 Good morning, so throughout the year, some of the residents and fellows have kind of asked me about some of the different ways to suture lenses and I think most of them will agree that I'm a pretty bad drawer, so hopefully this will explain, you know, clarify some of the things I tried to explain to them during the year. So there are several different ways to manage dislocated lenses, you know, certainly you can put in an ACIOL, you can suture a lens to the iris or sclera, you can suture the same lens to the iris or sclera kind of depending on what's already in the eye. So ACIOLs aren't a bad option, I think everyone knows how to put them in, they're fairly quick. They do have several disadvantages of course, glaucoma, CME, corneal decompensation, the sizing of the IOL is important to prevent IOL rotation which can lead to chronic inflammation and iris entrapment. So iris sutured lenses have advantages, they are pretty easy to do once you know how to do them and avoid potential angle complications seen with ACIOLs and there's the absence of suture, so it's a risk seen with sclerosis sutured lenses. They also have disadvantages, pigment dispersion, inflammation, hyphemus, CME. So this, I do have a video but I wanted to kind of point out a few things. So this is obviously a dislocated lens. They have captured it, brought it up and captured it in the pupil. This is a modified mechanical iris suture, he's using a tunnel proline to go through paracentesis through the iris, behind the haptic through the iris again and then he'll come out here. The way Chang described it in his paper, he had actually put a visco-elastic cannula through a different paracentesis I didn't caught. This suture pulled it out. You can actually just pass it right through the peripheral cornea as well. And then tie a seeps or not which I will show you. This was a paper written by Gary Condon and he was just showing if you actually have to put the lens in the eye, you would fold it, orient the haptics vertically and so that they would go under the iris and you would also capture the optic in the pupil. You can create a paracentesis at 180 degrees away and put it in a cyclo dialysis spatula to stabilize the lens that doesn't fall back. Dr. Crandall actually wrote a paper in which he described placing the sutures in the iris before the lens is actually placed in the eye. I have a picture of this so it'll kind of make more sense when you see the picture but he just basically passes the suture through the cornea, through the iris, back out through the iris and then back out through the cornea and then he uses a Sinsky hook coming from across the eye, grabs the suture and pulls it out of the eye and then ties a knot around the leading haptic which is outside the eye. So this is just a picture of that. Those are the sutures and then he's pulling the suture out of the eye, tying that knot and then he's going to put the lens into the eye and this is this knot which I don't know if I would really know how to tie. I've never actually seen him do it. I've never actually seen you do that. So some advantages. The sutures are placed in the iris in a closed setting that knot can slip on the haptic so it adapts to the other suture when you're tightening it and so that will potentially help center the eye well and keeps the pupil regular and you avoid optic capture and blind attempts to engage the iris and the haptic with the suture so reduce surgical trauma and minimizes iris manipulation. So when doing an iris sutured lens there are certain considerations. You want to make sure you're placing the suture more peripheral to avoid the central iris which is more mobile so it can lead to more inflammation and irregular pupil. You don't want the bite length through the iris to be too large that can lead to pupil peaking. If it's too small it can cheese wire through the iris and lead to less secure fixation around the haptic. If you tie the sutures too tight that will also lead to pupil peaking and there are different techniques of tying sutures to the iris using either a seeps or not or microtying forceps or tying them outside of the eye. This is just a UBM showing the acute alteration in iris profile at the point of fixation and of course adequate pupil area dilation afterwards. It's on here actually. How do I go back to the desktop because it's in that file. So this oh it's plain. This is just showing a folder IOL directing it the haptics pushed vertically opening it so that it's captured in the pupil suture going through a corneal loon through the iris under the haptic out through the iris and then out through the peripheral cornea. And then you use a kublin hook to grab the peripheral suture and bring it towards your wound and so you have a loop and then your suture and you just need to identify sort of pulling on the suture to identify which part of that loop is attached to the needle because you want to use the other one to tie or not. So it's just a 3-1-1 and then you pull both ends to tie the knot down. So indications for primary transcleral fixations on your dialysis PXF, RENT, naturally dislocated lens secondary would be contact lens intolerance and AFIX, CME associated with iris fixated anterior chamber lenses, corneal decompensation and IOL dislocation. There are certain advantages you avoid contact with the corneal endothelium or the regular mesh work minimizes contact with the iris and it's more applicable to patients with distorted pupils, iridectomies and disrupted anterior chambers, patients with mygalocornia. Disadvantages technically more difficult, longer surgical time. Potential endoplamitis if the suture erodes through the contrativer sclera, potential for IOL tilt vitreous incarceration and intracular hemorrhages as you're passing the needles. So this is the lens they use, a CZ lens. It has these eyelets so you can pass your sutures through there to secure it. These are the needles, the CTC needle, it's no mention. You should use either a nino-prolene or a NIO Gore-Tex. Dr. Kendall seems to use the NIO Gore-Tex in children. So there are a couple of different ways to suture. You have a double-arm suture pass it through the eyelet. You can either blindly pass it from inside to outside the eye. You can either go this way or you can go the other way. This seems a little bit more dangerous than the other direction. This is just showing, this is basically showing the same thing. This is kind of going under the pupil and out of the eye. And then once you pass the other one the same way, that would be secure. And that's kind of what you end up with. So Hoffman pockets, you know, are pretty interesting. Basically you'd create a conch and toggle pertumia, two of them 180 degrees apart, two scleral tunnels, and then you would use a 26 gauge needle, which is bent. So this can be, this pocket can be about three millimeters, but you should be entering about two millimeters close to your thalamus with a bent 26 gauge needle. And you take your 9-O-Proline suture, enter through a corneal wound, and you catch it with this needle and pull this needle out of the eye. So that seems a little bit safer than blindly throwing needles from inside to out, because at least you are measuring this distance so you can approximate. The sulk is a little bit better. So after you've done that twice, you have the two sutures coming out of the roof of the scleral pocket. And this is just showing how to retrieve the suture ends from underneath there. And then you would tie them down. So you would end up with four point scleral fixation, two over here and then two over there. So it's pretty secure. This is a similar way of doing it, but starting from the corneal side, you need to make a corneal incision between three and four hundred microns and then dissect back. So the advantage is that you wouldn't need to open the country tie-up. And then you would do the same thing, docking the suture in the same way, and then pulling the sutures out in the same way as you did with the Hoffman pockets, and then just tying them from the corneal side. The way I've seen Dr. Crandall do it more recently is that he's actually been using a 23 gauge MVR to, he hasn't been making these pockets, he's just been using a 23 gauge MVR, going two millimeters posterior filimbus to make that scleral incision. And then, so there is an incision here, and then using an ILM foreset to come in this way, and then taking this loop and putting it into the eye with a kuglen hook, and then just grabbing this loop with the ILM foresets and pulling it out so there are no needles in the eye. I've seen him do it with the Cortex. So with the scleral flap technique, there are obviously risks of thinning of the scleral flap. The knot can erode, it can bleed when you're making the flap, it can buttonhole the flap, and it takes a little bit more time to do that. However, if you just put the knot under the country tie-up, there's a risk of endoplamitis, if the knot erodes. This is just showing, you know, if you have, you know, a three-piece lens there, and you don't want to take the lens out of the eye, you can just loop, you know, you can basically use the same principles and just loop, you know, 26 gauge needle, put it in a pulling from the other side and grab it and pull it out, and so one will go under the haptic, the other one will go over, and so you're basically looping the haptic on either side. So there obviously advantages to loop fixation. You don't need to take out the lens. It's a larger incision. If you were to take out a lens, if you, you know, there's increased risk of vitreous loss, risk of iris trauma, post-arbitivistic autism, and if you would do it this way, there's potentially less inflammation than iris fixation for in the bag dislocations. And this is just showing kind of what you end up with, with a loop there, and then you could put one on the other side too. Yeah, it's just one is going under, one's going over, and then you would tie the knot out here. So, you know, you have a bunch of different choices, you know, the method of introducing the needle from external, internal, internal, external. I like the way Dr. Pernel's been doing it recently, suturing the haptic using the last or the islet, the number of points of scoral fixation, and then the method of avoiding suture aversion. So, you know, if you, you can apply those same principles to suture in a C-ony ring. It's basically the same thing as well as an omid segment. Thank you very much. It's a fibrin glue. So, the fibrin breaks off the fibrin, the break very, very rapidly and in essence, you know, his results on, I'm looking at you. Thank you.