 We ready? Let's talk about cataract surgery complications. We won't be able to go over every complication, but we'll try to go through the more common ones, how we manage them, and answer any questions that you guys have about those thoughts. So posterior capsular tear will probably beat you over the head quite a bit during this lecture with this particular complication. There's obviously a violation of the posterior capsule. Posture capsule tear with vitreous loss will increase the risk of several different potential complications including endothelitis, cystoid, macular edema, retinal detachment, eye well malposition. Of course, it increases the surgical time and cost. It can compromise the desired eye well placement, which is in the bag. There is the potential need for further surgery, depending upon when that occurs and what occurs with it. And obviously there can be because of the additional surgical manipulations, delay in visual rehabilitation and recovery. So the best management is prevention. Let's just try and keep it from happening, right? So several things we can do during surgery to help us to stabilize the anterior chamber and to help protect the posterior capsule. So first, in terms of stabilizing the chamber, well constructed wound and capsule rexis, proper fluidic settings. In other words, the inflow equals to the outflow with the FAKO machine. And that of course helps to avoid post-occlusion surge instruments. We can use a modified FAKO tip that is rounded as opposed to a sharp edge. We can use soft silicone or a polymer IA tip. We of course saw those who were in M&M last week. We saw what happens with the tips if they're not soft and gentle. Surgical technique, of course, we can protect the capsule with the second instrument with final fragment emulsification. Can I ask a question about that? Sometimes I worry, like the second instrument, like the chopper, it seems kind of sharp. Yes, you want to use a second instrument that is blunt-ended or gentle. So if you use a sharp chopper to do vertical chop, for example, once you've completed your chop maneuvers, you can remove that second instrument and go to a drysdale or some other type of second instrument that is more capsule-friendly. You'll see that with surgeons that like to use the vertical chop technique if they have a sharp chopper. So you can make that change the way you hold the instrument. So if it's like a chopper that's like this, holding it and angling, so the surface area that you're using is, this is obviously not a sharp edge, and it increases the surface area that's provided to help hold the capsule back that can be useful. I will tell you, it's not foolproof. That capsule can still come around and get the phaco tip because the surface area is not great on those second instruments, but it may be helpful. Hydro dissection using a dispersive viscoelastic can also be helpful. In select cases, obviously there would be an increased cost with that, but placement of the viscoelastic, the tamponade, the capsule, particularly in cases where there's not much cortical material in place, very dense cataracts, white cataracts, you might find that useful in terms of helping to keep the capsule back in place. So those are a bunch of different things that we can do to help prevent this particular complication. The other things that we can talk about, just recognizing when we are at higher risk for these types of issues. So if we can post your capsule, such as in a posterior polar cataract, as we talked about, again, a dense cataract that has little or no cortex to mold the capsule in those cases, we might use a dispersive viscoelastic to help hold that capsule or mold it. A soft nucleus, so a young patient with a posterior subcapsular cataract, sort of an example of that. Not much energy is required to penetrate through all of the material. You might use a variation on a technique called a brown maneuver where you might pop the lens out of the capsule bag, at least partially, to remove the lens more safely, either that or a flip and chip maneuver. Zonular weakness. So in cases where, of course, we're always looking for these issues at the VA pseudo-exfoliation, prior trauma, prior intraocular surgery, such as vitrectomy, or less common causes, congenital aniridia, congenital conditions that might be associated with zonular weakness. So those are different situations that we're looking at, saying, okay, this is a more risky situation for different complications. Let's plan and prepare in advance to know how we're going to handle things to try and prevent it and be watching for these types of issues. So if we have a posterior capsular tear or management goals, every maneuver is made to try and avoid extending the tear. We want to maintain chamber stability, so pressure gradients will drive the vitreous out of the eye or drive the vitreous to go to areas we don't want it to and so we want to try and maintain the pressure gradient between the anterior and posterior chamber. We don't want to irrigate towards the tear of the vitreous because we can hydrate the vitreous or disrupt the vitreous that way. We want to use OBD or viscoelastic copiously, but not excessively. We need to place what we need to maintain the space and maintain the pressure gradient, but if we fill it too aggressively, it can cause the tear to extend, it can cause disruption of the vitreous and cause it to come forward. That's what we want to be careful or we want to understand the balance there in terms of what we need it for and not being too aggressive with it. So the steps when we recognize a tear, we leave the main instrument in the wound. The viscoelastic will be injected through the paracentesis to tamponade the vitreous, sort of maintain the space of the anterior chamber. We might buoy any residual nuclear material, try and hold it in place so that it doesn't fall back. We want to reduce our surgical settings, so some might describe these as flow-max settings or low-flow settings, or you might just use your epi-nuclear settings because they are typically slower settings. If nuclear material remains, we can faithfully add or perform extra capsule extraction techniques as long as the vitreous has not come forward. We want to partition the space or compartmentalize the lens material and vitreous. If we're going to faco it, we're going to move the pieces manually away from the tear. We're going to use, again, OVD viscoelastic to support those, keep the vitreous face back, prevent things from coming forward, and you're going to faco above the iris plane. You can use some dispersive viscoelastic to protect the corneal endothelium. You can also use a modified sheets glide. I can serve it as a pseudo-capsule. You can slide that in, or you can even place the lens, a sulcus-placed intraocular lens or an optic capture with a sulcus position of the haptics can be placed to serve as a pseudo-capsule. So lots of different ways to reintroduce the partitioning of the end-to-end poster chamber to try and help prevent vitreous from coming forward. When we go to remove cortex in the setting of a tear, we're going to, again, low-flow settings, we're going to turn everything down. We'll start with removing cortex furthest from the tear and we're going to strip or try and remove the cortex towards the tear to minimize the amount of stress that occurs on the capsule and particularly on the capsule in terms of where the tear is located. And depending on the location of the tear, we may need to attempt dry or manual cortical removal techniques. In the end, if we leave a tiny bit of cortex in that area, it may not be the end of the world just making decisions about how to do that safely. Bimanual IA can allow irrigation to be separated from aspiration so you can direct the irrigation away from the tear. That'll help to maintain chamber space as well. So this is often what we will go to in the setting of different capsular tears, keeping the main one closed and allowing us to separate the irrigation and keep it away from, I mean... So what happens if we leave a lot of cortex like in Dr. Lin's case that she described? Well, you're going to get a big somerings ring because that cortical material will proliferate the lens of the cells. That's what will happen eventually. Probably won't need surgery. No, in most cases, no, you shouldn't. In her case, she may have maybe wise to do a gag early on within a few months so that you can get through that material. If it's really thick material, you may have to do surgery to remove that very thick PCO, so to speak. Alright, let's talk about if vitreous has come forward or encountered what we do. In most cases, we need to deal with this before we move to any other step. So we can use triumcinolone as a stain or other stain to help ascertain whether it has come forward and whether it's been successfully removed. Bimanual vitreous with irrigation directed away from the vitreous terrace. So similar vitreous with the posterior capsule terrace are similar to bimanual irrigation aspiration. We want to separate these two so that we're not irrigating into the vitreous, hydrating the vitreous, and causing the vitreous to come forward. So there is coaxial vitrectomy equipment available with some machines. Again, I don't encourage you to use it because you're basically going to be doing a core vitrectomy. You're going to be sitting there for a while because you're hydrating the vitreous and encouraging the vitreous to come forward with that instrumentation. You can consider a par's plane of placement of the vitrector, and that would, in theory, help to draw the vitreous back. It might help to minimize the amount of vitrectomy time that you have to use, but it will require knowledge and understanding of placing a trocar in a different gauge of vitrectomy instrument versus doing a conjectable pyritomy, creating a small sclerotomy and going through that and having to suture-close that sclerotomy and the pyritomy. But that's certainly a way to do things, and some advocate doing that. You can also consider a dry vitrectomy of the use of OBD, so you're just removing some vitreous placing, this goelastic, to sort of hold it back, and then going back and forth that way, or a bimanual technique with irrigation again. Yes, go ahead. So how hard is it to get transit alone? Because it seems like, you know, you'll get it when I feel like it might be helpful. So, you know, here we're able to get it reasonably easily because we can have our pharmacy prep it, whether it's removing the preservative and some of the ingredients to catalog or using a preservative-free form that is already designed to be injected into the end of the poster chamber into the vitreous. Like triacids. Exactly, like triacids. How about like an open-close situation like where primary children's or... It may be more challenging to get it there. You might have to see if they have triacids asking them to have that in place. If they don't have it, you're just going to have to use other means to identify vitreous, either through, you know, my call to bring the people down, looking for peaking, testing with wax cells at the wound to see if there's anything coming forward. It's not always going to be a perfect situation. Fortunately here, you have access to it. That's why we talk to you about it and teach you how to use that. And then when you get out to wherever it is that you're practicing, you can certainly inquire and try and encourage them to have triacids available because, again, it's already prepped and available to place into the eye safely. But you may not have access to it. I didn't have access to it in private practice. It seems like it's a lot better because you can actually see the vitreous. Oh, yeah, absolutely. I mean, it's a very nice way to place, just inject a little bit of it. Confirm there's no vitreous coming forward and give you that peace of mind, but not always, unfortunately, not always ideal where you're at. Okay, let's talk about management of lens material with vitreous prolapse so we can use what's called the viscote trap technique. We're trapping the residual nuclear material near the cornea with a dispersive viscoelastic. We'll fill the AC with OVD. We can perform the vitrectomy to remove any vitreous into the interior chamber. Replace the OVD that's removed. Once we've confirmed that our vitreous is cleared and properly compartmentalized, we can focus on the lens material. Again, as we've talked about, we can create a pseudo-posterior capsule either with a trim sheet's glide, a poster chamber and tracker lens that's placed properly in the sulcus or optic capture reverse, optic capture, whatever you want to do, but trying to create that pseudo-posterior capsule can also be very helpful in terms of again, in giving you the clearance to go ahead and place a phagohand piece in there and take that residual material out of the eye. All right, let's talk about vitreous loss. We've talked a lot about posterior capsular terror defects. We can also have a zionular dialysis that can create a situation where vitreous can come forward. We've talked about vitreous stain, off-label use with a kennelog and preparing it to remove the preservative or, of course, we can use triasins in the vatrectomy settings. So we want to start in the cut IA mode. So you'll have the option, at least on the Alcon machine, of being cut IA or IA cut. Basically what that means is in the cut IA mode, you're going to irrigate first, then it's going to go to the vatrectomy cutter mode. Aspiration would be in the third setting. So you're not going to aspirate anything in this cut IA mode. It's going to allow you to cut the vitreous, allow it to retract back posteriorly and minimize the aspiration forces that might draw some of it forward. Once you've removed the vitreous, you can use the vatrectomy handpiece to remove residual particle material. For example, you can go to an IA cut mode and aspirate in position two, aspirate that without being in the cut mode and then move to the cut mode to remove it. In the vatrectomy settings, when we're trying to remove vitreous, we want a high cut rate and a low aspiration rate. So you'll notice if you look at the settings of your attendings in terms of vatrectomy settings, usually the aspiration rate is quite low. If you're moving to try and remove cortex you may want to, or remove OVD, you may want to tell the surgical scrub tech to increase your aspiration rate to help you remove that more efficiently. Again, I encourage you to separate the irrigation to my bimanuals opposed to coaxial technique and we can always, of course, consider parts planar approach for vatrector use in select cases or if you feel more comfortable with that. All right, so if vatrectomy was required, a thorough dilated exam in the early postoperative, actually, any time you break or violate poster caps, we should do a dilated exam in the early postoperative period to evaluate for any retinal pathology. Because of the traction we're placing on the vitreous, we could create a small retinal tear or we could predispose them to higher risk of retinal detachment. We want to evaluate for those, catch them early, obviously, to provide appropriate treatment and quality. If vitreous presents postoperatively, so you're looking at them day one and you're seeing vitreous that was entrapped in the wound, there's risk of what we call wicking, which can allow for bacteria a path to get into the eye so increased risk of infection. You can stain it with fluorescein at the slit lamp, you'll get bright green at temporary stain if the vitreous has actually been externalized out of the wound. If that's the case, if vitreous has just incarcerated the wound but it has not been externalized, you can use the ag laser to lice that vitreous that's come forward and if you can lice it, it will retract back typically into the poster chamber eventually. Sometimes it can be a little bit challenging getting the ag to focus specifically on that, but if you can get it liced, and it's not too difficult as long as you can visualize it, then it will retract back. Sometimes there will be some pigment from the iris on the vitreous helping you to identify it and visualize it. Regardless of presentation, wherever we're finding it, we need to find a way to deal with it because it's potentially creating vitro-retinal traction, and that of course increases the risk of retinal tear and retinal detachment associated with that, and it can also increase the risk of systemic macular edema with that tractional force. So for the tear, one of the things we can do to try and prevent it from propagating, depending upon how big the tear is initially, is to create a primary, or not a primary, a posterior continuous capsular axis. If it's a small linear or incomplete circular tear we can use instrumentation to just create a continuous posterior capsular axis. We're going to use OBD to create space and maintain that pressure gradient between the posterior and anterior chambers. So our MST sets are going to hold the instruments that we want to use for that. And then we can consider reverse optic capture with the intraocular lens in the bag and the optic captured through that capsular axis, or you can just place it in the capsular bag. I probably wouldn't reverse optic capture and I would just place it in the capsular bag. Or you can do a sulcus placed three-piece lens, haptics in the sulcus and then capture the optic in the anterior capsular axis. So lots of different ways to place a lens safely in the bag, but if you can create a circular posterior capsule, capsular axis, now you've stabilized the capsule, it's not going to extend further and it may make your life a little bit easier in specific situations, just depending upon the extent of the tear. Most of the time, in my experience, the tear is probably too great to create this, but if it has to be a small tear that's created or an almost circular tear that's created, you could just finish that and stabilize that. So let's talk a little bit about lens placement in the setting of the posterior capsular tear. So if we have an anterior capsular rinse, I don't know if anybody has seen that in the offering room yet, so that can happen with a second instrument inadvertently striking the anterior capsular tear. The FACO could accidentally strike it and create a tear. If you've done a femtosecond capsular axis, if there's been a small tag, sometimes it can create or increase the risk of having a small anterior capsule rinse. You can place a one-piece acrylic in the bag. You're just going to orient the haptics 90 degrees away from that tear to help prevent it from propagating further. You're going to go to low-flow settings to remove the OVD. You're going to be a little bit gentler to try and help prevent that from propagating around the capsular equator. A small posterior capsular tear can facilitate in the bag placement of the IOL. We just have to be careful not to extend the tear. Of course, we talked about this, converting the tear to posterior capsular axis prior to placing the IOL. We never want to place a one-piece acrylic IOL in the sulcus. Shorter length, thicker haptics, sharpened, finished edges to the haptics, is going to create UGG syndrome, and you're going to have to remove that lens. I've never seen a lens in the sulcus, a one-piece that didn't have to be removed. If anybody ever suggests doing that, you just tell them, no, we're not doing that. So if you have an attending, I don't think we have any attendings now that would suggest doing that. That looks like it's happened. Get that haptic into the either into the capsular bag and reverse optic capture it. What that means is haptics behind the capsular axis and the optic interior to it, or remove that lens and place a lens that can be safely placed in the sulcus. Alright, let's talk about sulcus fixated lens. So three-piece lens with sea-loop haptics in the sulcus, and of course we can capture the optic in the rexis. In other words, placing the optic posterior to the rexis. Racing it in the sulcus, we want to reduce the power by approximately a half-diopter. If it's a higher-powered lens you may even reduce it by a full-diopter. If it's a low-powered lens, you may not need to reduce it at all. A low-power lens, something under about nine diopters probably does not require change in the power. If it's about nine to seventeen or eighteen, probably just a half-diopter. If you're over about eighteen you may look at a full-diopter. If you're at a really high power, say twenty-seven, twenty-eight and beyond, you may even reduce it by a diopter and a half. So there's sort of a table that's available on that. But rule of thumb is for the average Iowa power, it's about a half-diopter reduction. A large anterior chamber, they've got a large sulcus. You may not have a lens big enough to fit in the sulcus that will help to avoid sunset or sunrise with a lens that descends because of the size of the anatomy of the eye. In that case trying to capture the optic will make a big difference in that situation. Or a larger diameter IOL which was a star silicone three-piece IOL with a larger diameter IOL. It's no longer being manufactured, so we don't have that available. So it's a matter of figuring out if it isn't stable in the sulcus suturing it to the iris, finding some way to fixate it, you may need to do that. And Bobby Osher, who's a surgeon based out of Cincinnati, he trained Bob Sione. He's got this what we call the bounce test. You intentionally descended the sulcus IOL and watched for it to bounce back into a more centered position. If this doesn't occur, rotate the IOL haptics to a new position and try it again to make sure that you've got a stable sulcus position for that lens. And if it's not stable, consider suturing it to the iris to fixate it. Most of the time it will bounce back or be fairly stable. And the average eye, the anatomy is such that that lens should be fairly stable. But you've got a very large eye. This is particularly useful in terms of testing it seeing if you can find a position where that lens is going to remain stable. Alright, so if we have inadequate capsular support, what are our options in terms of lens position? An anterior chamber intracutor lens is always an option. Contraindications to that, control glaucoma, extensive anterior synechiae, iris tissue loss, different things that would create situations where we might worsen the glaucoma or worsen the synechial extension or if we don't have the support of the iris we can't place the lens safely. When we're placing an anterior chamber lens we've got to attempt to size it or fit it properly. This isn't fool-proof. Sometimes this doesn't work and you might have to go back in and remove the anterior chamber lens and replace it. But we're going to measure the horizontal corneal diameter. We're going to add a millimeter to this size and that's the sizing that we're going to use for the anterior chamber lens. Each haptic needs to be flexed, lifted and allowed to recede into the angle structures to minimize any iris entrapment. We're trying to minimize the risk of that. Alternative options maybe some points here in the U.S. will have an iris claw eye well that is foldable. Right now the lens that we have is FDA approved that's used in faking refractive procedures. It's a PMMA lens you have to make a big wound to get that into the eye. So I don't necessarily use that for this but certainly that's available in other areas of the world. A poster chamber lens we've talked about this. Iris sutured, one of both haptics can be sutured to support depending upon the amount of capsule support that exists. A scleral sutured lens can be used as well. So those are the different options that we have if the capsule support is inadequate in terms of lens placement. Of course can leave them a faking if they don't have much vision potential as well. How do I mean? You still want to size it if it's too big it's going to vault too far forward and create increased endothelial cell loss over time. So I would suggest sizing them if they don't have much vision potential as well. You still want to size it if it's too big it's going to vault too far forward so I would suggest sizing them. In most cases that BNL lens is going to be reasonable. It's a larger lens again you don't want to put something that's too big into the eye. So sizing can be helpful but I think here at the Moran we only have two sizes of anti-chamber lens. We have an Alcon lens which is a little bit smaller and then we have the BNL lens which is a little bit bigger in terms of the size that we stock but they have a little different sizes that they manufacture and so if you are planning on doing a secondary lens planning and placing an interior chamber lens you can do some of these measurements get an estimate of the size that you want and order some additional sizes just in case you need to make a change to that but it's obviously measuring the corneal diameter is a poor estimate. I mean it's a poor man's estimate of the size of the sulcus different ways to estimate that correlates to it to some degree but not perfectly. The BNL lens it's a big lens so if you've got a small eye I wouldn't put it in a small eye it's going to vault too far forward still good to check that if you're thinking anti-chamber lens while you're in surgery you only have a couple of options otherwise try and plan in advance so you can order different sizes to have them change it to another lens does that make sense? Does a white to white can we use that? Yeah you can use the white to white you may want to measure it yourself as well with calipers at the slit lamp just to confirm that that size is appropriate but if you're planning on a secondary lens you're going to use those white to white measurements to give yourself an estimate of what you're looking at look at multiple values okay all right let's see like I said we're going to beat you over the head with poster-capsutera information so final steps after we've managed poster-capsutera we've done everything else we've talked about thus far we can use acetylcholine or myacal to constrict the pupil this of course helps us to identify if there's any residual vitreous that we've missed if we see peaking of the pupil that would suggest there's vitreous coming around there's tension on that area of the iris it helps to tamponade additional vitreous prevent additional vitreous prolapse and allow you to more safely remove the OBD with bimanual IA or bimanual detracting instrumentation you can remove it manually just injecting or irrigating that OBD out we want to try and avoid chamber collapse as much as possible sometimes it's a little bit challenging to completely avoid that but obviously if that chamber collapses in theory you could have late vitreous prolapse loss of optic capture of the IOL a number of different things that can impact that so ideally trying to find a way to stabilize that chamber using your assistant to help you in that regard suturing the primary wounds prior to these steps can assist in preventing chamber collapse either suturing it with 10-0 nylon or 10-0 vicaral or you could use a wound sealant like for sure to stabilize that main wound and just use your Paris and TCs to finish up the bimanual OBD removal that will help to stabilize the chamber as well if you've dropped the nucleus avoid heroic efforts to recover it retina people are very good at taking care of this for you and if you go after it aggressively a lot of vitreous retinal traction increase risk of retinal detachment retina people won't be as happy with you if you do that as they would be if you just go to them with with a dropped nucleus consider a poster-assisted levitation technique if it's just sitting in the anterior high load phase not too far posterior and that involves using OBD to essentially elevate that lens back to you there's a surgeon by the name of I can't remember her name she's out of Iowa I think she's retired now but she's an adjunct professor here at the Moran she's created spears to stab the lens and bring it back I don't think I have any. We could look it up and see if we could find Lisa Arvester's her name see if we could find some video on that show that to you just for fun placement of the IOL still recommended because modern retracting equipment is very good at handling even the densest of nuclei in the poster chamber optic capture can be very helpful to the surgeon for subsequent PPP stabilizing that lens so that they don't have to worry about that being an issue to a different type of complications iris prolapse or injury this is more likely with a posterior wound injury short wound so we need to try and have an uphill orientation if you will to our wounds to reduce the risk of this it's greater risk with conditions that result in a floppy iris so flow max to exfoliation other diseases that impact stromal integrity or muscle integrity prevention strategies pupil expansion devices such as an Alugin ring or iris hooks cohesive OBD like intracameral epinephrine sugarcane these things might help to stiffen the iris or phenylephrine has been shown at least in one study that was published from a group I believe in England that seemed to help stiffen the iris in IFAS cases preoperative nonsteroidal anti-inflammatory drops can also help prevent that by helping to expand or maintain dilation of the pupil if the iris has prolapse the management is we want to look for posterior pressure we have OBD behind the iris whereas the lens position is in vaulting forward we want to try and release that pressure first before we try and reposit the iris because if there's a significant pressure gradient there we try and push the iris back in we're just going to damage the iris the iris is just going to come right back out so we can release that pressure by loosening the lens so in the case of hybridisection if the lens is vaulted forward pushing that lens back into position releasing that fluid that's behind it releasing OBD from the paracentesis wound to reduce that pressure gradient can also be very helpful and then we can gently sweep the iris back into the AC we've created some space reduce that pressure gradient and we can use a small amount of OBD to hold it in position some advocate considering creating a PI in the area of prolapse to equilibrate the pressure gradients certainly something you can do one thing that may be helpful particularly if you have a short wound before it's happened multiple times creating a paracentesis beneath your wound through the sclera and then placing an iris hook to hold the iris back can also be helpful at the end of the case myocall or myotic agent can be used to help constrict the pupil and reduce the risk of having this happen right at the end of the surgery in general the principle is the greater the manipulation of the iris the greater the myosis pigment loss distortion, flaccid nature and possible bleeding for the minor iris root or root tear can occur so if you're having a manipulated multiple times we really ought to be thinking about doing something more definitive to hold it back whether it's a PI whether it's an iris hook and trying to do that before it gets to a point where it's so damaged that you end up having to abandon that wound into a different wound or you end up creating a significant problem that has to be dealt with with a secondary surgery or some sort of iris replacement device we want to try and avoid that situation incision complications so wound leak of course increases the risk of endophilitis if the we can suture the wound if the IOP is lower the chamber shall go back to the OR and do that if we find a small wound leak but the AC is stable there's no shallowing and we have a stable IOP we can use an aqueous suppressant with a bandage contact lens and follow it closely for resolution or whether we need to go back and suture that if there's any distortion or it's difficult to close with suture take a step back and look at it make sure you don't have a wound burn that you've just not recognized prevention of course is good wound architecture good surgical technique with instruments in the wound trying not to stretch the wound too much with your instruments learning how to pivot within the wound as opposed to putting a lot of pressure on one side of the other of the wound a wound burn or wound contractures of course is generated through excess heat released from the FAKO handpiece usually in an occlusion setting so if you hear occlusion bells particularly if you're not occluding lens material you have to take a step back and figure out why is it doing that before you allow for too much FAKO energy to cause harm and create a wound burn it's usually most commonly seen with inappropriate sizing of a wound and tips sleeves so this can pinch off the irrigation which is of course very important to cooling the tip excessive FAKO with full tip occlusion so those warning bells you keep hearing those and you're using FAKO and it's not clearing that increase the FAKO energy to clear the lens material that's just dense lens material or take a step back and figure out what's going on is there OVD occluding my tip I just need to take the handpiece out clear that out be sure to think about why is that occlusion warning still going off full occlusion will eliminate aspiration that's why we're concerned about that of course that's a key component to irrigation flow and so if again if those warning bells are going off we need to figure out why they're going off increase FAKO power of course to clear the tips we talked about with dense lens or we can aspirate the OVD overlying the lens before beginning to reduce the risk of OVD plugging the FAKO handpiece and creating a situation where you get a wound burn certain viscoelastics will propagate heat better than others some have more exothermic properties so it's important again just clear a little bit of that off the top of the lens before you start the case to minimize that risk wound burn management it's just difficult suture closure of the wound it sucks I've never had, I've never done it but I've seen videos of it it looks very unpleasant so try to avoid a wound burn would be my recommendation other incision complications decimates membrane tear this will most commonly occur with insertion of surgical instrumentation so you just have to be careful as you insert it and remove it to minimize that risk if it does present during surgery you can use viscoelastic to tamponade it you might be able to use a single suture to hold it in place at the conclusion of the case sometimes you can use gas suture local just small amounts of viscoelastic in many cases they're very small you might see them at the very end of the surgery if they're very small usually they'll just hold themselves in place with hydration of the wound and I BSS placed in the AC to hold it in position but if it is more extensive we have to use something to try and hold it in place let's see those are a couple of quick things on incision construction so you have different concepts clear cornea and near clear scleral tunnel options it's most important to ensure ease of access in the eye with surgery placement can be decided on they have a prominent orbital rim my stigmatism management can be used for existing anatomy like a tube or a trap, a corneal scar the more anterior the entry of the incision the more astigmatic effect the greater the endothelial cell loss with a clear corneal incision of course we want to start it as postures as possible right at the limb this if we can clear incisions require shorter tunnels compared to scleral tunnel incisions as you all know a scleral tunnel you can use a set blade to create the initial groove too short of a tunnel you can prematurely enter into the AC or you can actually enter into the super coronal space be aware of that it's an intraocular bleeding hypotony it can be a little challenging because there's a little bit of an uphill entry component to it which results in more glowed movement and corneal striae with instrument movement clear cornea if it's too short it's tougher to seal greater risk of a leak post-op it's too long you get corneal striae instrument movement is restricted more with that and it can be difficult to access the sub-incisional nucleus and cortex to remove those who have been operating starting to understand these concepts a little more alright high IOP we've got a differential that we've got to consider in terms of what could be causing that retained OVD retained nuclear material fragment endothelitis, TASS, aqueous misdirection malignant glaucoma so we've got this differential that we've got to consider trying to figure out what the underlying cause is that will guide our management assuming no exam features of less common causes such as aqueous misdirection or TASS endothelitis most commonly it's going to be retained viscoelastic material in that case we could consider burping the wound we want to use pre and post antisepsis some sort of antibiotic or poet on iodine solution that's been prepared for use on the surface of the eye with wound burping understand that it only reduces the IOP temporarily it only takes a couple of hours to replace the aqueous and so you need to make sure that you've gotten a good response and then you're adding some sort of aqueous suppressant therapy to help maintain that reduction in IOP so burp the wound, place the drop that you're going to use or the medication give them a dose of it, check the pressure in a couple of hours to make sure the pressure is being maintained at a level that you're comfortable with of course we can use topical and systemic aqueous suppression alpha-gan and some of the other topical agents aren't going to lower pressure a ton they might lower it by a few points, keep that in mind and so if you're looking for a big drop in pressure, systemic diamox is going to be your friend in terms of these post-operative IOP management cases for a few days just to help keep that in check if corneal edema is present we want to be more aggressive with our IOP reduction effort, number one it'll help to facilitate clearance of the corneal edema, number two the corneal edema is a suggestive of potentially higher pressures that have been present, we want to get that pressure lower and more aggressively lower it because it suggests that there are greater risk for having another pressure spike and of course always confirm the efficacy of your work recheck that IOP either that day or bring it back the next day to make sure that it is effective and you don't want to bring them back in a week with a blown pupil because of high pressure over that entire week alright, so retain nuclear fragment this happens to be the cause of the elevated IOP post-operatively nuclear material will incite a significant inflammatory reaction in IOP spikes we've got to manage it until we can get it out surgically aqueous suppressants and frequent steroids you may have to do gonioscopy to identify an unexplained IOP spike with increased inflammation in the anterior chamber so look for a small nuclear fragment in the angle if the material is cortical or epi nuclear the response is usually much milder and you may be able to manage it medically and the body may be able to clear that small amount of material if it's a more significant amount of material you may have to go and still surgically remove it wound leak let's see, I think we've talked about this already and we're all done with that does anybody have any questions about anything we've talked about thus far? okay so let's see if we can find I wanted to find that Lisa Arborster Spears I've done some videos but you didn't show the Spears you didn't find the Spears? she had like a Miyake video of her I know there are some decent videos of management of a poster capsular tear here on the closed PowerPoint on YouTube, Jason Jones let's see what we can find so Jason Jones is a former president of the Moran he's now a high volume surgeon in Iowa so we can watch his management here of a poster capsular tear he's creating his wounds they're very deliberate in terms of the angle that he's using Rex is completed almost you can see he's got a sharp chopper there he's doing sort of a modified vertical chop technique there going peripheral and driving it posteriorly and towards the tip ideally coming across so that the tip remains occluded and then he can keep it buried and make another maneuver there so you see now we've got a break there posteriorly he's not come forward he's kept this instrument in you can see he's got a cannulinized placing some Bisco elastic to tamponade the vitreous from coming through that poster he still has some lens materials he's going to try and compartmentalize that within the interior chamber now that he's stabilized the pressure gradient he can come out with the main incision then go in with some additional Bisco elastic to help compartmentalize the lens material he's just placing some Bisco elastic posterior to that lens material trying to compartmentalize it and he's going to go in and remove it I think he's got, it looks like he may be injecting a little bit of Bisco elastic behind as he removes it you can see these multiple edits into the video that's likely because he's going in with Bisco elastic injecting and then going back into the Fago hand piece and just going back and forth in that regard you can see here he's just manually removing that small final piece here you've got bimanual vitrectomy instrumentation there see how his irrigation he can control that, keep the irrigation pointed anterior and he's removing now cortex using the betrector so again you can go from a cut IA to IA cut setting there so you can aspirate that cortex and remove it safely and a little more Bisco elastic tamponade the vitreous keep the chamber form properly the bimanual of course you can switch sides with the betrectomy hand piece allows him to get the rest of the cortical material out here a little more Bisco elastic you can see he's expanding the wound on this lens here this is a single piece acrylic he may be placing it in the capture bag or doing reverse optic capture we'll kind of watch and see what he's doing here it allows them to use the single piece acrylic lens that they had planned on using so they don't have to open a different lens that would be the main purpose behind it reverse optic capture sometimes used for negative dysphotopsia so you'll go in and actually prolapse the optic here to the rexis and that reverse technique sandmask it advocates that for patients who have persistent negative dysphotopsia so that dark arc that they will sometimes complain about initially that the whole lens could just fall back exactly if the poster capsule is not stable you put the whole lens in the bag it may not be stable in stable situations that lens may de-center may fall back may tear to extend as you put the lens into the bag it's not a situation that you want to be doing unless the tear has been stabilized it's circular it's not extending then you could consider placing the lens in the bag in this case he was doing reverse optic capture he's placing the haptics posterior to the rexis the optic he's actually prolapsing and keeping it anterior to the rexis it'll create a square shaped rexis when you look at it it must have popped up it was hard to see video quality is not terrific but at some point here as the lens material clears the poster capsule pops up I think it's right about here see that so as it comes through you'll hear Dr. Manless talk about avoiding lolly popping the lens so getting into the center of it and breaking through the back surface of the lens material and then allowing the poster capsule to pop up in this case I thought he was doing a good job I mean it looked like he had an edge position on the lens material which normally will result in the lens sort of carouseling but in this case it went all the way across and then the lens popped up or the capsule popped up to the phagohand piece this will happen to every one of you if you do cataract surgery it's not a matter of if it's a matter of when so just understand how to manage it and of course if you're here with us but it's just important to understand the basic principles maintaining those pressure gradients to minimize the risk of vitreous coming forward managing depending on the situation when it happens managing the lens material and getting it out safely and making good decisions about what lens and where to position it and making sure that the vitreous hasn't come forward at the end of the case just a few things you can do to look at that does anybody have any questions so if you're going to reverse to capture you don't need a change so that's a good question some will advocate changing it like you would with a sulcus lens by about a half diopter in that case just get another lens I like the three piece lens the optic capture looks better and it's a little easier because it's something I'm used to but this is something that some of them will advocate they'll just because that's the lens they're using they'll just reverse optic capture it the patient's slightly more myopic third to a half diopter different from what the lens calcs are calling for it's a way to deal with things or if you get in a situation like I presented let's see if we can look at these videos again so you get in this situation like I was in with the eye a hand piece where did it go? with the eye a hand piece we've already got a lens in the bag we're just removing OBD it came up and still don't realize that it came up and it's broken until I'm watching the lens here or I've got this vitreous you can see a little stringy material coming to the tip so in this case I could have lifted that lens out like I do and left the lens in the eye we could have reverse optic captured that lens and not had to remove it and replace it with a three piece lens we decided not to do that just for refractive purposes but that would have been an alternative option in this situation where you get a break in the bag with the lens already in the eye reverse optic capture if you have an intact enteric capsule rex this is a very reasonable way to manage that particular case alright any other questions? okay, thanks guys