 All right, welcome everybody to subspecialty rounds. Seems oxymoronic that we call it subspecialty rounds and it's comprehensive rounds, but best it is, we're just gonna spend some time talking about cataracts, makes us feel like specialists. Although we have Dr. Chia present, he's a glaucoma specialist, so he knows what that feels like. All right, today I'm gonna start with one case here. I haven't seen this in a long time, had a recent case, and so I thought that would be a good opportunity to present and also dig into it a little bit to see if there's anything new out there with regard to persistent corneal edema after routine cataract surgery. This case, patients, a 95-year-old female, reduced vision with specific complaints about difficulty reading, and so that's why we signed her up for surgery. Herocular history was otherwise unremarkable, so you had no past history of trauma or other prior ocular surgery. You can see her best spectacular visual acuties were about 2050 in both eyes. Otherwise, pretty normal exam. Pupils normal, confrontation fields, EOMs, IOP, all in the normal range, and no remarkable abnormalities in that regard. For pre-opsilit lamp and fundus exam, had some mild arcus to the cornea, but was otherwise clear there are no gutata or other issues. Deep chamber, normal iris, blends about three or four-plus NS, as you would anticipate in a 95-year-old who had not had FACO in the past. A DFE, normal exam, normal nerve macule, et cetera, so good visual potential based on the exam. So our assessment, of course, visually significant cataract with functional impact on reading, plan was for cataract surgery. Given the density, a few adjustments that I typically make in these cases will use viscotes as the viscoelastic, try and help protect the corneal endothelium. We use a balance tip with our Alcon centurion machine to try and improve the efficiency of nuclear removal, reduce the amount of FACO energy required for that, and then often use a burst mode. I'm just plugged in. Technical difficulties, hold on. Okay. Meanwhile, while we have everyone, just want to do a reminder that we do have our resident graduation this Friday, resident and fellow will be honoring of course, residents and fellows during this event. I don't know any details, although I understand this could be a roast to remember. All the subtle smirks and smiles of the residents as, at least anyone that's seen it, apparently this one could be legendary. So I'm doing what you generally shouldn't do, which I'm raising our expectations for it ahead of time, knowing that it's actually going to deliver on that. A couple other announcements. We do have our medical students who are going to be coming through soon. When our medical students come through, they are amazing. Just want to echo Judith's words. Please make sure and write down your thoughts, impressions and then send those right away. That really is the best way to get your thoughts together when they're fresh at the top of mind because they all do look pretty similar later. And then Megan, if you can just make him a co-chair, co-moderator so he can screen chore just so that he can do that. And you don't need to join up. All right, thank you. And so again, just a reminder, please write down notes impressions for the applicants. We will have an after interview open house just like we did last year in January, but that'll be our only time to meet our virtual applicants, those interviewing virtually. Thanks, Bill. All right. I came early and set this up, but I did not set it up properly. So thanks, Jeff. So back to the case. I promise you didn't miss anything on those slides that weren't very exciting. Everything I read was exactly was on there. So again, our plan is for cataract surgery. We talked about some of the adjustments we might make with the FACO machine and some of the instrumentation we might use just to try and make things a little bit more efficient. And of course, with somebody that's over the age of 89, we talked about independent risks for complications related to surgery. Obviously with the density of the lens specifically, we did talk a little bit about the increased risk of corneal edema, persisting for a little bit longer than typical with denser lenses with her age. So the actual case was uneventful, uncomplicated. I'd be perfectly honest. I thought it was a little bit smoother than I would have anticipated with that level of density of the lens. Her post-op, early post-op visits and see significantly reduced best spectral record acuity of 2040. The example otherwise, pretty unremarkable other than the substantial corneal edema. It's just 24, pupil is normal, out few is normal. The corneal of course showed substantial edema. There was no microcystic changes, just decimate folds with thickening of the stroma. Gracie was deep informed with about one plus cell, no fiber, no hypopion. Her eyewitness was round and reactive. Post-op chamber lenses well-centered, well-positioned. So our assessment is we've got a significant post-op corneal edema. So we continue, of course, the prednisolone. I had an aqueous suppressant just to try and help support the endothelium by minimizing any pressure associated impact on its functionality, although the IOP was pretty normal here in this case. In cases with significant corneal edema, there may be benefit to measuring with a device other than our typical gold manipulation tenometer because that can create a little reduction in the measurements because of the corneal edema. So you may need to add a few points in your head if that's the way that it was measured. And then we were gonna follow up in a couple of weeks to see if we were seeing improvements. In terms of the differential, with this amount of corneal edema, obviously you're thinking about a number of different things. So pass as was described here in Grand Rounds just a few weeks ago, pretty substantial edema, but usually you're gonna be seeing, you're going to see a more significant and your chamber reaction in terms of inflammation, which we did not see in her case. Doesn't mean that it wasn't maybe a variation task, but certainly wasn't presenting in that classic, very high, very significant inflammatory reaction scenario. Gouda less or Gouda less endothelial dysfunction. This was described in the early 90s in the literature or potentially you missed the Gouda, you can always look at the other eye to see if that is the potential case. In her case, there were no Gouda. There's always the possibility of a retained lens fragment so usually that's more focal in terms of the edema, usually the lower inferior cornea and usually you can see a small fragment in the inferior angle. Sometimes you have to do gonioscopy to identify it. And that's typically something that will show up a few weeks after surgery, usually as you're tapering off of the anti-inflammatory that the inflammation will show up and the edema will show up. Endothelitis obviously typically more severe, AC cell and vitreous inflammatory reaction more pain and none of what she was having. You can of course see this with a high pressure postoperatively, we looked for microcystic changes to sort of suggest that that's the case or that's present as we talked about measuring with a tonal pen or some other device other than the Goldman Appalachian Tenometer to get our best most accurate measurement of the IOP. An iatrogenic decimates membrane detachment also could present this way. You expect to see more bolus edema in that case. And so again, in her case, it appeared to be essentially a just significant postoperative probably fecal emulsification injury, maybe a butadolus and a field of dysfunction based on her presentation. Let's move forward here. So my working diagnosis that again, fecal induced and a field of dysfunction possible is that this is an anothelial dysfunction case without butata we haven't done or had not to this point done anothelial cell counts we wouldn't know for sure. So the plan of course has continued to allow time for recovery. We've postponed surgery on the other eye until this had a chance to recover and we're stable. We know what we need to do with that first eye to help her see better. We've got her on PRED, a BID. We stopped her topical onset after four weeks. Aqueous suppressant. I continue that for the first six weeks. The last IOP was 12 and thus we discontinued that and at eight weeks for edema is still grading out moderate about two plus. We've seen some clinical improvement, but it is persisting. So now what? Obviously this will be frustrating for a surgeon and for a patient waiting for this to recover in my experience. I don't have a ton of cases that have had this particular presentation in my experience. It tends to recover if you give it enough time and so try to preach patience. Obviously easier to do if you're not dealing with it. We continue PRED at a low dose at twice daily in terms of assessing the other eye and trying to figure out what might be going on and preparing or planning potentially for surgery in the other eye. A number of things that we can do. We can look at the endothelial cell count in the other eye to see if there's any abnormalities in terms of the cell count, the morphology of the cells as well and we'll see if it's suggestive of endothelial dysfunction or butadolous endothelial dysfunction. We can do an anterior segment OCT to look a little more in detail at the eye that is recovering to see if there are any abnormalities that might be suggestive of an etiology for the condition. If the edema does not clear within a few months, obviously we can involve our cornea specialty services to talk about whether a desecrademec would be indicated and timing on that. In terms of the other eye, whether you do a combined procedure, I think that would be of course based on whether there was evidence of significant endothelial dysfunction driving this persistent corneal edema in which case maybe a combined case would make sense. Other alternative or experimental treatments, I didn't find much in the literature. There was one paper on trans-corneal oxygenation which did show some improvement in terms of central corneal thickness as a marker for the effect from that versus no treatments. But other than that, there's really not much change out there. It wasn't great, but not much out there in terms of differences there. So unfortunately did not find anything or shattering or knew that we could add to this case. And again, it is recovering gradually. So the expectations will continue to see improvements that will likely take a number of months. Does anybody have any questions or comments on this particular case? Randy and then Nick. I don't see one eye. I'm not sure what happened to the two of them. How did the other? That's a burying in that. Burying in that, it's pretty good. So have you considered blocking? Blocking? No, I mean that, yeah, that's the other thing that I came across. I would change the level of the sound off. If you place something like this, this person is allowed to spread it well down and stop in that, try to get that out. It's not that series of words that you're getting and going on. But you're putting that together and going forward. You don't point it out that thousands of years are an issue, it's not outside of the purpose of this. And it's just whatever you need, they need to have it on. And that's just, that's the value of it. Certain things are, and we'll see that that's totally up to you to get it on. So the second of my thoughts to the other eye, I'm going to use, you're not necessarily self-counseled but a lot of people have helped you know that, but I'm sure that probably you're just thinking. Yeah, I agree. The imaging's definitely planned to look at the other eye as you've noted, trying to help us figure out what's going on. Yeah, it's not the rock inhibitors with, when people do the decimates strip and just leave it to sort of heal secondarily, they use a rock inhibitor to help stimulate that. Nick, what he said? The only thing I would add is that only Dr. Olson can actually see guttodilus spooks, mere mortals can't see that at the sweat lamp. And we don't see that, but this would be a good one to get the pathology on. So if it does go to do on DMACC, make sure we get the pathology because we can actually see the diffuse thickening of decimates membrane in those little tiny, I don't know what we call them, gutettes that can show up micro-gutata. And so we'll be able to tell that on there. It'd be interesting to see what this specular microscopy in the other eye looks like. The other thing that we found in the past is when I've done specular microscopy every once in a while, I've looked at those corneas, they're crystal clear, everything looks normal, and they'll have a cell count of 600. And you just every once in a while, you'll get surprised and the cells that are there are just functioning, barely, barely functioning, keeping that cornea clean. It doesn't take much to put them over the edge. So I think a specular microscopy in the other eye would be helpful to guide you. Thank you, Nick. Just an addition on regards to that, I had one of those as well. And then when you asked afterwards, you said, oh, oh yeah, I got hit in that eye with a snowball or something. So you can get traumatic loss without any obvious sign with very low cell count and those can be fragile too. So good point, Nick. Mark. Hey, Bill, I'm sorry. I forgot what you were starting on 745, but do you have a specular for this eye? I don't. No, I'm arranging that. She's a patient from South Jordan. I don't have that out there. So it's arranging to get her up here to look at that. And how far out is this? She's about two months out. Yeah. I mean, I definitely would stall on EK because a lot of these eyes get better. And I think keeping them on low dose steroid is often a good, you know, like pred twice a day does seem to speed recovery. But I think that's the missing link. I mean, you got to get the cell count on both eyes. And just so you guys know, the automated Conan, especially, don't even look at the number. Look at the picture. Unless you count the cells individually, the automated number is almost always wrong because it's just not, it's counting, especially if there are a goote, it's counting those incorrectly. But yeah, I mean, you definitely see this uncomplicated, easy FACO and then edema. You know, we see it in glaucoma patients, obviously. We see SLT patients. We see that there's definitely, you know, maybe an inflammatory component as well that's happening. And it's an uncertain kind of endothelial, I think maybe auto-immune thing that can happen as well, which may not be pre-existing. The last time I had a case, like it was a number of years ago and we shared this patient that had an eye stent with a FACO there. I mean, her lens was denser than this one, another mid-90s female. Yeah, definitely no question that angle surgery causes this corneal decompensation when there's no stripping of decimates directly. There's no reason for it. There's no hypotony, flat chamber, whatever. I mean, I don't know if Norm's here, but over the decades, we've shared multiple, multiple, multiple patients where it seems to be an auto-immune kind of process. And so, but yeah, the specular would be really helpful. Thanks, Mark. Anybody else have any questions or comments? Appreciate all those who have shared. If not, we can... And Dr. Chia is on now. Dr. Chia is on. Terrific. We'll turn it over to Craig. Hello, everyone. Can you hear me? You can screen share, Craig. Sounds good. You can hear me okay, though. Are you guys able to hear from where you're at? Jeff, I don't know if you can confirm if you can hear my audio. Yeah, audio, good, and video, good. Okay, sounds good. Well, I apologize to everyone for not being there in person after I managed to go three years evading COVID and it finally snuck up and got me this weekend. So I'm out this whole week and it's definitely not something to toy with. It's been rough for the last three days. I'm finally feeling a little bit better today, but I appreciate your attention. Bill asked me to present a few cases, some interesting cases. And so I'm going to present two cases, one on a fake Ocapsulotomy technique and then the 6-0 polypropylene flange technique. These are my financial disclosures non-relevant to this topic. And I just wanted to highlight to everyone, next month is Alan's birthday, his anniversary or his birthday. And just I want to acknowledge Alan for the work that he's done for our center. His legacy continues to thrive, both within our glaucoma division and as well as our cataract division, reminding us that we need to continue to always look for new and better ways to do things and to be able to challenge norms and to be able to get uncomfortable sometimes. And that's how we progress in the field. That's how we maintain our edge. And so I just wanted to acknowledge Alan for the incredible impact that he's had on my career and just the legacy that he's left behind our institution. For our early trainees that are coming through the program now that never had a chance to interact with Alan, I would recommend that you go down to external relations and pick up the issue that was dedicated to Alan, I think a few years ago. And it's worth the read. I actually have a copy in my office if you'd like to come by and read it. But it's just a reminder to me of the type of person that he was giving in so many respects and also pushing us to be our very best. So there are many strategies that we use to mitigate the Argentinian flag sign. And so maintaining high anterior chamber pressure is certainly paramount to any of these techniques. We also have the needle decompression. Typically I would use a 27 gauge, one inch needle filled with the SS and a syringe, half filled so that I can draw back the plunger. As soon as I puncture into the capsule, I'm immediately pulling back on the plunger to aspirate the liquefied cortex. There's also the cortical milking technique by Sunpap Chi in Singapore, which is essentially very similar in the idea that you're milking peripheral milky cortex out to the periphery initially using a highly cohesive viscoelastic to indent the anterior capsule to overcome the intra-capsular pressure. There's also electrocautery with the Zepto unit where you can immediately perform a capsulotomy in just a matter of nanoseconds. Flags has also been considered as an alternative to overcoming the Argentinian flag sign. Micro forceps, Dr. Olsen et al. had published a series of cases using microutra as micro forceps in order to maintain that high anterior chamber pressure to be able to perform a capsulotomy through small paracentesis incisions rather than through a main incision. And then finally, the fecalcapsulotomy technique. Much has been written about this technique from Chris Tang. I encourage you to read his papers in terms of how that technique works. So I'm going to present this case. It's edited down to about 15 minutes or so. I'm happy to speed it up and pause it as we go along. I also want to acknowledge that we have absolutely outstanding chief residents this year. It's just been a joy to work with all of you. And I'm sorry, I probably won't be able to attend the graduation because I'll be in quarantine still until Saturday. But I want to give a shout out here to Sean Collin, who was my trainee on this case. He's also the primary surgeon on this case. This is a roughly 58-year-old Caucasian female who presented to me with a white cataract. Ultra sound of the posterior segment was normal. And so I'm just going to let the case go here and kind of narrate as we go along. It was difficult for her to fixate and to maintain good achinesis. So we went ahead and did a subtenons injection there. Then I'll be using, I just used an optical zone marker to roughly delineate what the capsule rexis will look like. Heros and teases as incisions are made on either side in order to provide adequate access to the anterior chamber at all times. I'd like to use a small bubble technique for the tri-pan blue. I'll then inject the vision blue inside. And whoops, let's see what happened to the video here. Give me a second here. So there you can see the vision blue being displaced by the viscoelastic. And now a keratoma is made, a keratoma incision. Now for the keratoma incision, as you'll notice in this case, we struggle with the size of the incision. Initially, based on Chris Tang's paper, it was important to maintain high flow throughout the fecalcapsulotomy technique. But maybe I'll pause here for a moment and just leave it up to the audience to chime in about what their standard approach would be and why to overcome this milky cataract. Hey Craig, it's Nick Mamillis. I learned from Dr. Olson and Dr. Crandall to use the micro incision forceps through stab incision prior to making the primary incision and using a highly retentive OVD in the anterior chamber to keep that anterior capsule flat and to keep that liquefied cortex pushed down and knock wood. Using that technique, I've not seen an Argentinian flag sign now. When you've got, you don't make the wound because the viscoelastic can burp out the main wound. So you really gotta go through the side port incision with the microutrata forceps. And if you can keep that, disco visc or a highly retentive OVD like that in the anterior chamber and keep that from flattening out, you can keep that from extending. You start small and then spiral it out and as I said, using that particular technique I haven't had an Argentinian flag since then. So hey, this is Randy. Yeah, I mean, the big issue here is obviously when you get this intubus and cataract is that you've got increased intercapsular pressure. And we know spontaneous breakage in the face of normal intraocular pressure is a exceedingly rare event. I'm not only sure if it's been reported but it's lowering the pressure in the anterior chamber. And even though you can put a lot of viscoelastic in the anterior chamber to maintain that pressure with the main incision. And I've seen people with that that as soon as it burps out some viscoelastic, boom, there's the Argentinian immediately. And that shows that there's a very, very high pressure inside that capsule. So just having a single small side port and then with a highly retentive, I mean, Helan-5 was one that would work well, you just aren't gonna get, you've got enough, you're filling with the capsorectus forceps that I've just never seen it able to burp out through that small incision. And I'm with Nick, I mean, it's been a while since I've operated but I certainly did a whole slew of these since I had that series that I reported in JCRS and never had it. So I think it's an avoidable complication and that's certainly the way that I found was most effective. Craig, just one more comment. You know, it's interesting, you know, as we've gone through the years or we've taught residents how to safely, you know, open up the capsule, it's technically not easy. And this is one that's really interesting if I think about, you know, if I was, if indeed, you know, we can arrive at a place where this is consistent, there's a known and very low rate of complications. This is what I would call kind of a mere mortal being able to go in and just open up a capsule straight away for capsule rexess. Clearly you have to get the fluidics right. The two times I did this, it worked out well. It still makes me a little uncomfortable only because it's unfamiliar but I think it's technically certainly easier than the kind of tried and true, you know, methods that Randy and Nick have outlined whether or not it's safer and better long-term, that's the question. Sounds good, I'll let the video play. I did want to add that I did apply a highly retentive viscoelastic and now I'm just going to pause for more just to highlight the settings and also just to point out a few things. Normally I operate through a 2.4-ish incision and I use a pink sleeve on our centurion fecal platform but here I've decided that I'm going to go through a slightly larger incision and I'm going to use the same needle, not a larger needle, but the same needle but I'm using the purple sleeve which should allow for better flow, inflow into the eye. I've also cranked up my infusion pressure. Normally I operate with an infusion pressure or IOP of around 40, in this case where we've ramped it up to about 80 to 90. So I've got more flow coming into the eye. I've got more flow coming around the needle and according to Chris Tang in his description we're using a low vacuum setting. So this is your typical sculpt mode. I'm using somewhere between 80 to 100 millimeters mercury. My standard power settings on my fecal aspiration roughly 20 to 25 or so. So this is a sculpt setting that I'm using to initiate here or that Sean is using to initiate. So now the technique is such is that you just have to plunge immediately and immediately start aspirating. You're combining the idea that you're constantly infusing water into the eye and then you're also aspirating immediately the liquid cortex. So here we're burying in and boom, you can see that opening and there's a little tag there and surprising that tag is still maintained. Sean is gently aspirating the liquefied cortex and then he'll actually use the fecal tip and actually finish off the last tag there. And there you can see just before he withdraws there's still more liquid cortex. So we're putting highly retentiviscal elastic to maintain the chamber before we come out. And then now you can see this case almost proceeds relatively normal here. And in some cases where you feel like there's still a significant amount of pressure inside the eye you may actually start to see the capsule rex as one or run out. But I would say for the most part as Sean is propagating this capsulotomy it's behaving normal. There's not a lot of run out. There is still some minor liquefied cortex as you can see emanating from the opening but we're not seeing any runouts here and it's very controlled. In hindsight, what some things that I would have done differently I certainly would have used a tighter incision. I think I had the wrong keratone that was maybe a three millimeter rather than a 2.75 so it didn't match up nicely throughout the case. I'm gonna go ahead and let this case run and just point out a few other things throughout the case that I think Sean did extremely well. But here you can see we've got a great capsulotomy opening and we'll go back in and we'll start to do our fecal. As you can see this is not just your white cataract it's also burnescent as well. We're using a standard sculpt setting here and then we'll actually do kind of a double sculpt we'll sculpt distally and then we'll rotate again to be able to get that some incision a little bit better to be able to get down to the plate. So now I've done a few cases or one more case since this fecal capsulotomy case that I'm showing you here and now I've just decided to maintain my normal pink sleeve 2.4 millimeter incision. I will ramp up the settings and then allow the needle to immediately penetrate and then aspirate the liquefied cortex. Here we're using this is a throwback to Allen. This is a pre chopper. We just felt like we were able to get better leverage down at the plate because our fecal and second instrument weren't able to give us the leverage we needed to be able to crack the plate. So we're using both ends of the pre chopper here the rounded side we can get all the way down to the plate and touch the plate without risk of perforation through the plate and through the bag. And then now we'll proceed with just our simple chop technique here. We're dividing the pieces up and then Sean's doing a very nice job here of chopping those pieces and maintaining safety. I'll speed up this case. The case went very routine from this point on. One of the things that I had to do throughout the case though is that we had to place some sutures because I mentioned to you that I used a keratone that was not normally in my set. I thought it was a 275, but turned out it was by closer to a three. And so I had to place some sutures throughout the case to reduce the risk for surge. And so we'll go ahead and just advance here and get down to the last nitty gritty here. So we're down to the last chip. I've placed two or three sutures actually to close the wound up to keep it a little bit tighter. We don't have any sleeves larger than the purple sleeve for our standard fecos. So you do have to just place an interrupted sutures to close up the gap and limit the amount of egressive fluid. So polishing, not much to polish in this very dense lens. This galastic lens is placed in the bag. And then at the end of the case I've actually replaced some of the sutures and we'll just place two interruptants to close this incision. Because of the density of the nature of the lens that I went ahead and injected some dilute trimesinolone which we use for vitreous stain. And usually if I'm planning on injecting it into the anterior chamber for inflammation control I'll ask our pharmacist to mix it a little bit more concentrated than our standard dilution for vitreous stain. So that is the fecal capsuleotomy technique. I was very surprised at how controlled it was and that by maintaining a high pressure infusion pressure we're maintaining that anterior chamber space and overcoming intercapsular pressure in order to mitigate against the Argentinian flexion. Questions before we move on to the next case? Comments or comments? This is Dr. Olsen. I think it's the same concept, really. I mean, as long as you're maintaining good pressure inside the anterior chamber and the main incision is being supported by the sleeve and the rest so that you're, and then you've got the inflow. And yeah, I mean, it's great. It's neat and people don't have to learn how to use a microcapsulotomy forceps. So I think it would probably be very effective. It makes sense. Yeah, I think one of the issues as I've traveled around the world, micro forceps are still a luxury item for many parts of the world. Certainly they're used to using, I know San Duke Rui, when I watched him do cataract surgery in Nepal, he was using an assistotome on an infusion line. So he essentially was doing the same thing through a micro incision coming. Actually, he didn't even make a paracentesis. He just punctured it in through the peripheral clear cornea, running it through an infusion on an IV pool in order to maintain the chamber space. So I think you can get creative here. If you didn't have access to microutratas and micro forceps, I think this is a reasonable technique to be able to overcome the complexities of chamber shallowing. Hi, Craig, this is Marissa. Two questions. Could you just do this with your normal wound size, your keratome and the normal sleeve? Like I guess, why do you have to change both of those? And then could you describe what you're doing with the foot pedal as you enter? Are you going into FACO just to break through the capsule and then backing off so you're only aspirating after that? Yeah, so great question. So to answer your question, after this case, Sean Collin was still on my service and we did another case where I just used my normal pink sleeve, 2.4 incision sleeve. And but I still ramped up the infusion pressure closer to 80 to 90 to really push in more fluid. I made sure that the incision was tight. We went in, you know, I think we really tried to keep the incision as true as possible to the particular size of the sleeve to reduce the amount of egress coming around the sleeve. In terms of the foot pedal position, so you're going immediately into FACO 3 as soon as you touch the capsule and you're maintaining at least into position two to be able to aspirate the liquefied cortex. In this case, there was a small little tag that we actually, I don't remember exactly. Maybe Sean, if you remember, I feel like we just aspirated the tag and then just ripped it off rather than actually FACOing the tag off. So I don't think I used any additional ultrasound power to remove the tag, but you definitely would need to maintain position two in order to continue to aspirate the liquefied cortex. There was also a point in the video where Sean is kind of bouncing the lens in order to try to milk out that liquefied cortex that's behind the lens in order to bring it forward. Hey Craig, it's Brian Zog on Zoom. So two questions that I have. Do you run risk of wound burn with this technique or is it short enough that you're not worried about that? And then the second question is, but when you create that FACO opening, what do you do if you create like a perfectly round opening with nowhere to continue or initiate, I guess, a tear to complete the rexis? Yeah, great question. So wound burn at the very beginning, although we did use a highly retentive of viscoelastic to maintain that space, we did aspirate a little bit above the cortex. I think the risk that we run with a wound burn is if you're FACOing under viscoelastic for a significant amount of time. So we did aspirate a little bit above the capsule in order to be working in a dome of BSS rather than just viscoelastic alone. And then your other question was about, what do we do if we actually need to, if we create a perfectly round rexis? So I'm gonna go back to it here and just show you here that that's exactly what we have. We had a perfectly round capsulotomy opening. So we're just aspirating there and then we're ready to plunge. And then immediately we're in position two at least to maintain liquefied or to aspirate the liquefied cortex. And there's a tag here still and we'll remove the tag. And then what we're left with is a perfectly round capsulotomy. So there really was no tear for me to then initiate, but as you can see with the utrata forcips here, and I think part of it is also with the tri-pan blue staining in order to make the capsule just slightly more brittle, we're able to actually just grab the edge and then start the tear. And that was able to be propagated around and successfully completed. Other questions? So I don't think it really matters. We were using a fully torsional setting rather than longitudinal. I don't use continuous FACO on my Sculpt setting. I use a high pulse rate of like 40 pulses per second and 100% all torsional power, no longitudinal power at all. Some people feel that I think it would be, I guess theoretical that maybe a longitudinal might be better because you're just going forward and backward and just really cookie-cuttering that capsulotomy rather than going to and fro with the torsional movement. But in this case, we didn't have any issues with any radial tear-outs. Okay, we'll move on to the next topic. We live in the land of pseudoxfoliation and it's just amazing the amount of pathology that comes in our region because of that, both from a glaucoma service as well as late dislocation of IOLs. Nick, I don't know if you're, I forget the statistic in your paper that you and Liliana did a series of patients who had IOL dislocations and postmortem it, I think it was maybe something like 30 or 40% had on or were never categorized as pseudoxfoliation, but postmortem you were able to see that on staining. Is that true? I don't remember the actual percentage. Maybe the mic's not on for you. Yeah, we got the mic now. We found a very high percentage in the spontaneous dislocation of IOLs in our first study. We found that 50% actually had exfoliation but was interesting. Got a further large group of specimens from Northern Germany, from Thomas Conan, who's an outstanding clinician. And of those that we saw, we found that two thirds of all of the spontaneous dislocated IOLs within the bag were found to have associated pseudoxfoliation. And what was interesting about that is they only recognized about half of them ahead of time. And this is a department chairman, outstanding clinician. And so sometimes the findings of exfoliation syndrome can be quite subtle. So we were very surprised when we found out that actually half of the ones had unrecognized exfoliation syndrome. And so here in Utah of the ones that we see here, it is somewhere between 50 and probably 66% of all cases of spontaneous dislocation of an IOL within the bag or associated with exfoliation. Yeah, wow, that's incredible. But it's definitely matches with our clinical experience patients who come in with a spontaneous dislocation of their IOL and with no prior history, no IOP spikes and no obvious signs of phenotypic signs of pseudoxfoliation. So in any case, one of the challenges that we have with fixating these IOLs is what techniques do we have available? Historically, we've used non-absorbable sutures, typically EPTFE or also known as Gore-Tex or polypropylene. Yes, in full disclosure, Gore-Tex on its packaging says not for ophthalmic use and I think they're just trying to cover themselves. But many people have found that this is really one of the gold standard sutures that we use for non-absorbable sutures for skeletal fixation, whether it be for IOLs, CTRs or capsule retention segments. Finally, we have the double-flange Yamani technique, which many of us have adopted in order to fixate patients who fixate lenses that don't have capsule bags. So I just wanted to highlight that, this polypropylene technique has been something that's evolved over the last several years, primarily since Shin described his double-flange technique kind of Brava, McKabe, Mahler, et al. Many have actually described using polypropylene suture and flanging it for skeletal fixation. Recently in JCRS, last a couple of years ago, there was a nice series by Ehuda Asia on the 6-0 polypropylene flange technique. There's a part one and a part two series. I encourage you guys to read it. It's his case series, talking about the outcomes of his particular population, but also goes into some of the fundamentals of how to use 6-0 polypropylene suture. So now I'm gonna just switch to a different screen here. Just this video is gonna be better suited. So now I'm gonna let this play. This is a patient probably, I wanna say around mid-70s to late-70s with a spontaneously dislocated IOL. I'm using an optical marker here, or sorry, a Mendez ring in order to mark the visual access. This is prior to dilation or maybe the patient received one set of drops but wasn't dilating very well. Another clue that this is likely related to suit explanation. I can't see the video, Dr. Chaya. Oh, okay, let me see. It's still on the original one. Okay, let me just get out of this. Let me share it again. Is that better? Yeah, we can see it. Okay, so this is a Mendez ring that I'm using to mark the visual access and I'm gonna mark my zero and 180 but I still don't know exactly how this lens was oriented in terms of where the haptic-optic junction is. This patient actually just a little bit more feedback about this is actually a patient who has a prior bleb. I mistakenly forgot to add that as part of the history. You can see he has a shallow bleb here superiorly. So a patient with known suit explanation who had a bleb, existing bleb with a spontaneous dislocation of his eye well. So this galactic is injected. I'm gonna make my main incision and then in a little bit we'll place some iris hooks just to understand. I knew that the lens was not a toric lens. So I wasn't as concerned about having to maintain the orientation to maintain the astigmatism correction. So my plan was to fixate the lens at the horizontal meridian in order to avoid trauma to the blood. And so what we're gonna do here is after we create our incisions I'm gonna just advance this a little bit. We're gonna place our iris hooks in order to be able to locate the haptic-optic junction. So I don't think there's anything wrong with using ML. You can ring in this instance if I do like iris hooks just to be able to sequentially move them where I need them. And sometimes I don't need all four. Sometimes I just need to have enough exposure to be able to see where the haptics are. So maybe I'll just pause here for a moment and then just open it up to the group again about what would their preferred technique be for suturing a capsular bag IOL complex here. Or if you would even maintain this lens. Certainly there's a good argument to say why not just remove the entire bag and start all over with the Yamani technique or another scleral fixation technique of choice. Hey, Craig, it's Randy again. I mean, it's been a while since I was actively surgically engaged but I used to lead these and would suture my making sure that I last through the haptics in the bag and suture the bag haptic complex and bring it back in under a little Poffman pocket so that the sutures were hidden down and I follow those patients for, I've now got some 10, 15 years, they were very stable. I used to use Nino polypropylene but we know even that sometimes will degrade. So I think the Teflon would also work but I don't see many people doing that anymore but I thought it was quite effective and it minimized the amount of surgery needed because you just had to place the sutures and I know people complain how hard it is sometimes to get those sutures through the capsule and some secondary cataracts. So I would always put a sharp needle from the outside and they use my suture needle against that sharp opening so that you could between the two control exactly where the capsule was and pass then the needle through the capsule underneath the haptic and then into the opening of the needle and bring it out inside of a Hoffman pocket and you just had to do the other one as well and that last suited and brought it in in good position. So an old technique, I know I don't hear many people talking about it anymore but certainly the patients that I'm so following that I've seen, they look good and stable, so. Right, yeah, as Dr. Hoffman, you alluded to this Hoffman pocket technique but those of you that don't know what a Hoffman pocket is, essentially you're making a limbo groove and then dissecting posteriorly with a crescent blade back to make a pocket. Then as you suture your complex, those sutures are passing through the pocket and you'll use a snare either a kuklin hook or micro forceps in order to be able to externalize the sutures on top of the cornea where you'll tie your knots and then advance them down into the pocket. So the advantage of a Hoffman pocket is it allows you to not have to create a pyrimony and to be able to bury the knots of the sutures easily. Others, I'll go ahead and let the video play here. Again, we're identifying, so my video is frozen, give me just a second. And so here you can see that the haptic bulb is here and so I have a good sense now of where this haptic optic junction is but because I mentioned that this patient had a superior bled, I'm prepared to have to rotate the entire bag complex. We're performing a limited anterior tractomy here just to make sure there's no vitreous in the anterior chamber, a little bit of vitreous stain just to look as well. And then just to ensure that there's nothing in trapping the complex. Now I'm gonna grab the edge of the capsule in order to bring it back towards the center. I'll use a push pull here as well. And here I can see the other location of the haptic optic junction. And I brought that up above the iris plane in order to just secure it a little bit. And then I'll reposition the iris hooks, actually trying to get this in the capsule itself to hold it in place, but it's not very successful. The capsule is quite fibrotic and I just don't have enough space there in that location. Putting viscoelastic behind the lens in order to give me a little bit of safety in case the whole lens complex wants to drift Replace the iris hooks and now I'm gonna be marking the sclerotomies in the horizontal meridian. My first anterior most sclerotomy is roughly two millimeters from the end of the blue-gray zone. And then the second sclerotomy marking is three and a half millimeters back from the blue-gray zone. Then we'll cut a piece of suture off, a 6.0 proline. We don't need a needle for the needle on the suture for this. We're just simply gonna place it in the eye and dock it into these needles. I'm bending the thin-walled 30-gauge needle. This is the same one that we use for the Yamani technique. Then the suture is placed in the eye. I'm an opposite paracentesis. This patient's having a little bit of difficulty, so we'll do just, I think, a cut down here in order to give him a subtenon's injection. So I like to make the first pass posteriorly, so I'm cradling the lens from posteriorly. Just in case the lens wants to drop back, I have an option to levitate. So I'm gonna go perpendicular to the sclera and then flatten off. Then I'm gonna locate where the haptic optic junction is and with counter traction, you use a micro forcepsin in order to puncture through the haptic optic junction. The 6.0 proline suture is then docked into the needle and then externalized. I think what's important here though is as you externalize the needle, you do still have to maintain some counter on the lens. Otherwise you could just continue to tear off more zonules. So a little bit of gentle counter traction there. And then that suture is externalized and then flanged. Now personally, I prefer a larger flange just to make sure that those flanges are visible but flush with the sclera and definitely buried underneath the conging type of antenons as well, ideally. And the other end of the suture is then folded on itself and brought back into the same paracentesis. And then we'll go through the anterior most sclerotomy here with the same needle. Perpendicular to the sclera as soon as you puncture through then you can level off and then docking that suture into the needle. So this needle has not passed through. It's simply just in the sulcus space above the eye wall complex and then we'll remove the other end of the loop. So that's one end of the complex and we'll repeat the same thing on the opposite side. Again, folding over, docking the anterior most. One of the advantages I like about this technique is rather than simply lassoing around the haptic where there could be a risk of having the suture slide off the haptic as it cheese wires through the back complex. This is very secure. You're going through the actual lens material itself through the haptic optic junction. And then here you can adjust the tension on both ends of the suture in order to get the eye wall back complex as close to the center as possible. And I will flange the anterior most at the very end and adjust. And what I'm looking for is kind of a snap Mac sign that as I put tension on the suture and here I'm constantly just adjusting and trimming. And I do this multiple times to in order to get the right tension that I need. Here we'll make sure that that's buried underneath and then we'll do the same thing to the opposite side. I haven't figured, this is really just more art than anything and just a feel for how much suture you need to trim off. There is a theoretical risk that you could pull the polypropylene too hard and actually cheese wire through the haptic optic junction. But I think it's a lot tougher to do with 6-0 protein. I actually feel like it's more likely to happen with a thinner caliber suture where you can actually cheese wire through the lens material. But 6-0 protein is quite sturdy. And there we've done our double flanges for both sides. And then we're now removing our iris hooks. A little bit of anti-retractomy at the end just to make sure there's nothing that has prolapsed. We'll suture the incision and then the case is completed here. So in summary, the 6-0 protein technique, polypropylene flange technique has been used in a variety of techniques not only to fixate an Iowa bag complex. It's been used for capsular tension rings or capsular tension segments. It's also been used in iris reconstruction for urinalysis repair cycle analysis class. And also I've been using the same similar technique, the 6-0 polypropylene flange technique for iris prostheses as well. So a very versatile technique. Are there some issues or some cases where maybe I wouldn't want to use this technique? I think patients, if they're very astute, they may notice the small blue rivets above the sclera. And for some patients that could be cosmetically unacceptable for patients. And so maybe EPTFE or Gortix suture would be more appropriate for those patients where hiding the suture color would be most important. Now, I have found that these are very small flanges. I don't want to give you the impression that these are like massive blue dots on the sclera that are noticeable across the room. You really have to get close. And I think even with a slip, I have to be able to see them in detail. But these are things that need to be followed over time. Liliana had a nice editorial a while back talking about some of the complications that can occur with this flange technique. And one of them is conjunctival erosion and nebulomitis. So I do think it's important to be meticulous and how you flange these. I do think that a little bit tighter to get that snap back sign where you see the flange pulling back into the sclera is essential to keep these flanges from eroding through the overlying conjunctiva. But overall, since I've used this technique in the last six years for a variety of techniques, both for Marr fans work and Irish reconstruction, I have not seen any conjunctival erosions at all. But I do think that you need to be prepared to address those as they come and make sure patients are aware that if they notice any injection, form body sensation, irritation that they be evaluated promptly in order to make sure that that complication is not occurring. Thank you for your time. I'm happy to entertain any questions or discuss this technique further or other techniques.