 Good morning. My name is Alan Crandall, a professor of ophthalmology at the Moran Ice Center of the University of Utah. And today we're going to discuss nuclear disassembly techniques. Slide two. There are no inconsequential steps to good fequemulsification. And by that, I mean exactly that. You have to make the stab incision correct, you have to make the main incision correct. Certainly it's very important to understand the physics of performing a good capsule rexis. And also you have to understand the physics of the OBDs, ophthalmic viscoelastic devices. And we'll talk a little bit about that. And then also the physics of the actual fequemulsification technology. Next slide. The strategy for each type of cataract should vary with the hardness of the nucleus. For example, it's hard to do some techniques in very soft nucleus. We see that in pediatric cases. We see that in somebody who has congenital cataracts that need to be removed when they're in their 20s and 30s. Their nucleus is not very hard. And if one tries to do a divide and conquer technique or a chop technique, it's not going to work in that type of nucleus. So in a soft nucleus, I usually flip it, bring the nuclear chip up, and then remove it at the plane of the iris. Most cataracts, certainly in someone who's over 60, they're likely to be what we would say is a 2 to a 3 plus nucleus. Now in that type of nucleus, you should learn to do a divide and conquer technique. Pre-chop is an excellent technique. And then most people have converted to some form of either horizontal or vertical chop techniques. And we'll certainly go over those. When it comes to white cataracts, there are multiple ways of dealing with them. But one of the most important things is to do, to stain the capsule with some device. You could use ICG, but most effective is the TriPan Blue. And that's of course, both of those are FDA approved for that technique. It is also, in white cataracts, again, very important to understand what the OBD is going to, how it's going to help you or could hinder the case. And we'll talk about that. And then with very hard techniques, there's a combination of techniques that we use. Most of the time, a stop and chop type of technique works very well. But don't forget, small incision, extra cap. That's a technique that we use a lot when we're visiting third world. But it's also a very important technique to understand, even in a few cases, in developed countries. If we look at a divide and conquer technique, this is still the number one technique used in the United States for those surgeons. You divide it into four different components. But basically, the two most important ones are the non-occlusive phase, which is sculpting. And what I mean by that is what you do is you need the power that you need to make the nucleus not or to allow the nucleus, so it doesn't move while you're sculpting out the grooves. And then you rotate and rotation needs to be done very elegantly. And what we try to do, we may even do that in a bimanual type of technique where we use two instruments to rotate. It's a little more zonular friendly. And the power that you would use then, usually I would start with, in my foot positions, obviously in foot position three, I would use a linear modality so that I can increase the power. So just to the point where I can debride the nucleus, debulk it, and not use any... You have to use enough power so that the nuclear material doesn't move. Because that's very zonular, stressful if you do that. So the two, the rotation and sculpting need to be done very elegantly. And you want to make sure that you use enough power so the nuclear material doesn't move. And then you have the quadrant removal portion. And sometimes I'll actually divide the cataract into six or seven pieces depending on its hardness. And in the quadrant or this type of removal technique, you use occlusion and power modulation. And that's where you really have to understand the difference between a burst mode, a linear mode, or a pulse mode. What you want to do is figure out which modality allows you to bring the pieces in. And again, there needs to be some occlusion to get it to the point where you want it. But after that, you don't want occlusion. You want the material to keep coming in. And I'll show you a complication that can occur if you don't understand that. In our next slide, we will hopefully... So this is what's known as a torsional. You can see here that in a traditional technique, the tip is moving forward and backwards. And in a torsional or ellipse type of technique, the tip is not only moving forward, but it's rotating. What that does is it prevents the tip from being totally occluded. And again, if you don't have occlusion, you won't get any problem with the posterior capsule, such as can happen if you break your occlusion and you get surge. Talk a little bit more about that. Choppers are important to have and important to understand. The chopper that we see here on this next slide is a variation of a Nagahara, and it's a sharp tip. Any of the companies, all of the ones in India, China, the U.S., and Europe, everybody makes a version which is similar to this. And the tip, as you see here on the slide, is very sharp, and it allows you to go through the nucleus and to chop a piece off. We have to understand that. So there are two types of chopping. One is known as a horizontal chop. Now, in a horizontal chop, what you do is you're a fecotip. It's important that it is occluded. And you go back to foot position two. So you bury the tip in foot position three. When you hear the bell showing that you have occlusion, you want to drop back to foot position two so that you have it. It's still occluded, but you have control of the nucleus. And then with the horizontal, you take your chopper. It goes under the capsule rexis, out to the edge of the nuclear material. And then the handpiece, this part doesn't move because if it moves, you'll flip off the piece. And the chopper then is drawn toward the occluded tip. And then right before you get to it, you move the instrument to the right. And the chopper is slightly to the left, and that will split the nucleus. In a vertical chop, which is actually my favorite way of chopping, what happens is the chopper, and again, there are different kinds. A Nagahara chopper, for example, has a soft bottom, so it doesn't work great in hard nuclei, but it's safe in a two to three or four plus nucleus. And in this case, again, you have to make sure that you bury the tip. Allow it to occlude. Once it occludes, slowly get off of the fecal handpiece and don't move it. Because one of the things that people are just learning how to chop do wrong is they're still in foot position three, and they're backing their hand up. And what that does, of course, is push off the nuclear piece. And then if that happens, you don't have occlusion, you can't chop. So you see when people are just converting to this, they tend to move their hand position back, and that pushes the nucleus off. You have no control. So in this case, again, we bury the tip, and you can see that we're buried all the way to the sleeve. So this tip is under your control, and the nucleus material is under your control. Then you bring in the chopper, and you go straight down to just pass the nuclear tip. And then your left hand does the work. Your right hand stays exactly stable. The left hand goes down. Once you get past two-thirds of the nucleus, a movement to the left can be used, and that will split the nucleus material. So again, the two type of techniques, vertical, your tip is, and the reason I like vertical, by the way, is because you're inside, you can see it, you're inside the capsule. There's no risk about when you do horizontal. Sometimes you can't see your chopping piece, and it's possible that you can grab the nuclear, pass the nucleus and grab either the posterior capsule because you're going to be fairly close to it out there, or you can go too far and actually pop through the capsule bag in that zone. So that's why I personally like the vertical chop technique, but they both are very effective. So in this slide, we're looking at a chop technique, and you can see that we're in foot position two. The ultrasound is off. We have a reasonably slow but good aspiration flow rate, and we have high vacuum. So that means I have now control over this piece, and my chopper now has gone down through the tip. This is a vertical chop, and then out, and it splits the nuclear material. Here's another example of a slightly different nucleus. The other one was a little bit harder, so again, what you see here, we are now in foot position two. We have ultrasound zero, so again, if you have any ultrasound, that tip will be boom, and even if it's a slight, then you are not occluded, and you won't have the ability to chop it. Now here, you'll notice that the vacuum isn't very high. It isn't critical how high that vacuum is unless the nucleus is very hard, because in this 2 to 3 plus nucleus, 79, which isn't much, allows me still to control this nuclear piece, and then my chopping instrument can go down and break the nucleus into quadrants. For quadrant removal, however, again, we want to decide what are, understand the FACO physics. You'll see here, this is a, this is an nozzle, which means the tip will vibrate this way and this way, so that prevents occlusion unless you get high vacuums. And if you look over here, so you see that I'm in foot position three, the bottle height is about 100, so you're keeping the chamber deep with that modality. Aspiration flow rate, you can set it, if you want things to happen fast, what I would do in a normal nucleus is I'd have the aspiration flow rate at about 33 to 36, and that allows for things to be moving fairly quickly. Then over on this side, you see that I have, in my power, I have both regular longitudinal and I have a torsional. And the reason I do that is I want the tip to move forward to grab the piece and the torsional to prevent occlusion. And that, what that allows you to do is under these irrigation 100, in this case, the aspiration flow rate, it's on a linear modality, we're right now at 25, which means things are happening relatively slowly, but if I go to the top of the aspiration flow rate, I can get it up to 33, 35, and that, again, will make things move quickly. Below that is a term that says the rise time. And you notice that it's set to, what happens then is as soon as the tip is occluded, you are telling the machine to slow down when you have a negative rise time. And if you want, again, things to happen quickly, you would have a positive that would speed up the aspiration flow rate. So when I'm teaching residents, I will usually have the machine slow down when it's occluded so that nothing happens very quickly. And then I have linear control of the vacuum, which I use different amounts of vacuum to keep things moving at the fecotip. If there's no occlusion, you can't pop the posterior capsule because you will not develop surge. So what you have to understand is if you hear the ding, the machine saying you're in an occlusion mode, you have two capabilities. One would be to go ahead and go back to foot position two. The problem there is you're still occluded. So I don't like that, but what I usually do is just slightly increase my power so that it moves through the tip so it's no longer occluded. So you just want to slowly raise your fecal power. And in this case, your longitudinal would probably go up to about 25, 30, 40 percent. Then that pushes the nuclear piece off, prevents occlusion and prevents both surge and womb boom, which we're going to see here. So in this video, we'll see a number of different techniques. In this case, you'll see that the fecotip is going to be buried in the nucleus, and then the second instrument comes, and it easily allows me to crack. So again, go to foot position three, back to foot position two, and then your other hand, your left hand, your non-dominant hand, whatever that is, then proceeds to do the actual cracking. So see here again, once again, you're in foot position two, and you can do a little three if you have good control of the nucleus. Now if you look at this video here, this is a drawing of what a nuclear, any kind of cataract looks like. And you have to understand the lines that are more or less natural. Those lines will allow you to divide the nucleus into quadrants or six or eight pieces. So you see here that the fecal hand piece comes in, it goes, the left hand does not move, dominant hand does not move, and the second hand removes it. So here you can see again in this cartoon version of it, the second instrument comes in. Again, here this is going to be a horizontal crack. So we now have occlusion, no movement, and the non-dominant hand comes towards the tip and moves to the side. That's what you saw on the previous machine. And this again is a horizontal chop, so you'll see the other version, which again I like a lot, is the so-called vertical chopping, which means really basically that you're going down through the nucleus inside the capsule rexus, which again I feel is just a little bit safer than doing it from a horizontal technique. But it's important that I really understand both of these and understand what foot positions you would like to be in. So again there we have our vertical and our horizontal. So we'll see here this again with another hand piece, you see them in even a slight modality of three. As long as you have good control of the nucleus, here's another chop technique. And here you can see once you have control, you can actually use, you can make multiple chops with even just one good grab of the nuclear piece. Here again you see that second instrument's chopped down and moves out. One of the things that we did is we made a video showing this actual technique, which is embedded in this slide. And we're using what's known as a Miyake view. So you are now looking at a, from the vitreous side. And you can see the zonules here and you can see the ciliary processes. And so this allows us to analyze all the different types of techniques which are safe and how they work. And this, we do this on lots of different things. We do it on CTRs, we do it on different implants. We do it on, in this case we're doing on a chop technique to look at what we have to do to understand the modality. So again you're not going to break through. So here again we'll do a horizontal chop, the hand piece goes out, we're not occluded. And then we go into the nuclear chip, bury it. The chopper is then brought to the tip. And you notice the right hand or dominant hand is not moving whereas the non-dominant hand does most of the work. So you see there's a little safety soft tip at the end of this chopper. And again different choppers for different types of modalities. So this would be a horizontal chop. The vacant hand piece is almost doing nothing but stabilizing the nucleus. And the second non-dominant hand is then drawn toward the nucleus and out which then splits it. This is hard to do. So in that case what I do is I re-bury the tip a little further, deep. And I just slowly go down splitting out these actual pieces into the different quadrants. So you can see here on the vertical and horizontal chop it's really critical to understand that. So here let's just look at this. You can see again where no movement with the dominant hand, the non-dominant hand is what is actually cracking. And once it's into its pieces whether that's four, six, or eight, then you switch to a quadrant removal technique. Which again what you want to do is you want to bring the piece to this, what we call the safety zone, which is in the middle of the capsule rexus just above the capsular bag. But in either plane of the iris or slightly low that protects the endothelium from the fecal energy and also from the fluid that's maintaining the chamber balance. In this case you see we don't have a lot of height. But we're at about oh probably 70 or 80 millimeters of mercury above the capsular bag. So all of those once one understands that. So this video is designed for you to allow you to replay and look at the different modalities so that you truly understand each of these, this part of the technique. So you will see there'll be Miyake views and then those will be followed by standard cataract technique. And you'll notice that some of these videos are not of the new machine such as the infinity or centurion because the physics doesn't change. Once you understand you don't have to have the newest and most valued new materials because the physics works. Now you see here this is one of the first things that we need to do when we're chopping and that's to make sure that we have good hydro dissection. And so what I like to do is I use what's known as either a Chang cannula or any cannula for hydro dissecting and you can see right here that what I'm going to do here is what's known as the flip technique. So this is a soft nucleus so rather than actually trying to break it into multiple pieces what I've done is I've flipped the nucleus into the, so it's aiming towards my hand and in this case temporal incision. My left hand which is my non-dominant hand will then be used to really stabilize the nucleus. Again this is a softer cataract and these are very difficult to try to divide and conquer because you don't have enough material to grab. And you can see here that the second non-dominant hand is actually holding it in position so I can chop off the top of the nucleus. Then I will use an occlusion mode, a quadrant removal type of mode to simply bring each of these pieces up and you see that the dominant fecal handpiece stays right near the center of the capsule rexis. So you want most of the action to occur right in the middle of the rexis so your actual fecal handpiece needs to be slightly past the halfway point toward your temporal incision because that will then allow the piece to be emulsified in the actual center of the cataract. And it's also important to really understand again that the incision is critical. A square incision will usually be very easy to manipulate but more importantly those are the kind that are you can at the end hydrate the wound and bring the wound sealed completely so it doesn't need incisions. In some of our procedures we also have to deal with pupils, uveitis, glaucoma patients and this part of the video shows a way of opening the small pupil. Most of the time now I would use a Mayugen ring which is made by MST, no financial arrangements for me unfortunately. And then so what I've done here is used, what's known as a beeler, it's a splitting, it's a device that allows you to stretch the pupil in different pieces. And one of the things that we know, once we have the capsule or the iris open at least five or six millimeters there is no problem with doing the chop techniques. One of the things that I would encourage folks to do nowadays because we now know that if we leave any cortex eventually what's going to happen is that you're going to either get a summering's ring problem and then you're going to get iris chafing and you get pigmentary dispersion and also most importantly you're going to get capsule phymosis. The capsule phymosis then stretches the zonules and particularly in trauma cases, Marfan's cases and pseudo-exfoliation which we really deal with a lot, you're running the risk of having the capsule phymosis and then spontaneous subluxation. So one of the, we used to teach how to do small pupil fecal and it can be done but I would really encourage you not to do that. The technique is doable but again I think we don't do a good cortical cleanup and nowadays I think it's important not only to do a cortical cleanup but also to really make sure you remove the anterior lens epithelial cells by using a SINGER sweep. So this part of the video is about 41 minutes long just giving different ways of doing different techniques so we won't really discuss each of those. You'll see the maneuver we were just talking about is when does one use some type of device that can stabilize the bag. There now are a number of different types of devices. The one you're seeing on the video now is a SIONI variation of a capsular tension ring and so the islet sits above the capsule and then can be used to stabilize and usually we suture that to the scleron. If the patient's over 65 or 70 then I think you can use 90 proline that we know they last usually at least 15 years and it's the needles that they come on are very nice. Nowadays we would use 80 Gore-Tex and anybody that's younger than certainly 60 I use Gore-Tex because it should last indefinitely. This is an off-label use of the technique of the Gore-Tex suture so it's important to have your patient know that you're using something that has been proven to be safe and to last a lot longer but that it is not FDA approved for that technology. This part of the video you'll see we're using different Iris hooks and you can have capsule hooks now that are made both by FIC which is called the McCool hook and the MST hooks which are designed for the capsule bag. They're a lot better than these Iris hooks because they're designed to stabilize the bag. It's also important to understand the Capsar tension segment which is designed by a previous fellow, Icon Med while he was here at Moran and what this is 120 degree PMMA with the eyelet sticking up so you can actually use it as a hanger. What I do is I put it into the Capsar bag and it's just above the eyelets, it's above the capsule rexes and then you can use just a simple Iris hook and move that Iris hook that you originally had holding the Iris and then put it into the Capsar device and what that does is it makes it a hanger and you can convert a very difficult case into a more or less standard case. So we use two of these devices and it makes it very easy and again in the video you'll notice that we are now showing a Miyake view. It's nice to understand where these devices are and how they sit in the Capsar bag. If you're going to use a Capsar tension segment you have to understand that it doesn't do it provides the holding capability in that 120 degrees but it doesn't open the full bag so I almost will always use a Capsar tension segment at the same time. So when you're using a Capsar tension segment you need a full Capsar bag opening with any of the devices. I usually like to use a CTR Capsar tension ring that is as large as you need. I almost always use at least the 14 millimeter one unless the eye is very hyper-opic in which case I'll go to a smaller one or if there's pediatric cases I will usually use about a 12 and a half millimeter Capsar tension ring along with the Capsar tension segments. So we'll be switching back and forth between the again you can see here a very dislocated posterior bag and yet we can convert it safely with the hook you can see that we can now proceed to removing the cataracted and then suture it to the sclera at any point in time. About 31 minutes of videos with each of these different type of techniques so you can see how to use them with an AC tear which remember if you have an anterior tear of your Capsar excess you can't use a CTR because it'll split it out but you can use a Capsar tension segment and you can use the iris devices or capsule devices to allow you to finish the procedure and so we have different ways of looking at different devices. So in this video segment you can take your time go back and forth and look at all these pieces. Another technique that I think is underutilized is what's known as a pre-chop technique. This has been around for a number of years. It's been popularized by Aukahoshi in Japan and he and I have been teaching courses on this for about 15 years and it's important to understand the value is that you can divide the nucleus into as many pieces you want with this pre-chopper and what it does is it allows you to divide the nucleus with no flow so there's value in certainly cases where you have IFIS intracapsar floppy iris syndrome and if there's no flow then you get the pieces into a quadrate and you can very easily remove them at any point in time. This is the Aukahoshi version. I have a slightly different design version which I use for femtosecond divide pre-chop and also for very hard nuclei. The pre-chopper can be used up to about four to five plus and then after that it won't bury in the tip so you see what we do is we just simply put the device into the capsule bag just below the midsection or even to the lower posterior segment and then just split the nucleus and then rotate and do that again. So here's the video just showing what we do. Most of the time I actually don't use dilating drops prior to doing the cataract surgery. I like to have the capability of doing it on the table and I'm using, as you saw there, it opens up very quickly. So here's the pre-chopper. It goes in just past the center of the midline and then you just simply open it up and the most important thing is to make sure that you have the crack going all the way through to the back of the lens. So here you see the nucleus has been rotated and now we have it into quadrants with no flow and now we can put our, since it's already in a quadrant, we have to sometimes debulk a little bit to bring these pieces up. Talk a little bit about different kind of phaco tips. The standard tip is what's known as a kelman tip and it comes in different degrees, zero degrees. An actual kelman usually means it has some kind of bend at the tip. Most of the time the bend is so that the phaco tip is, you can see your cutting device as it goes through. This, which you're looking at on the video here, is what's known as a reverse kelman. So the tip is aimed towards the posterior capsule. Most folks are not comfortable with that until they get used to, again, understanding the physics of this. The physics, all the energy is going back toward the posterior capsule. But it's a, when you first start to convert to this, it looks a little scary because the piece, the phaco tip is down, but I find it to be a much more efficient way of removing the nuclear pieces. And you can see here, I mean, I burst mode. Why do I do a burst mode? Again, you have to understand the physics of these different modalities. Longitudinal means the tip is going forward and backwards. Any kind of an ellipse or torsional means the tip is moving sideways. And a burst mode means that when you go into foot position three, you are, as you go down further, you're increasing the amount of bursts per second. It goes one burst per second, two bursts per second, all the way up to a continuous mode. And that allows me to decide what is the most efficient for different types of nuclei. Most people would just use a pulse mode. The nice thing about a pulse mode is that you know that the machine is working usually 30 to 40 pulses per second. So it's off on, off on, off on. And the advantage of that is it decreases the amount of energy and you can control how much linear power you're adding to reduce, to remove the nuclear pieces. So again, you have to understand the ability that when you're in foot position three, you want the nuclear pieces to continue to move towards the tip. You don't want occlusion. So you just increase the burst per second if you happen to be in a burst mode or you increase the power if you're in a pulse mode in burst, you're controlling the amount of burst per second. In the pulse mode, you can set it to burst per second to 30, even up to 60. And the advantage, again, there is to decrease the amount of energy while keeping the tip moving. So let's go to, in this case, here's another, let's go pre-chop, and you'll notice that there's a Malayugan ring, which is made by MST. And there are variations also made by our lab in India. So there's a capability of getting this device everywhere. And Malayugan, I like because it has the four holding device right there, but also there, you really have eight points of contact. To me, it's really nice for these IFIS cases. And so here's another pre-chop. This rex is, or the pupillary opening is probably only six, which I think is enough. Again, I encourage people not to do small pupil fecal. You can do it, but you will not, you won't be able to see your peripheral nuclear pieces. It's very easy to leave one or two, but more importantly, you're going to leave too much cortex. And that's going to lead to capsulfinosis and also to, so further increase your chance for late dislocation, especially in these, in cases of pseudo-exfoliation. So the video here will show a number of the pre-chops. And again, the second instrument, once you, it's still nice to have good control. You see the aspiration flow rate up here is 35, so things will happen fairly quickly. And what I usually do, particularly on a hard nucleus, is when I get to the last piece, I'm going to reduce the aspiration flow rate to a much lower number so things don't happen very quickly. And then we change the on-off over here. You can see this is a burst mode where I have a T on. In other words, every time I hit foot position three, the power is 70 milliseconds on and the rest of the time off. And again, you can change those power modulations depending on the hardness of the cataract. Now, this is again a small pupil. And again, you'll see that we can easily do it. And in this case, what I'm doing is I'm trying to get the capsule rexis underneath the iris, because I know the iris is only five millimeters, and I think we want our rexis to be at least five and a half for all pseudo exfoliations, and no reason that that shouldn't be the case in all these. Again, here we can divide this nucleus into four quadrants, or eight sometimes I'll do that, and then we can remove those. Again, the video will just show you that capability, but I really, again, encourage you to make sure that you get all the cortex out, and you still do lenzepithelial sweeping to remove that possibility. The other thing to understand is the reason there are all these different tips is that each tip has, allows you to do different modalities. I use the reverse common because as I say, the energy is down, and so all the fecal power is delivered inside the capsule bag. But if you're going to do chopping techniques, a reverse common is not the best. So what I would suggest is something you can bury the tip easily. So if you're going to do a full chop, then what you want is either a zero or 15 degree standard common tip. They are the easiest to bury, particularly the zero degree, which you can occlude that tip very, very easily. Then you have full control to bring in your horizontal or your vertical chopping technique, and you can refer back to that video to look at those different modalities. So again, understanding the physics of what you're doing is critical. So in this case, what you're seeing here is, I want you to look at this wound here, but also note on this video overlay here in just a second. If you look, we'll show you that back. I'll back that up and show that again. There was a point when there was no nuclear material at the fecal tip, and yet the machine is telling you it's occluded. And the problem with that, it means that the fecal tip's clogged. Well, it's not a big deal. Well, it is because the fecal tip then heats in less than a millisecond, and certainly way less than a second, you're going to have a corneal burn. And you can already see the whitening of this wound edge here. And also note that the fecal tip is at the edge of that incision, which again means there's no flow around it, and you're going to get a wound burn. It turns out that if you look, this happens much more than it's reported, because most of the time it's just subtle and doesn't cause any problems. Many times, if the whitening will be so bad and the gape will be so bad, you not only need sutures to close that wound, but often you have to advance or bring in iBank sclera or cornea to aid in making sure that you don't have any chance for endothemitis, which means the wound has to be 100% sealed. Can you comment then on techniques to avoid wound burn? Yes, so what you want to do, one is to make sure that the handpieces have been totally irrigated and kept clean before each procedure. So make sure that your technicians are taught that at the end of every case they must use at least 60 to 100 ccs, and that doesn't sound like a lot, but it's a lot of fluid to make sure that there's no retained viscoelastic or retained nuclear material in the tip, because what will happen is over the day that it's going to get worse with each additional case, and at some point the tip will then be occluded, and once it's occluded, again, it's a very, very short time before you've got a wound burn. So one thing is to make sure that each tip is clean. The second thing is to make sure that things are... you've got to watch your FACO tip and make sure that things are happening at the tip. And as soon as you see that the nucleus material is not at the FACO tip and you're still hearing FACO power, you need to quickly go off, bring the tip out, clean it, or exchange it, and then you can resume. So you really have to be listening. You'll see here on this one, there's a very short period where, like right here, again, there's almost... things are not happening at the tip, and yet the occlusion mode was going off. So that's why the wound burned very, very quickly. And so you can see right here, it's dinging and we're not stopping what we're doing. So in this case, we're still putting energy into the eye and nothing is happening at that FACO tip. So you've got to watch your FACO tip and if you hear a ding, you either increase the power to move it or in this case come out, but again, you can see the wound is really at risk for a significant wound burn, which most many times isn't very dramatic, but it makes... the wound then is not as good as it should be and you increase your risk for end-off-the-minus. So it's really critical to make sure that you have good occlusion. And then there are different sizes of the tips, 0.7 to 0.9, mini flare tips, reverse combins, what I happen to like, the video will display that. And staying centered in the wound is another... Yeah, we talked about that. We talked about that already. We want to make sure that everything... when we're doing FACO, that the nuclear material is above the plane of the iris, just barely, not high, so you don't damage endothelium and that things are moving. So the FACO tip itself needs to be just before the halfway point so that the nuclear material itself is in the most expansive part of the... You have to know which sleeves are designed for which size of your temple wound. So there are usually three different sleeves. One is for an incision that is less than two millimeters, that's called a nano-sleeve. In other words, very thin. You have to be very controlled with your movement so you're not lifting and moving this incision because that will cause more of a burn. And why is it not doing that? So let me go back to the video. Doing here. Good. Now we're going to switch gears a little bit and talk about white cataracts. These are very common in developing second and third world countries. But also we do see it to fair amount even in developed countries. And so one thing you have to do is you have to understand staining. I use almost always tripam blue. It's a very, very good way of staining the capsules. There is evidence from German studies that have been done that it also makes the capsules a little bit totter so it makes it much easier to really see the capsules as you do your capsule rexis. And it works really quite well. You can get these in compounding pharmacies but since DORC, which is a European company has FDA approval, I would suggest that you use those. You have to understand that in these nuclei that are 4 or 5, the nucleus is thicker than you're used to and so you have to really go deep. It's best to use a chopper that's designed for this. This is one that's designed by Roger Steiner who is head of the chairman, UC Irvine and it's a very nice, you see it's a long chopper that allows you to go through these very hard nuclei. And the trick is to make sure that you understand, again, vertical versus horizontal chopping. I like vertical on most of these that you're seeing here. This slide demonstrates the maneuvers when you're doing a horizontal. And so when you're doing a horizontal, you've got to make sure that you're above the capsule because if you're not, you're going to split it and you also have to understand that you can't move your dominant hand because if you do, it'll spin and the nucleus itself will start tilting. So that can cause a big problem. And then the other problem with these hard nuclei is the very, very leathery posterior part. So what I like to do there is I do multiple small chops, vertical chops, until I get to the very back of the nucleus and then that last vertical chop, well, you can see the nucleus, nuclear piece being removed. And the other thing that you can do is you can flip and then you can use either a snare, which is now commercially available, or you can then just flip it and do your regular vertical horizontal chop. You have to be careful making sure that you don't put any sharp nuclear pieces against the posterior capsule. So here we'll see a white cataract and this is the tri-pan blue. Tri-pan can be delivered underneath the air bubble, as I've done here, but it can also be done if you need to put devices in to expand the pupil or when you already have viscoelastic. You simply make a layer of water using just your hydrodeception cannula underneath the capsule and then you can put the tri-pan blue and it'll stain it. So when you're dealing with these white cataracts, you'll notice here, and I'm backing up to this to display that, I usually start them with a sharp system, but also if I think that there's material that's going to come up to the tip and possibly come out, that you might see, for example, a more gagny or an intumescent cataract. So here I'm using a large 26 or 25 gauge sharp tip. I enter and then before allowing the capsular bag to split and create the dreaded Argentinian flag sign, what this allows me to do is I can remove the flocculent cortical material and it prevents that capsule from splitting out. You'll see here, the other trick that we would sometimes do is make our initial rexis four to five and then after debulking the nucleus, you can widen it to five or six towards the end. Again, here I'm going in with a little BSS on a syringe to remove flocculent material and you can see, usually when you see these areas that look like they're cortex clear, cortex clear, that's usually a sign that the lens has a lot of flocculent material and that it's under some type of pressure. So when you see that, make sure that you remove the nuclear or the free margagni and flocculent cortex before entering with your fecal tip because it's an easy chance for that to split out and since the other value of having staining is if you at any point feel like you have a need for a capsular device to stabilize the nucleus or put in a CTR, the fact that the capsule stain makes it much easier to define your parameters and the geometry where you need to place these devices. So I'm a big proponent of using capsule stains particularly in these type of cases so it protects you from having trouble seeing that cortex and seeing the nuclear material. You can see here this is a divide and conquer type of technique just creating a center. You can slowly go down until you get to the whatever piece you have and then you can see that I was using lots of energy and the nucleus wasn't moved. Then I'll bury the tip, get a hold of it and then the second instrument then occludes and you have to see that posterior nuclear piece make sure that it has to be free because if it isn't you start to bring pieces up that'll flip that nuclear piece and that can cause severe zonular stress and capsule rupture. So make sure that you have full control as you can see here I'm slowly burying this tip and then once I get it to I have excellent control then I go in with my non-dominant hand and in this case this is a combination of the most variation between the chop techniques and you say that instrument is going to go way to the back and free up that posterior leathery portion. The video has a number of different white cataracts for you to analyze and to look at. I encourage you to use the, look at them, relook at them each time so this is a burst mode I have over here and look at the different kind of modalities that might make sense to you. It's really critical to truly understand OVDs as well and talk a little bit about that so when you're doing a hard cataract I like to use a very dispersive OVD to protect the corneal lindothenium and I'll often put multiple new aliquots of that in during a very hard case to prevent any nuclear damage and also again remember that the energy you need to keep it away from the endothelium so you want to be just at or below the plane of the iris and then you really have to again understand that flow rate so that you have good control of each of these pieces. So in this video that you're seeing right here we are just gaining control of this hemi section bringing it up to divide it and again using a burst mode to decrease delivered energy and then very changing the modalities so that things happen at the rate that you want them to happen. So in summary, fagomulsification really is understanding physics. You need to understand the foot positions, foot position one, fluid on, foot position two, fluid plus vacuum, foot position three is aspiration, flow in, flow out and of course delivering the right amount of fecal energy to keep things happening at the tip. So again, look at your whatever fecal unit you have make sure you have different setup differently for divine conquer you want a lot of energy you want no occlusion you want low vacuum. For chop techniques you need to have good control of the nucleus you need to have be able to bury the tip go into foot position two so that you have control then either do a vertical or horizontal chop and you can do that also in a stop and chop where you just bury the tip halfway down and then again use your non-dominant hand to split the nucleus. And it's important to understand multiple techniques. The fallback is always divine conquer but divine conquer is not as efficient and particularly on hard nuclei there's too much movement to stresses the zonules whereas the chop techniques are very easy on the zonules and you have to also understand that every nucleus is different so if you understand the physics then you can change them as needed on some of these more difficult cases so it's really important to while you're training to use different foot position, different modalities even on nuclei that you can do easily so that you learn the control of the foot position and learn the different modalities when you need them for harder cataracts or you need a different thing for softer cataracts so with that I'll wish you a good day thank you that should be great but I wouldn't