 Yes, well, also, I think you see the excess of our system In you know basically making sure I don't have a problem making sure that That we don't get infections and etc etc, but we will go way overboard and waste the phenomenal amount of resources What's impressive about Yeah, the other the other thing that they do which is really Really beautiful in the one of the rooms where they have the four operating room table the fourth table is for training so the three three super folks will be or their Faculty will be doing their cases and then one one of them will rotate during one of their down times to the Table with the resident or fellow on it. And so there's always teaching going on in all of the ORs at all the time So it's it's really fantastic. So Randy. I just showed a Couple slides of our trip to my trip to point of cherry We were just discussing third work a little bit of third world the fact that they don't have any more Infection Lord even when they're doing these multiple cases the other and I've been tracking my cases Just myself and Alan Robin and all of them are just looking at what happens and the average use of BSS per case In my setting is 60 ccs per case, which means that you are throwing 430 ccs a fluid away every time because we have to break down and start over so Just a few thoughts Now I was hoping we'd there's just a couple things I want to talk about with with this for top We're going to get a lot of that Pretty soon So let's just go here Randy I was just saying this is a really Random talk this morning. So absolutely nothing that goes on so This for top. She is this is a interesting problem I think Randy's done probably more work and Nick have done more work than almost anybody on this issue And I'm really this is a this is a case of positive this for top Yeah, because I want to show it for a couple reasons But when you examine a patient that comes in with a complaint with 2020 or 2015 vision They can they'll describe these phenomenon and you look at the eye and you'll think it's perfect And if you look at the eye and they give these complaints and you think it's supposed to your capsule clouding Please don't do it because it's almost never there's lots of causes for these Lens-induced causes and I'll show you one that is a lens-induced causes But remember you can get these kinds of phenomena from some of your issues Capsular issues, but and that's the problem because in fact if everything looks perfect, there's a little PCO The thought if they're bitching a lot the thought that they're gonna Improve by PCO removal is not good make sure you get corneal Examination and see a mean and ready. This is of course the one of the surveys that you do And you might want to you want to comment a little bit on positive dysphotopsia or work No, I think it was 96 I think we're learning more and more as time goes on but And so this is a this is a real patient of mine sent down from by Rich Hoffman and Eugene Oregon and One thing to notice this was day one so a lot of times they They come into your office. They want the lights out. They they're they're describing this phenomenon and Unfortunately, you know, she was 20 20 at that point So they told her she was crazy and she may have been but Hence the reason why she's down here But at any rate point being that she would this she was sent down about six to seven months later And she is a professor of statistics at the University of Oregon But also notice what other things that are going on all this time She kept a pretty good luck. I had to read this in the dark as the room was dark when they came in and Usually the patients they talk about she actually had the PCO rate a few other things She talked about were you know reacting during surgery and then she did a nice analysis. She did our web search for us Which was very nice. You see here positive dysphotopsia She's quoting rates of 15 to 30 percent and she just talks about her what happened in her case Yeah, and unfortunately some of the early papers on this are from our group and Some had a handle it were from our group. So she flew down and we took care of her And you know, it's just very interesting to see that this kind of analysis Here's her evidence-based guideline that she sent to me and which was nice and Percentage of YAG patients and but these are her drawings These are her drawings and they were gone with the exchange of that lens 30 seconds afterwards She opened her eyes that they're gone Yeah, that's exactly what happened and the other problem too is they they thought her a lot of was Implementation and tear films and things like that so triggered her for way way too long Yeah, you didn't see the pressure but she was a steroid responder She came in with pressures of 48 at the time because they were mishandling that Here's some more things that she drew All these little images. So you do really have to listen to these folks now what I'm gonna do here Is I just want to show? Yeah, one one case where where the reason for the dysphotopsia is fairly obvious so For you for in practice if you see these kinds of scratches on The anterior surface of the lens and on the posterior surface of the lens and this is a restore So this person was told for seven years or three years Excuse me, but she was crazy everything was perfect And then she was referred in you guys got the Actually, this is a case report, but I don't want to show the whole thing here But you know so one point is even three to five years later seven years is the longest side I've done maybe eight years you can get these lenses out and not and put a new lens in sometimes you if they're Some of the plate lenses they can be very difficult to remove But what you have to do is just take your time Open the bag and you can see there's all a little bit of capsule pymosis as you're going on And then I'm going to jump to the end So there's what I use as I use a viscocanolostomy cannulus sometimes because that's only 32 Gauge 32 goes in very easily Sometimes you lift up the capsule with the second instrument. So let here this is another thing you use can use Well, yeah, and this is this And this is the The old rectal bubber because it's a little dull at the end that goes in very nicely So there's lots of different tricks. We can talk about that, but I just want to show the very end of this removal So you get some idea. So just to show you what happens with or can happen with these lenses I already knew that I was going to put a CTR in so I was willing to to do a little bit more there I'm showing what's what the problem is Everybody easy to get this part out, but this whole Part haptic, but most importantly this little piece at the end You've got to get that out and don't ever pull to the center wrote counter rotate Just the opposite of what you're putting it into and you can see here. This will give you an example What's going to happen? So just watch that Boom and the same thing on the other side. You've got to get that out But the other thing you can do is you can also if you want You can do You can leave the haptics in Rather than rather than take out the bag and then the same thing occurred on the other side And then we just by the way, I put a restore back in because her other I was 2020 and she loved the restore And this one so you I did use a CTR to keep the angles separated But you can see that that'll pop out and Nick you guys saw this this case as you know, it's a case report comment on and By the way, when I when I did do these cases I do fold them in the eye and bring them out rather than cut them Because almost all these are sent to me are legal cases and I wanted them to be able to analyze the Yeah, I will yeah Well, the lens that was in was an SN 60 W app which a wavefront lens and so I just took it out and use an AQ A lot of this Question That's that's negative discotope. See it. That's not that's not positive And I think if you one of the things if you ask I I think it's almost a hundred percent if you ask them will notice the Blinder issue Yeah, and they use they frequently do go away or they neuro adapt because they really probably don't go away And so you don't have to do this on a lot but it but you know resists they resist the temptation to just pop the capsule which is what a lot It's you normally what we do. Oh, this will this will get rid of it because it's not going to get rid of it And Yeah, so I and I use it three months as well But that but that one of the points that Randy brought up and it's really important when you're talking to your patients is Acknowledge their problem as real don't you know, don't think that they're crazy, you know 2020 I can't see you know our natural inclination is yeah, you can probably see okay But you got to acknowledge that they may have some problems. So just a next little topic Which is stimulated a lot is You know, what am I doing differently this year than say three years ago? So this is true. This was a talk I gave at the Academy last year on pseudo-exfoliation Can an old dog learn new tricks But the other question is do we need new tricks, you know when you're when you're trying to analyze things You're gonna put into your armamentarium and you go see something that looks pretty cool You know, sometimes it's worth integrating into your system and sometimes not so this is a really true point Issue so Why worry what now I'm talking pseudo-exfoliation, of course capsule rexis issues pupil dilation problems on your problems sticky cortex capsule phymosis late subluxation so otherwise No issues right Routine rather day. So and one of the questions that we had we haven't answered but we're trying to get a handle on is What do we do here? Well, what can we do if anything here to see if we can decrease that rate or make it at least Tell when we retire and somebody else has to deal with it. So we won't I think the issue is One always assess the patient pre-op if you can look for pupil dilation make sure because you got to have a game Plan ready minimize design under stress and then do what I like to call elegant Surgery as much as you can this is it was an interesting page case that also Just to show you Things are randomly. It's 12 years post-op. This happened in August. It's it's in that's also a case report in the Journal patient came in for a few routine yearly examination Dilated looking perfect. No didn't see any pseudo fake it nothing Call me later on the afternoon said my vision's blurry I said you're still dilated if it's very the next they come in came in he had bilateral Simultaneous anterior subluxation of the IOL which I did take him the orange picture that day But you know so these things can happen. So I hit what he did was he was dilated and he started working in his garden The afternoon and when his pupil came down he trapped both lenses No, well, I didn't tell him not to bend down I think you didn't tell me not to play basketball ears. I recall You have to add that to your list. I Had to add Yeah, I called the first-year resident they wouldn't do it I don't know why but I wanted to keep it down in the lower part of the system So this is an important question I think and and I think it does some of these have changed what we're doing and some so there's a beautiful work That came out of Nick and Lily on it's in the work here and Ryan's on As you can see this just beautiful displays point is You can see is with with the CTR's the Potential advantage of CTR's it makes Refixation a little bit easier, but if you want that lens out it also makes it harder So sometimes what I'll do if I have to take that out is is bring it out separately and you can often just put a Some kind of a 10-oh pro nylon suture through one of the eyelets So that won't be lost when you bring it up and then if you open it up And then you can often you bring it out that way you don't have to go through as large of an incision so So what are the different things that we're that I'm doing now that I I'm certainly I Frequently viscode dissect in these cases that to help allow of the rotational movements some work done here by the Abbey boss of it as daughters when they were here is that they showed with Miyake views that the Viscode does get back there I usually use one that's going to be retending so I'll often use a viscote, but you can use I don't I don't really care what you use But so don't if the if the lens doesn't rotate easily one don't do it And you could rehydrate a second viscodes act But again make sure that you don't rotate if there's any any stress on the on the zongles That's gone So I do like in those cases I do bi-manual rotations So you can really reduce the zongles of stress and you make sure for the residents you do not push down because that The purple part of the bag will seal around the the nuclear Tissue and then as you try to rotate your pop zongles. The other thing I'm doing routinely and expressly in So that's fully aces cases to reduce anterior lens epithelial cells by Using sweeps and we're working on some newer sweeps and some newer ways to do this It does not reduce PCO, but in a pretty good study by for a Haleo and Oliver fendle It does reduce capsule pymosis So again that this is something you could do easily at the time the extras 30 40 seconds I think is worth it and then if you're using CTR's I'd really like the new one the injectable one it comes It's very easy it comes in an L and an R left and right And of course everybody thinks the L is for the left eye and the R is for the right eye And that's not the case It's how it comes out of this and just for the residents what you want to do if it's a generalized zongle apathy Which most PXC is it doesn't matter which way you go if it's a if it's a trauma case Then you want to use the good zongles, so you aim it towards the weak zongles to get it in rotation The other you know the other way you can end up stripping more zongles if you put too much force on the other direction Comment so this is a cave. These are Miyake views. We were looking at this To do we were looking at the weather but the ultra chopper does which is very good But I wanted you to so this was when I started to think of start thinking again about rotation Look at that up here. Let me just rerun that One more time So we were not looking we weren't even looking at this but look at the look at the stress on the zongles so rotation is not benign you got to do it as elegantly as you can and Make sure it's pretty free. If it doesn't start to rotate. Don't do it Do you think Yeah, I do what I do is I have to read I reduce flows I reduce all sorts of things The other thing that I do now you say well I remember teaching courses on small Bakel we could do it through a one or two millimeter pupil And that and I look at my own videos at the time And I still have some from the late 80s and early 90s and I say what an idiot because Even though that that was not a very big That wasn't that I was the pupils good-sized in pseudo X. I think you got to get it bigger You don't want to lead cortex. You don't want to do it anything so I think Right exactly so you wouldn't so even though I didn't I could have easily done it through that I decided I try not to the other thing is if the bag is even in the slightest bit floppy Don't come out of the eye Without filling the bag even just a little bit so the bag will not come up because they'll keep coming up and keep coming up and then remember on the last part of your of your Nuclear disassembly I usually drop the flow rate Down to about 25 so things don't happen quickly again to try to reduce that then this is the CTR Pulling up so the other thing that we used to teach is Radial stripping so this is another beautiful display that Lillian and Nick and their guys from Argentina or Brazil look at the if you look at this that thing again I want you to start that over I want you to look right up here So they there's only cortex. There's no bag and look at the look at the pull on the zonules Then I look at the end as you go down There's almost no Forces being put on the purple part of the zonules and you can't always do that But you really should try to do that and so you see here. This is the reverse view This is a tangential and so what are we doing differently? We're not stripping to the center and number one It's safer, but number two. It's faster. It's way faster once you get the technique down You can often go around in one or two moves and so it reduces that time but more importantly It also reduces the zonule stress So these are just some cases a few cases that I do the other thing I'm doing differently to a little bit is my rexis and I'll show you one of that in a minute. So you can see here and these are Just going around randomly around and you can see just it's gone. I mean that's that's happens all the time So the difference that I'm doing on these for a second So again, there are two types of rexis one is a standard tear rexis where you fold over and lead it and you're using the zonules on that force to just to tear around you re-grab and re-grab and re-grab and Who's a first-year resident? Well, everybody knows the little maneuver, correct? So what is what is the purpose of the little? Brian little's maneuver. It's a rescue. Yeah So what what you do is you see that that it's going out So you you stop you fold you fold it refold it grab it and pull it to the center, right? So why not try to incorporate that in an infinite number of times by tearing centrally all the way around and It sort of gets free it's freaky the first couple hundred you do but it's going to be it's worth it So if you watch what you can do is now this this won't be a perfect worm None of them are by the way, obviously, but if you pull to the center you can usually do most of these cases in Three grabs the trick is don't grab it close start it in the direction You want it and then just pull to the center it goes all the way around And so I've reduced the amount of time doing the rexess, but also Because you're doing a infinite number of Brian little maneuvers. They don't tear out very often Nick you want to come in? Okay Why do it on everybody yeah, exactly exactly You're pulling your next chunk right next to you so it just follows all the way along rather than So then the other thing is let one of the things that's happened is we our microscopes have got so much better that we Realize all the crap that we leave in the eye So we decided we maybe we should really remove some of these lens epithelial cells And we're trying to design better ones these the singer sweeps work pretty well But there's often a little street on the capsule or on the bag not the bag but the wound because of the way they're designed So we're trying to redesign them so that you can really see them This is what with one of the new zyscopes you can really see Beautifully you can go all the way around I'm not as anal as Sam basket, but he puts two extra stab incisions in so he can do 360 on every single case so kind of interesting so The other I'm not gonna discuss that but I wanted to show one more One question One thing about that I like about the SN lens is it's so floppy it's so much easier to get in To these cases so I if I'm really worried about Johnny those Either I'll use a three-piece or I'll use that just because of that Just it's just so tacky and it really is just floppy as I'll get out So one more thing I wanted everybody to know about I don't know if you you all know this but you know We're we're talking about CT ours, which you saw we know that the Sione Modification of the CT R is a single eyelet or double eyelet that comes up over the bag an Ahmed Segment or a cap retention segment is about a 90 degree and it's PMMA and it has a single eyelet We I use that a lot in cases Trauma cases where you don't need you know Put it to put the Sione rings in by the way if you're using the Sione use the new G1 Don't use the old. It's a much softer much easier to put in and now there's a modification another modification That actually comes from here, so I want to show it to you This is the um body. Sorry about this. I told you it was gonna be random So this is a kid a second. I have a kid. I'm what I'm doing is doing see Sione's on the other eye and then Looking at the embodies on this eye. So basically as you'll see here I you won't so this is it's quite a bit different because it is It's very floppy. So it has it says first. I thought this isn't gonna work But so but so what I've done is these are this is obviously Gore-Tex these are in these kids. I go about two and a half Millimeters posterior and then I use MBR 23 or 25 gauge MBR blades just to make the these incisions and then you put Gore-Tex in and so Ballas thing has two loops and the so I've separated these by about four sometimes five millimeters and Goes through that eyelet and through that eyelet And there it's a little you'll see it's a little bit floppy putting it in and they and it isn't elevated So the first time you use them. It's a little it you think you're expecting to do it like a Sione or an Ahmed segment but you just pulls up very nicely and this eye is Beautifully centered the other one and this actually had a very very dislocated That you couldn't see the lens in the pupil So I don't really bring that down to do the do the Rex's on these cases. So it's really um, I Think it's gonna be a very interesting Modification and we have them here. So if anybody wants to try them just let let Bala know I think they I don't know if they're actually carrying it yet in the thing But we have him here. So I I just think this is For some of these cases, it'll be quite good. So this is the what they look like sort of at the end of the procedure is Very beautifully centered and and at the distribution of the energy is really that there's no pulling on the Rex's right? It's a very very nice idea. So just food for a little thought on some of your some of these types of cases So you get lenses where you really have a 180 to Zonio, I did put a CTR in obviously because there's sometimes even in these Marfan's kids This is this kids but 10 You just want to make sure that you have Potential for putting other devices in so With that I think I'll stop and let everybody go play have one more thing We'll talk about next time. There should be sort of reposition of interocular lenses. That's a long talk. So any questions Diagnosis Yeah The the the the other point with the with those lenses is there's no really good sulcus lens in the United States The best would be the star and that their their optic is bigger than it's kind of hard To get those into the bag that the ma-60s are really you know You look at the size of those you can do a 50 which which would get you out there But you'd have to carry a lot of of ma-50s get a big size because that's a six and a half millimeter optic And I think a 13 and a half millimeter thing but they but these the hope is you get those They're gonna be in the angle in the sulcus and have five Fiving around it or Whatever holds it in there, but they it's just not designed for that Yeah, they I've seen some decentered ones on those set to me for I will exchange on those because they've captured it in the bag And then as the bag starts to move the whole lens I So the point of point is old dogs can learn new tricks and some of them are worth putting into your armamentary