 And today's talk is about how to run a surgery, eye surgeries. I'm specialized in video-legendary surgery and cataract surgery, and these 10 years I teach my resident cataract surgery over 30 of them, so today what I teach is the main talk. My resident called my course Yamane Dojo. Do you know Dojo? Like a karate. And there are three rules of Yamane Dojo. The course is only six months, even if they can master it or not. And the goal is understanding surgical theory and make it safe to operate. So do not just do, not just do, but they must consider how to, and they must promise they will teach more than two doctors in the future. And they can select course in Yamane Dojo. The soft course is just do as instructed. Maybe I think the resident who selects soft course will not be a surgeon in the future. And most of Japanese select the middle if the selection is the three. Most resident selects hard course. The goal is then think by yourself and think by themselves. So they will be independent surgeon. And super hard course is must be understanding all of surgery and they should be a high-end surgeon. So I think the most important factor to master surgery is knowledge. Not skill, but knowledge is the best. Most important factor. Of course and skill and decolonization is also important. I want to say again and knowledge first and decolonization what is now. You must recognize the situation and think what will do. Then the skill it needed. So there are many tips to master surgery for beginners. Today I will not explain about all. So when I said to resident to do CCC capital axis some doctors cannot insert chisotome needle like this. They can insert a normal Bisco elastics. They can feel the Bisco elastics but they cannot insert chisotome. Then the important thing is they must think why it is difficult. What is the difference between the Bisco elastics and chisotome? So every week we do surgery with me. They do surgery with me and afternoon we show video together and make discussion. Then I ask them why you cannot insert the chisotome. This is a chisotome and this is a corneal tunnel. So if you proceed the chisotome, the tip of the needle hits the corneal wound. So you cannot go over. So how can resolve it? Never hit corneal with a needle tip. So you should turn the needle like this from this to this. Then you can proceed because nothing ledges to go. Then the resident changed their procedure. The direction of the shaft of the needle significantly changed. They did like this but now they did like this. So they can master how to insert the chisotome. So when they started to PA, first they cannot divide a nucleus. Then I ask them how to divide a smoked squid. Maybe you never eat smoked squid. So please imagine a beef jerky. How to divide beef jerky? Do you hold a center and then divide? Maybe you can't. You started to divide from the tip end. So you should divide the nucleus from the edge, then center. When the nucleus is very soft, it is difficult than the modulator you heard one because you cannot push the wall. It is easily to break. So how to divide this soft nucleus? I said resident imagines jelly. Actually, I said a tofu but today's jelly. All Japanese can use chopsticks. So they can hold jelly. That is not so easy but we can. So imagine the nucleus is like jelly. So you must push nucleus softly. So do not broke the wall and it takes a long time to divide. If the nucleus is hard, it's immediately divided. But if the nucleus is soft, it takes a long time. So just imagine a soft material. So Cripper run noticed. Chopping is easier for soft nucleus. That is a good idea. So when we practice surgery, we must consider for what we will do. The purpose of practice is remember, collect movement. So if the movement you try is wrong, you just remember wrong movement. So first, you must think what is the correct. And practice is a chance to try new techniques. You cannot do new technique for a human, of course. So you should try on the porcine eye or a stimulator. And you should think what kind of training is effective. When we use porcine eye to master catheter surgery, I said, listen to don't fix the eye firmly. If you fix the eye, the eye never moves. But in the real surgery, the eye easily moves. So you should lose the eye fixation when you train. And when you master capsule Lexus CCC, you should increase biturist pressure because the porcine eye is still dyed. So the IOP is very raw. So no biturist pressure. So you should inject water into the biturist cavity. And it becomes difficult to complete CCC. And we must master to control the size of CCC. So you should make a small one or a large one or like a Mickey Mouse. So do not do just like a real surgery. But in practice, you should try everything. This is my favorite word. Teaching is learning twice over. So if you come to a 2 or 3rd, 2nd or 3rd grade, you should teach to the junior. It's not only them, but for yourselves. So let's move to treatment of Lens Capsule Lecture. This case is a very young mature catheter act. She has a diabetes and poor controlled diabetes. My legend showed her and she discovers that entochamber is not so deep, shallow. And three weeks after control of internal medicine, the IOP was raised. Then one of my residents do surgery. And she has experience of 20 or 30 cases. And this is the first case of a mature catheter act. She stained entochamber and started her usual procedure. Then the entochamber was teared, ruptured. Then the surgeon was converted. And my fellow completed this surgery. Fortunately, the tear did not go through the capsule. So he can insert the lens in the back. Then next week, I did the last one, left eye. So do you know how to avoid the entochamber? Yeah, how to decompress. You mean a lens decompression? Yeah. Good. Two points. One is, as he said, one is using heat on five. Heat on five can frighten the under capsule. This mature catheter act has elevated capsule. So you should use heat on five to frighten. Then I decompress the lens using satyr gauge needle. And I pull the sealage and asphalate the cortex. One important point is do not asphalate much. If the capsule goes down, it is difficult to do CCC. So just a little. So, as you know, this is called ascentine frag sign. Because if you use a toripan brew, and the tea looks white, so it's like ascentine frag. But in this case, we did not use blue one. We used green. So what's this? This is Niger frag sign. So how to treat posterior capsule rupture? This is a big program for beginners. The first step is the sponge to vitroctomy. Sometimes in ACLS and some doctors said sponge vitroctomy is not good because then you can pull the vitreous and reginal tractions will occur. So you should be aware of vitreous tractions just cut near the wound. Then you must remove the remained nucleus. This bisque extraction is a very effective technique and very safe. So you should master this technique first, injecting the bisque elastic and open the wound. So the flow of the bisque elastic makes the wound goes out. But if the nucleus is too large to remove, we have two choices. One is enlarge the wound and one is the PA. Of course, an enlargement of an wound is safer, but I don't want to enlarge. So I usually use PA with a low vacuum and low flow. Of course, it's a risk of nuclear drop. So I first push the bisque elastic, bisque cold under the nucleus and place the nucleus very slowly. And we should hold the nucleus with another instrument. Then the small remain nucleus was removed by bisque extraction. And after removal of the nucleus, we should cut the vitreous. I usually use 25 gauge vitreous cutter and I recommend to use cornea percentage side port. Do not use a main wound because vitreous will come and come if you use main wound. And how amount of cutting of vitreous is a very difficult point, I think minimal vitrectomy is better. Some doctors cut more and more vitreous, but it's a risk of making leaching out here. So I think minimal vitrectomy is better. Torium Shinoron acetonide is very useful to visualize the remained vitreous. This is my residence case and this is her first case of posterior rupture. So she remembered she must use Torium Shinoron, but she injects too much. So Torium Shinoron goes vitreous cavity and next day patients said, I cannot see, but three days after he recovers, he recovers vitreous cavity. So do not inject too much. So after removal of the nucleus, vitreous and cortex, then an eye oil insertion. When the capsule defect is small, we can insert the eye oil in the back. In this case, and this punch out was seen, but I could insert the eye oil in the back. This case is a 16-year-old boy with a trauma and he has a posterior capsule rupture by the trauma. But the parent want to use a multi-focal eye oil. So it's a difficult situation. I remove the nucleus with a 25-gauge vitreous cutter and I cannot use an infusion like this. Plaviously, and if I use infusion now, the nucleus will go to the vitreous cavity because of the pressure. So I just inject BSAs manually and aspirate with vitreous cutter. Then I removed and remain cortex. So this is a posterior capsule tear, but this part and this part of posterior capsule is remained. So I decided to insert multi-focal eye oil in the back. But the defect of posterior capsule is large. Of course, I cannot insert the eye oil in the back. So normally I insert the eye oil in the back in sarcos, sarcos fixation. We can use a large eye oil, 7 millimeters eye oil. So I usually use large eye oil for sarcos fixation. If the CCC is good, very centered and about 5 millimeters of diameter. I use 6 millimeter normal three-piece eye oil. First, insert it on the back and do an optic capture. Optic capture is very effective to stabilize the eye oil. So I like this technique. Just push one side and then another side. So making a good CCC is very important point. So vitrectomy should be kept to a minimum when you show and you solve a posterior capsule rupture and use elastic materials to prevent vitreous escape and nucleus develop. Eye oil should be fixed in the back or out of the back with optic capture. So let's move to the vitrectomy. The most important point of vitrectomy or this is same as cataract surgery is do not push the wound. You should move the instrument like this. You do not move here like this. In vitrectomy, total vitreous removal is very important. If the vitreous cortex is remained, residue of vitreous cortex is associated with the development of PBR. And it's also macropacca will occur if you remain the vitreous cortex. So this case is a retinal detachment and the patient has a PVD. However, we can see the remained vitreous cortex. I think this instrument flex loop is very effective to remove the remained vitreous cortex. You should remove the vitreous cortex, especially Maca earlier and the earlier with an retinal detachment. Chandelier light is very effective too, but there are some points to remain. You should set the chandelier opposite side from the retinal tear or assistant side because assistant can control the direction of the chandelier light. Chandelier light is very effective, but this advantage of the chandelier light is a halation. We cannot see under the chandelier light and it's very shiny. So turn the post turn the direction to the posterior pole. Then we sometimes use shade technique. Just pull the chandelier light inside the canura. This is a normal situation. We cannot see the retina under the chandelier light, but when using shade technique, we can see the retina under the chandelier light. After a full-year exchange, the halation is very severe. So we usually use shade technique and under air. So you can see the retina tear and you can easily do a laser photocarpalation. Liquid powerful carbon, powerful carbon liquid, PFC air is very and good too. This liquid has no color and heavy and low viscosity and high oxygen. Amazingly, this mouse in the PFC air can survive three days because of the high oxygen of the liquid. So he can breath in the liquid. So when using PFC air, you should pay attention about an increase of IOP. So you must lower using lower IOP using vitreous captor or some or using some special injection needle. And sublational migration is a big problem, so do not make it a small bubble. You should inject PFC air very slowly and now I aspirate the PSS using vitreous captor. And we must make one large bubble of PFC air to avoid sublational PFC air. And PFC air easily flatten the legionary, but you should remember you cannot completely drain the removal of the sublational fluid with PFC air. So after photocarpalation, I perform fluid air exchange and drain the SLF, sublational fluid carefully. We cannot drain SLF perfectly without fluid air exchange. This is a sublational path of carbon liquid and unfortunately, it sometimes moves to macro area. So if the sublational PFC air is in vitreous side or very, very, very, very, we can observe, but it is if it's in a upper side, we should remove it. So I aspirate it, sublational PFC air using micro needle. You can use a sublational needle to aspirate. But this procedure is very stressful, so you should avoid this situation. So for the exchange, it's very important procedure to repair LLD, Lational Detachment. And you should be careful with visual field disturbance due to lational air losing. The move patient's head to make lational tear comes the lowest position to remove the SLF. And when the IOL is moisted, condensation, you should use viscoelastic materials. In this case, it looks nice to drain SLF, but it remains. First, I performed laser photocoagulation around the lational tear, then I drained the SLF. Now I ask a patient to chin up, then I can drain the SLF totally. If the patient has a shoot, fake kick, and Yag laser was done, sometimes condensation of IOL is occurred. So I cannot see clearly. In this situation, I use viscoelastic materials, viscote, to avoid condensation. If the IOL is a silicone material, it doesn't work. So you should not inject secant IOL. Then the visualization was improved. And removing video cortex should be removed for prevent of complications, VBR and macro cutback. When using chandelier light, it is necessary to control halation. And BIA of a sublational powerful carbon liquid. And you should move patient's head to drain sublational fluid completely. So the final topic is the challenging cases. Today, I had two cases. The first case is an DME, diabetic macro edema. And this is a 70-year-old male with a diabetes. And he underwent PRP 2012 and cut out surgery 2013. Then the macro edema occurred 2014. Then he comes to our department. This is the OCT of the first visit. We can see the CME in both sides. What is the choice of the treatment? Now, of course, no. Before that, I checked the FHG. And the laser photocollabination is almost good. And a little small NPA is remained. Now, we use the learning based mom injection, of course. And as you can see, the macro edema was improved. But we must inject one more. Five times of injection for right eye. And nine times for left eye. And we did additional toriomachinolone, subtenon soptoriumachinolone injection. And laser photocollabination for macro annualism. But the macro edema was remained as a central. So what's next? Do you inject more anti-BGF? You can use Osvex steroid. A great PC. Are we direct to me? Okay. I selected other. What's other? Cystectomy. First, I remove the epilatinal membrane and ILM. And cut the forebear. And remove the cyst. Yeah. My friend researched this material. And he found this is fibrinogen. And the macro edema was disappeared. And after this, and he received no injection after this, one year, over one year. And some legal ends of macro edema occurred and peripheral side of the macula. But central macro was pretty good. I have only a few cases of this surgery, but my friend and Dr. Imai has many cases. And he published the paper. The final one is large macular hole. Inverted ILM flap, free flap, and lens capsule transplantation reported to be effective for large macular hole. This entry transplantation of the neural retina for large macular hole has been deported. And additional effect is expected. So I try to do this surgery. So this is a case of an 82-year-old female. And she has a large macular hole, stage four. The minimum diameter is 800 microns. First, I peel the ILM and making an ILM flap. Then I peel the ILM and the temporal side of the macula. And I measure the size of macular hole. I intended to harvest the graft from here. I made a little detachment and now making the graft. Making graft is very difficult because I cannot move the scissors freely just from here. But I wanted to make the wound graft. So it takes a long time, but I completed it. So now I got the graft and transplanted it into the macular hole. In the original paper, they use silicone oil tamponade, but I don't want to use silicone oil. So I fixed the graft with an inverted ILM flap and put a piece of elastic on the flap. And I want to close this hole. So I use an ILM to close the intentional hole. Use a free ILM flap technique for this hole. I made an ILM flap here, but that was too small. So I did a free flap. And food exchange was done. And SF6 gas injection was performed. This is OCT, major one month post-operative degree. The macular hole is completely closed. But unfortunately, there is no sensitivity on the graft. And how about the intentional hole? It closed. And six months post-operative degree, and the visual acuity has a little bit increased. And as you can see, the ellipsoid and ILM is very clear in the graft area. However, the graft did not work. This is one month, and this is six months post-operative degree. But at some point, and the sensitivity is improved from one month to six months. But I think this is because macular hole and coming smaller and smaller. So the center of the graft did not have the right perception. So the transplant latinar is engrafted, but there is no synapse formation. However, in animal experiments, it has been reported that transplanted photoreceptors and from IBS cells form synapses. So it may be possible to make the transplant latinar function in the future. So cystectomy may be effective for treatment of a resistant and diabetic macular edema. And latinar transplantation can be an option for treatment of large macular hole. But transplantation alone is insufficient to improve visual function now. So this is a take home message. And knowledge is the most important factor to master the surgery. And please find the best way from many options. I think cataract and vitro-original surgery is mature now, but new techniques are still coming. Thank you for your attention. Any questions? Fibrinogen. He did a musket, muspec, and only Fibrinogen was found. No cell tissue. Such as like your microneedle injection of the TPA or you're going into remove assist. What's your thought process in preparing for that surgery? How did you decide what's a good idea and what's a bad idea? That's a difficult question. And I don't know that. And I think every day about surgery and what is good and what is bad. And I saw many surgeries, not only myself, but others. I can learn from my legend when they mistakes. It is good for my learn. So that's all.