic material which normally leaches out of our normal in the bag technique You know to cause inflammation. It doesn't happen because it's sequestered and it's That was another piece of my thought about SBCC, which we'll get to in a moment Now remember we think it's normal and great when people see 2020 and they've got you know There's white Fibrotic thing and then this little hole that we've made for you know with the Yag laser and they can see out 2020 but that's not physiologic. This is physiologic. Okay, this is what what our eyes are meant to look like and The sooner we recognize that I think the better. Well in my opinion neither the bag in the lens nor the posterioptic buttonhole takes care of every problem and I bet anyone here who's clinically involved has seen bad lens Subluxations which is becoming more and more of an epidemic and we know one thing is in common of all bad lens Subluxations although most have pseudo exfoliation some have either surgical trauma or true trauma Non-iatrogenic they all have one thing in common then that is an intact anterior Capsula rexus and theoretically some degree of Phymosis And before of course the Capsula rexus, which was one of the best things in sliced bread for making Faco practical We had tons of lens Subluxations and not very many people who have pseudo exfoliation and don't have cataract surgery come in with spontaneous Subluxations of their cataracts. That's rare as hands teeth right but bad lens subluxation isn't and so I came to our realization about eight years ago that There was a better way to do this and rather than put the lens in the bag and I guess I was a little ahead of myself here, of course We don't really know if something's going to work for eight to ten years Which is the average time from surgery to bad lens subluxation? I don't have great data though. I did large numbers of cases I was strictly a clinic clinician and didn't have good data and no randomized trials But my experience told me that the right thing to do is to put it in the sulcus So let me show you this video. Are you seeing them all enough with the light the way it is everything? Okay with that okay, so you can see the pincushion effect of this very Loose bag trying to make the hole in the anterior capsule to initiate the capsular rexis And we finally get that done you can use crossed blades if necessary in order to get it done if it's really really tough but it wasn't necessary and We really don't have any good system to judge you know to really quantify the amount of zonular laxity in cases I don't know of any article that's really done well with that There was one fairly recently that with a proposal, but there was a lot of criticism about it And so you just have your own feel for this right and if you've got a pincushion effect And you can see the bag kind of move with me a little as I get around and probably the reason we're seeing so many Bad lens subluxations now as we're getting so good at surgery that despite very diffuse and significant zonular laxity We're managing to get these cases done in an uncomplicated manner and here I'm making no big movements to try to Maneuver the lens you know to free the lens or spin it and I'm doing Multidirectional hydro dissection another thing that I recommend in these loose zonule cases and of course in the Miyake lab You know they've shown us all the terrible things we can do to zonules from the back You know particularly with rotation and so on and your lab is just the greatest for for adding to the literature on these subjects so here I'm going to go ahead and do my regular fecal and even though it hasn't spun I always do I haven't sculpted in a millimeter in years a Vertical chop, which is really very friendly. You can see the bag waft all around in the back there And that was kind of a posterior polar as well You can see the attachments around that area, but it did polish off nicely And I always support the chamber coming in or out with irrigation with irrigation through the side port a kind of a poor Man's chamber maintainer because I don't want chambers to collapse and here you can see I'm very gently Delivering the cortex. You don't want to just strip the cortex out or you'll see equator And if at any point I can't get it free and I start to see the equator then I'll back off and I'll put capsular retention capsular expansion rings in order to perform the The removal of the cortex, but here I am successful and little by little and I think it's really important also in these cases that you Start subincisionally and then be very Methodical about every clock hour. I like to go one direction then come back subincisional and go the other supporting the chamber And now I'm going to put a CTR And we want to just gently lay that in to the periphery and feel the proprioception of not putting any pressure on that That's a whole nother lecture or we could put something through the The leading islet to not put pressure now I'm checking that I have a small enough anterior capsule arexus because I'm intentionally now that I put a CTR in the bag Going to put a three-piece lens in the sulcus and optic capture Through the anterior capsule arexus and my theory Was and is that basically the lens is supporting the bag the bag is supporting the lens and more importantly the optic Is a stent to prevent pymosis of the anterior capsule? so that Here you'll see and it's a little more difficult in these cases because you can't just push sometimes it even needs a Bi-manual technique because these zonules are so lax, you know That it can be a little difficult and you want to get you don't want to leave a lot of OVD in the bag because you have an Intact posterior here, but I've successfully optic captured and I'll show you the pictures afterwards and what they typically look like After I show you in this video. I will come out as an hour. That's okay with everybody I assume I'll be showing you a more a zonular loss case here in this particular video and And we come out with a result that is incredibly stable I think if you're good if you're in the clinical field you recognize and here's of course one with missing zonules So in this case, we're definitely going to use After completing that we're going to place Capsule suspension hooks. I don't like to use the Iris hooks because they're not properly polished and they put all the pressure in one place These are the Yamaguchi ones which are kind of like a hammerhead shark and here you can see I've taken any pressure off by having a Suture that I can pull so I can pull it around the equator without any pressure on the equator and here we This is now another case a post vitrectomy case and it just shows the optic capture anteriorly so much better I voice this over a little more contemporaneously, but you can see how easily that is so here's the fellow I have a patient with the standard bag in the lens with the CTR And we have to go do anterior capsule relaxing incisions With the add laser in order to hopefully prevent Phymosis and who know and here is what the eye looks like After optic capture the fellow I with that that very one with those loose sonials that you saw and this is what We're trying to prevent and you'll be amazed if you do this procedure That you'll see no pseudo fecogenesis in the eye where you succeed and put the lens in the bag and have a nice CTR You know if they're loose you're going to see this little bit of shimmer And if it's in the sulcus optic captured solid absolutely solid with no Phymosis So I did that for a number of years and was very happy with that And so here you can see the Phymosis of the fellow I and maybe not I should move this over so you can see the Whole thing, but basically you can see how beautiful this looks When it's optic captured now because of that experience and another experience this was a paintball injury case From long ago, and I'm just going to speed it up a tiny bit because I take forever getting the lens in because I'm very cautious This was a paintball injury with an irido dialysis and a traumatic iridoplegia and actually had an open posterior capsule from the trauma And after we got everything cleaned up I decided in putting this implant in that I could use that Fibrotic posterior capsular opening that was there from the trauma as well as my perfect anterior Capsula rexes and in this case I decided I wasn't so comfortable just leaving it in the bag Because of the fact that there was was some zonular compromise, and I wasn't going to sew the bag to the wall of the eye And so I thought that if I Capture both through the anterior Capsula rexes and through that posterior opening That this would lead to a nice stable implant, and you'll see that in fact it does and I followed this patient for this is probably 10 years ago And he did very very well You'll see Just speed up through here just a little bit, but basically We've got the whole thing in now, and we're going to in the sulcus, and we're going to optic capture both through the posterior Fibrotic opening as well as the anterior capsule and I won't bore you with every little manure. I suppose Well then again, maybe I will At any rate you can see that it takes a little bit of force in this case because it wasn't an ideal poster opening But you can count on the fact and this is a very good teaching video because of the fact that when you have Fibrotic capsule from old openings you can count on them being very very strong And you can use them for optic capture when you have subluxated lenses rather than have to so The wall of the eye or do large of atrectomies So that's how I managed this case and between thinking about Stopping bagel and subluxations stopping having to do enter of atrectomies in children Stopping needing to rupture the enter hyaloid in routine cases 20 to 30 percent of the time with secondary cataract I came up with the concept of a routine procedure that would address all of these issues and Basically, we have a five millimeter anterior capsular rexis. We remove the bag contents as usual We may or may not need to vacuum or polish the anterior capsules And that remains to be seen in some of the research. We'll be doing Menopati doesn't think so with this technique I've asked him and then we have our posterior capsule rexis with the intact hyaloid because of forming burger space sulcus implantation then of a three-piece lens and after we sulcus implant then we optic capture through both the anterior and the posterior rexis Now I don't think anyone has ever suggested that that is my unique idea and they for routine procedure And the concept is that we both stent the anterior capsule from the point of view of phymosis And we prevent PCO in every case and we sequester like the bag in the lens all lens Epithelial cells from touching the optic except right at the haptic optic junctions minutely and we sequester all the antigenic material and I Suspect that in addition and this is not my case because I came up with this just after I retired actually from patient care, but my friend Kathleen McCabe did this and This was actually her first PCCC So it's a little bit small that she had made and she's putting the lens in the in the sulcus and you can see our optic capture And I think that an extra bonus of all of this is going to be That there's just a chance that we might see accommodation if we're sulcus implanted and We have a unit which still keeps all of its zonular attachments together Including the posterior zonules and we have a capsule that does not become fibrotic or ever need to be lasered Might that not move with the right lens design and that's what I'll be working on in the future here also with Dan Goldberg who if you haven't read his his studies of Expanding Helmholtz's theory of accommodation you really should he has probably the seminal article in JCRS on that So here she has rather handily in her first case of PCCC By by optic captured and this patient was a macular degeneration patient that she chose for her first patient You know, I'm in just a dry AMD. So anyway, he's doing great, you know, but nothing to write home about more Amazing to me. I gave this lecture as the wolf lecture at University of Iowa about four months ago and Tom Odding decided he had a patient who was a monocular eight-year-old JRA patient who had had all kinds of problems with all sorts of Phymosis and inflammation after her first on uneventful cataract surgery in her first eye And he decided to use my bi capsulatomy technique sulcus bi capsulatomy and at four months to six months now I'm not sure about the six-month follow-up because she's lost in retina land according to her him however He said it was a perfectly clear opening and he has made two more attempts But the problem is that it's rather technically challenging and there are very few people who want to do a manual posterior Capsula rexis and so the learning curve and how to make this accessible to the average anterior segment surgeon is Where I'm at right now and why we're here in the lab that we're going to do with monosis today And I want to explain that a little bit. So I think I'm pretty much on time here So to take a breath then one of the possibilities is to use the femto laser and I I actually had some experience with Flax or however, you want to call it these days Before retiring because I saw Burkart Dick make a posterior Capsula rexis in a child off label Of course fooling the machine as to what all the gates and parameters were and that's what I wanted to do but unfortunately the FDA Decided to change their language of art so that all of the femto lasers are labeled as contraindicated under age 22 try to get that through an IRB yeah, and Also in court would be rather untenable even though there's no evidence that it's bad There's just no indication and they've decided to use the word contraindicated for that and My OR wouldn't let me put my surgery center didn't want me to put it in the OR because of the Logistics of using you know the ORs the two hours that we had which is required if you're going to sterile redock under general anesthesia And use this technique, but it's interesting that without going back to optic capture in adults He in his first series was able to see in 68 percent of people right after a routine flax when redocking He could actually see the distinct posterior capsule in the anterior hyeloid and he was able to do a posterior Capsillotomy with the femto laser and 68 percent of patients without rupturing the hyeloid and with a perfect opening And it's interesting that that flap Whizzened up out of the visual axis completely where you couldn't see it by day one post-op and every one of those patients He said now here is Abbe Vesaveta making with the lens X Burkhart was working with the catalyst and this is the lens X And I was on the surgeons advisory committee for catalyst, but I'm no longer obviously it's a mo And you can see that he's made a perfect posterior capsule arexus right here Which he chose to make smaller than I would But anyhow here's the anterior and the posterior capsule and that's all he sent me But it does it is quite possible to do it now There are economic barriers to doing this routinely for everybody right with a femto laser and only 68 percent could see that without And if you want to post her optic capture then you have to undock and then go back in the eye and optic capture Which you'd have to do in children to do this and it's doable I thought perhaps we could have centers of excellence Pediatric ophthalmologist could be credentialed to do this procedure and you know all the kids Stuff would be at least kids would be done there and that But it's really a premium surgery to never ever need to have a YAG laser again for adults You know to just get your quick femto done, you know afterwards but For the all those reasons, it's not practical here comes the reason for our lab and The menosis company has something called the Zepto perfect precision Capsulotomy maker which has a soft clear suction cup with a nitinol tubing inside of it and It can fit through a 2.2 incision because of this rod that makes it go flat and then open up again inside the Eye and they're in 510 K For ancheria capsulotomy and I went to them and said look we got to study this for posterior Capsulotomy and the way it works is without a thermal effect it because it sucks onto the capsule and makes the capsule kind of Kind of curl up around it when this proprietary DC current is applied It explodes the water molecules in the membrane that causes this simultaneous perfect continuous Capsulotomy and it turns out that it's extremely strong In paired eye cadaver studies, they found interest oops. I'll go back to that second. They found interestingly that Femto had the same strength as Manual don't forget these cadaver eyes don't move which is probably with you know The slight movements that we have with the even if it's a second to do a femto capsulotomy You know, it's not as strong and so many of the articles that we've seen and the The this capsulotomy was significantly stronger than either manual or femto Probably because the edge curls over and this is our ex vivo rabbit lab in California that I did with menosis This is me doing the surgery and you can see we are just applying the suction and then the Then you can see this perfect capsule of the anterior capsular flap This is of course open sky and an ex vivo rabbit and you can see how it hyper stains And that's really because on SEM you can see the edge just kind of curl over so that you're actually got a double edge That is continuous And that's why it hyper stains like that and is stronger than any other Method and here in this ex vivo eye. It was so lax and loose It was really hard to make a tear in the posterior capsule Of course in the human you saw the posterior capsule didn't move when I did that But it was a challenge just to get a little hole in that posterior capsule and then here I am putting OVD and nobody really knew till now even is there a burger space and a rabbit or what it's like We're going to find out a lot more at 2 o'clock today because we're going to be working to try to use this posterior To make a posterior capsulotomy and look at the pathology of it With rabbits that will be sacrificed right after the study. So here The anterior capsule is done. I've made the hole in the posterior capsule. I've Inflated burger space with OVD and now I'm putting the Device into the capsule and of course it's a tad big for this little rabbit eye, but it's working and And I let it go Round and then we're going to apply this suction like we did before and this is the anterior capsule right over here And what we ended up doing was actually getting an almost perfect capsular posterior capsular rexis Which you'll see here in a moment Probably because of the angle sub and you know where where I was used to being subincisional even though I was open sky I might have had a slight angle. So we have a nice PCCC. There was a tiny little tag Subincisionally that you'll see that I have to pull around And then it's strong enough to and that completed it And it's strong enough to do posterior optic capture even though this is kind of a big lens for this little eye and You can see I'm putting it in the bag and Able to capture it through the posterior capsular rexis into burger space Without vitreous presenting or breaking that posterior capsule And you can see it here. Okay that we did manage to capture it So that's the first time anyone ever tried that for further investigation today. We'll be headed to try to Elucidate how we can do this some more so that we can put something that they're saying might be a hundred dollars a case And keep in mind that if we have to capture we're saving Socialized medicine tons of money for Yag lasers. I mean millions billions of dollars And then I hope to do a subsequent live rabbit study where I compare the standard pediatric case With enter of a trectomy to standard buttonhole to my concept of SBCCC and I want to see what happens to fibrosis Which is a good animal model for that though, of course We can only infer what might happen as far as bag lens subluxation and we can't study accommodation in this model So disadvantages there's a learning curve manual femto laser Zepto There's something out there called a capsule laser that's being worked on that might do the job and newer Technologies may make this technique more at hand for people Lens exchange may require a pars plaintive attract me. Hopefully we won't be exchanging many lenses in the future There are femto technologies where we can write different Refractive indexes into the cornea and the lens Where we can without healing response without Deapothelialization right now we have the ability and you would still have the ability to piggyback, okay a lens Here because we have have it back, okay? So I'm hopeful that we could piggyback that would be another experience another experiment potentially But I would think the way to exchange a lens would be to Anterior irrigation posterior approach for a pars plaintive do a small enter of a trectomy poke the lens forward and then From above put viscoelastic to cover the area and then you could exchange the lens, but that would be a small disadvantage Elimination of course, there's always LASIK elimination of fee-for-service income That's beyond my scope of worrying about that and in fact might be a huge advantage Economically and imagine in the third world where people just manage to get one surgery But can go blind functionally blind again from PCO and may not be able to get that advantages zero visual access Opacification, I'm no doubt it may eliminate back lens subluxation I have hope Permit Toric lens use if we have especially if we have a one piece at three pieces a Toric lens Which we don't currently have we can only optic buttonhole a one-piece lens We wouldn't want to put that in the sulcus for a bi-capsulotomy capture But it would permit that with proper lens design And I think this technique if it proves to be useful may well drive lens design especially towards something that might accommodate We'll decrease dysphotopsia because there's no reason on earth to have a square edge anymore, which is just to retard PCO Which increases dysphotopsia will have quieter eyes is since length eyes since lens proteins are sequestered and Perhaps will decrease consecutive glaucoma in pediatric cases We will have an intact hyaloid for life You won't have to have people coming and complaining of their floaters after yag lasers you won't have CME or increase in RD and Also, it's better vision even if you have a 20-20 eye It's been shown that stray light is significant from the intact clear Polished posterior capsule compared to no posterior capsule manapachi has some nice literature on that as well So it will be clearer a better vision from the get-go and forever space for secondary refractive piggyback I hope and Then Maybe we'll have accommodations. So those are the holy grails This gets my juices flowing and hopefully others will as well And we'll see if maybe there could be a new future that would be different from the last 20 to 30 years That kelman offered us in a big leap. There has no been no big leap for a very long time and These are the people who I thank very much for their encouragement and help and knowledge and building my thoughts and I did just write a An article in the August eye world and hope to publish more hope to publish the case with Tom Odding That he's done and thank you very much for your attention and for showing up at such short notice Yes Right well, I I think that we're collapsing the capsules I mean time will tell and I guess the only real concern would be if the summerings ring would grow so thick that it Might intrude upon the haptics in the sulcus and push it forward I think that's you know, I mean that's why I didn't tell Tom Odding to do this on a Monocular eight-year-old J or anybody did that's why I want this rabbit lab to kind of see what's going to happen to these eyes and The same thank you for mentioning that I should put a slide Yeah, men Apache studied this very well for posterior optic capture not nobody studied it for by its capsule But for posterior optic capture it doesn't become even significant at all till you're up above 30 diopters And then maybe a quarter of a diopter because the posterior capsule is so flexible that it's basically the haptics in the bag that are controlling the The power and when you put it in the sulcus, it's the anterior capsule is so Unflexible that it basically keeps it in the bag So they're pretty similar and so I'm thinking that we would end up at the back plane with by capsule But there's no data needless to say Right Well, I haven't seen it happen. It hasn't happened to me It didn't happen to men Apache in over five or six thousand cases That he's I mean, I know he did five thousand cases of some time back And in his first hundred and fifty that he wrote about on that article it didn't happen So the point is that we're putting it on top of a bed of OVD Which is delimited by Weigert's ligament So if you had totally ruptured the hyloid, yes, that's possible But don't forget you need to put the haptics in the bag or somewhere else If you put the haptics through the posterior capsule or X's it's gonna drop. Okay, but the optic won't so There's some technique to it. No question about it And and so that's why you want to carefully injecting or you're not going to be shooting stuff with a tunnel assist You know into these into these eyes with open posterior capsules But it's extremely doable because after you get the rex is done if you want it in the bag Then you just blow up the bag with OVD and it's very obvious where your haptic is going And as soon as that leading haptic goes in the bag you're pretty much safe Yes Good question about a post-patrectomized the question is Why not now you wouldn't have to do all that business with you wouldn't put OVD into the posterior segment because it would just fall down There's no way to to complete it, but you can certainly do a PCCC and that would be the way to Center a lens in a retracted eye that still had zonules, but no anterior capsule question good thinking Yes So what that's about when you have a really loose zonules a truly sublexated cataract Or whatever you can do a cross-swords technique So what you're doing is you're just taking a tiny little blade from either side and and and yeah Just or to anything really and and you just sort of trap it between them and that way you're not you're not depending on Movement of zonules you're you're you're fixing it with it, you know with the Oppositional forces of your two instruments, so it's a way to deal with a really recalcitrant capsule for opening it Yeah, the problem is that you don't know if there's any space at all between the hyaloid and the capsule So you will at some point rupture your hyaloid and you'd have no way to know it really until you see vitreous coming So if you're lucky enough to see it, yeah So so that's why you just don't want anything that goes down So all you it's just a 30 gauge bevel up needle and that way you can kind of snag it a little and lift it up Slightly and then just give it a little zits. Thank you. Have a great rest of your day and hope our lab goes well Thank you