 We are going to go ahead and get started. I'm not entirely sure how long it will take to set the computer up. I hope not long because I don't really have a lot to say. But first of all, I'd like to welcome you all out to our patient grand rounds. I can tell by the size of the audience that having Alan Crandall on the docket is a big draw, whether he wants to admit it or not. I was actually a little nervous as we were, I didn't see him for the first couple of minutes. Unfortunately, he was stuck in a meeting upstairs. And if you know Alan, you know he was actually stuck because he would never be in a meeting by his own choice. Anyway, I thought I was going to have to get up and present and I felt really, really bad because that's kind of the old bait and switch, you know, you tell someone to come in for something really spectacular and then you switch it to something completely pedestrian like my talk. So the point of all is this is really to foster discussion. So please at any point raise your hand, ask questions. He'll be presenting some cases. I, this last week, had the opportunity to spend a week with Alan and Guatemala and I must say it was one of the true gems of my entire, both honestly personal life and also professional life. He's someone I look up to. He's still the person that I go to with any strange questions. And in Guatemala, where about 20 to 25 percent of the patients had pseudo-exfoliation in addition to their white cataracts, it was really nice to have him there to sort of help us along. So without further ado, Alan Crandall, and thank you all for coming. Very good. So I thought I'd start off sort of with a few basics. Whenever you give me these kind of talks, you should also mention your potential conflicts. Can you guys hear me? Okay, potential conflicts. Most of these don't relate to this discussion today, but it is something you have to consider. So I thought we'd talk a little bit about some of the sort of common things that we see in practice. And also, it depends on how weird we want to get. I have a few extra cases that I'd like some input from everybody as well. So when we're talking about this type of stuff, we need to look about things like what are the support devices that we have available? Iris hooks, which have been around a long time. There it is. I like the McCull hooks, but lately I've been using the MST hooks more frequently than before. The Mortar hooks. I'm happy to say that we're testing a new device. Is Bala here? Bala's redesigned. He's not here. He's redesigned a device that is similar to the Ahmed segment but has two holes. It's a little bit longer. Has two hooks that come above. And actually may be quite useful for some of these more challenging cases. There are contradictions for the use of CTRs. Of course, there's the anterior-capsular-terra, posterior-capsular-rent, unless you can convert it to a posterior-circular-full-capsular-terra-rexis, but we can do that. One of the questions we often get is when do you put in CTRs? One of our faculty, of course, is Ken Rosenthal of New York City, and he was the first to make a statement, I think, as late as you can, but as early as you need to. We've done lots of Miyake view studies here looking at the reasons for doing that, but basically, if you do it prior to paper, you do have better nuclear stability, but it does make it very difficult with the dense nuclei. I have a case that I went to show from yesterday, which is not edited, but shows a couple interesting things about dealing with those type of decisions. And it also makes cortical removal heart more difficult, so if you can do it after fake, it's a much better device. And remember the theory behind them. I use the biggest one I can have available. So if you have a very short eye, use a short one. Otherwise, just use the 14-sized C, so the eyelids overlap. That's the best. And they do help both early and late lens rotation, centration, and it's designed to maintain the contour in the face of these zonular weakness. And I'm not just presenting here to a group. This is all our partners. I'm just trying to get everybody to stop, and if they disagree or want to further some point, everybody in the audience, please pop up. Randy? So the one thing I'm seeing with CTRs, and I think I'll go around, you're seeing a lot of stories of them now. You have a place centered with CTRs in the capsule bag and the IOL exposure is so big. Yeah, I think it's a good point, because that's why with pseudo-exfoliation, for example, it's a generalized zonulopathy and you are not stopping the disease process. In fact, it helps center. There's lots of times when the CTR does make a lot of sense. I don't have a picture of Bala's new product. I've just used it in a couple of cases, and it's been very helpful. It's similar to Ike's thing except it has, instead of the islet being just here, it has another islet over here trying to get a mortuary to kind of raise the islet. So it's a little bit easier to use, but it's going to be another nice addition. And you can use those. I like to use temporarily as a supporter for the bag while you do your case. And then a lot of times you can do the ufaco, and then if, like you say, Randy, things are all loose, then I'll often do iris fixation or whatever. But if the bag is not usable or it's already loose, then you shouldn't just put in a CTR. You can use those, of course, to suture them to the sclera. And we're doing a lot of that. The MST hooks are very nice for those that haven't used them. I like them a lot better than... This is the McCool hook, which is definitely better than iris hooks, because the iris hooks are not designed for the bag, and they often have... Here is a little bit sharp, and you can pop a capsule with it. So you can use it occasionally. I'll use those for when I'm doing a Marfan syndrome, for example, to help move the lens while you're doing the case so that you can actually complete your rexis. But these are much better for that. And I like these a lot, and you can bend them very easily to kind of help you with the device. Now, one of the things I want to emphasize, one of the things I'm doing differently this year, what are the six things I do differently for suit exfoliation than last year? Well, one of them is to make sure we're doing a lot more... I'm using lens epithelial removers on all of those cases. It doesn't help with PCO. Aliyo Study in Spain showed that, but it definitely did help in their subgroup, and I've seen it in mine, decreasing capsule primosus, which we hope five or six years from now may make it... may have less, you know, less... let's say, late dislocations, but we won't know that for a long time. And then the other thing is to make sure I do bimanual rotation of the nucleus to decrease zonular stress. Again, studies that Liliana and I did showing how much zonular stress on the zonules occurs. If you use bimanual, you'll just make sure that the rotation that you're within the capsule bag and that there's no movement of the lens. It sometimes helps to debulk a little bit when you do that, and then you can use bisco dissection to further release pressure on the zonules and make the rotation a much more elegant technique for your removal. We're working with a couple companies to get a little bit nicer design. Mastel is making a really nice one. It's really designed to go in easier. And it's surprising when you look at how many cells we leave behind with the present technique. Nick, you want to comment on that? There's some studies with the group. Yeah, we're designing one a little. I think that fits the bag a little better rather than these that are all one-sided. It should go out a little further. When you're putting in a CTR, first of all, I think the new one from Mortu is a really nice way to do it. It makes it very easy. They come in L and R, and don't remember the L and R. The L and R is not for left eyes and right eyes. It's for how it comes out of the shooter. So what you want to do when you're putting devices in, if you have a generalized zonuleopathy, it doesn't matter. If you have a weakness here, then you would want to use the good zonules in order to help it go around. If you put it into the bad side, it can sometimes tear out further and sometimes won't go around. The other thing to do is you can rotate this tip a little bit towards that side to get it started. Sometimes you can even use a Sinsky hook to get the bend to start. Another good trick is to put a 10.09 on the shooter through there and you can actually drag it around if they're really weak, if you need that support early on in a case. This is a modification that I think is really... This is one of the other things that we're definitely doing now. We've all seen this. This is sort of a modified version of a beautiful video that Liliana did. I think it's critical to think about this when we're doing our surgeries. When you are doing... I've been obviously teaching the wrong way for 25 years, but if you look up here, this is a beautiful view. This... There's no... This is a cortex only. Now watch as you go away. Stress on your here, no stress, no stress, no stress. What's the point? You don't... There are a couple of things you don't do. One is as little radial aspirations as you possibly can. You can see there's cellular stress. And the other thing is the bouncing motion that we frequently do is a wasted maneuver. It doesn't do anything. The best way to do it is to do a tangential rotation. So again here at high mag, you can see there's annular stress. This is the cortex only not holding on to the bag itself. So again, you see as you go away from the area here, here's your zonular stress. As you go away, there's no stress on the zonular. So here's a good view of the radial view of that. And you just watch as you go around. The other thing is that if you do this correctly, you can go all the way around in one or two moves and it saves you quite a bit of time going to the center and back, to the center and back. And the subincision was a little bit trickier, but we're working on ways of doing that. But the trick is being at the top of the rexis, not inside the bag and pulling tangentially. Just show a few cases. These are in the OR. I usually like to start out this side over here and then you just kind of keep it in... You see, you don't need a lot of vacuum, you just keep it occluded and it'll go around and it saves you probably, I don't know, quite a bit of time. Everything flows very easily because you're interned. This is the other thing that I'm doing more on every case is making sure that I have a corneal marker so that I know my rexis size. So I have usually a 575 that if I have a pseudo-exfoliation, I might want to go a little bigger in that to decrease the stress if I have a really hard cataract, a little bit bigger than that type of stuff, so you can do that. Then you get the lens epithelial cell removals afterwards. So here again is another case. Again, keeping the tip, it doesn't matter whether you have a straight tip or a curved tip, just use yesterday the new MST single use things which we may be using more and more if we're going to run into the issues with sterilization that we have. You can see you don't need to make any movement to the center of the pulling so there's no zonular stress. And teach yourself to do this on all your easy cases so you do it every single time on something case where it is mandatory which is any case that you have pseudo-exfoliation cases. Nick, you guys want to comment on... Liliana, are you here? Do you want to comment on any of those? Right. It's a beautiful video and it's been translated into how many different languages. Yep. And let's see, a little bit... I want to skip down a couple of these to pseudo-exfoliation. So in pseudo-exfoliation which we see here, by the way, I was... We had a beautiful trip and our team did a great job. It was shocking to see the amount of pathology in Guatemala and one of the most interesting things to me is once again, we go to some place we've never been and all of the Mayan background, we had 70% of our patients had pseudo-exfoliation. 70. Chey and I sit down, 10 of the first 15 each of us did that first day, we were going, oh my God, you're kidding me. Just like our first trip to Ethiopia. You're just going, oh, what the hell is this? Yes. Yep. So remember, the small pupil and pseudo-exfoliation is really a marker for the possibility of a zone of weakness. This is particularly true when you go into like Ethiopia and other places like that. And it's... In that setting, it's probably... I think it's better to convert to an SICS in those areas because we don't have all the devices. Jeff, do you want to come in on that? SICS. So if you're doing a pseudo-exfoliation, immediately look for wrinkly into the capsule, it gives you a clue that there's a zone of weakness. I still think every case you should do, you should do it as elegantly as you can and you train yourself, obviously to do that for the resident standpoint in every single case. And don't be afraid to use a dye, particularly in pseudo-exfoliation that makes it a lot easier to see the different cases or the different areas that are weak. Cortical cleaving is really nice to do. I don't do hydro-delineation in pseudo-exfoliation because I think it makes the rotation more difficult and it makes the INA tends to be a little bit more difficult. Do you want to minimize your zoning or stress when you're doing these? If you're going to use a divide-and-conquer technique, make sure that you use enough power so that the nucleus itself does not move. Take off less tissue as you go, use more power, make all those deals. Pre-chop is really good and this is one thing that's going to be interesting to see, but I think the femtosecond laser may have some value in these kind of cases because one, you get a good rexess and two, it softens it up so it may decrease the amount of zoning or stress. It's interesting to see I hope we'll be doing some studies where we'll be able to kind of evaluate that as the time goes on and vertical chopping in smaller pupils. Nowadays, and one of the things I'm going to talk about at the Academy is it's silly I remember giving courses 20 years ago and I know you did too, Randy, on how to do a FACO through a 1mm cataract. You can do it. There's no issue with that. We can do that, but it's silly to do that when we have devices now that will allow us to expand the pupil because what happens when you do the small pupil FACO, you can't get all the cortex out. You don't get all the cortex out. I don't think. There's no reason not to expand your pupil big enough so you can do the axis, big enough so you can see the cortex and then you can see this weakness if you get into that type of deal. And then the other thing is definitely do not do tangential cortical removing on this. Here's just a case. This is a case I knew that had the lens was moving prior to surgery so I knew it. You don't need to watch the whole thing, but the point is stain. You can see the nucleus move as the rexus start the rexus and you can see as you're doing around you can watch the in front of the rexus, you look out here and you'll see wrinkling and that wrinkling when it goes around is a suggestion that you have zonular weakness in that area. So once you get a good rexus then you can do a number of things. But in this case do viscodes section to create some space and then I'm going to use Ahmed segments in both areas because then you have an anchor on both sides that allows you to do that. So you just simply put in one segment. Yeah. Not really, I like to use the question is dispersive versus cohesive, correct? So in that case I generally use a cohesive because I can create a little bit more space and I like I don't want but I don't want a Helan GV. I mean Helan 5 I don't want for sure because it's impossible to really get it out of the way. So here you can see you have two anchors. Randy or Nick you guys want to anybody comment on their choice of viscoelastics during that? Those are different opinions. Right. Yeah. Yeah. Yeah, so don't you know any of the any of the Provis, Helan, Helan GV is probably okay. Then you can see this turns it into now this Randy is a case where I agree with you 100%. This is a loose on your case. So at the end what I'm not I could put a CTR in or you could put things in that would work but I didn't feel like that was enough. So in this case I go ahead and put in I do an iris iris fixation bag put the optic in the bag but iris fixate the eye well because I think that's a good that's a good point in that person. Yeah. Yeah. Yeah. So you don't do that. Now this is this I found was an interesting case. Obviously this is a pseudo affiliation case. And because you see I marked it this is going to be a it was going to be a toy cleanse. And there was no zonular issues beforehand. I watch as I do this. I didn't believe it. I go what? I go oh crud. Game plan. So this is game plan B. So we got about 180. Now the reason I want to show this is if you have a now you can ring in you cannot do some of the manipulations. You can't bring nuclear pieces up as easily. So take them out and in this case it's much easier to convert to a more standard type of iris and you can get further out on those. So in this case I'll fortunately the the zonular weakness was only in 180 degrees. So I just put a ring in with a CTR and iris fixated. So that's an this again shows I love to show this video. This is a fantastic day. Nick and Leon and I in the OR. You see nothing moving with the ultra chopper which is a really good thing but I want you to get to the one case that changed the way I do FACO in pseudo exfoliation patients because we saw this occur now I want you to see this is a pseudo exfoliation case. You can tell it's a cell rexis. The zonules look a little weak but as you look through here when we get to this rotational motion look at that. So what's the most dangerous thing that I've been doing incorrectly all this time? Rotation. That's why I do them by manual. That's why I'm putting pseudo acts. Why I'm not rotating if there's any hint that it doesn't spin absolutely beautifully. Debulk it bring the hemisections up technique or whatever but decrease your rotations with pseudo exfoliation and there's a 360 zonulopathy so you could say well you could rotate toward that and use the good zonules. There are no good zonules and I think that I have been causing some of these late dislocations because I've been small rexis not getting out of the cortex not removing the lens epithelial cells and doing what I thought was nice rotation but not good rotation. Comments you guys? Yeah absolutely. So just one more for those you know since we now have the new centurion the centurion has two ports one where you can leave an ultra chopper on and you don't need to take it out and transform it so this is a white this is a cataract. You can see here that you get a nice rexis size 5 don't get a small rexis on these cases and then what I'm going to do here is I'll use the ultra chopper to thin it out or not to thin it out but to debulk as well as allow me to break it so you'll be able to use these with the centurion you can use it with any of the alkan units anywhere I used it both in Guatemala and a lot in Tanzania and Ethiopia we didn't have different places we do but as you rotate again you debulk a little bit make sure the rotations are very nice I won't bore you with the rest of these you can see here that get to a nice number quadrants and you can develop a little thinner pre chopper so you can get the open easily make sure that you have a crack all the way down before you do anything because if the bottom fibers are really tight it's very difficult to get those pieces out and then make sure you change your standard you got to make sure you're using a burst mode or a mode that's more effective in making sure that you have an efficient way of debulking use and no problem with don't ever come out of the eye without filling the bag with Bisco elastic first so if you're going to come out you want to change anything around so the second sixth thing I do differently with Sudo X is I never come out of the eye without filling the eye with something beforehand because the bag is going backwards and forwards and I think you have a good chance of decreasing the problems then on the last piece decrease your flow rate here I've got a slow you know 33 aspiration things that want to have happen on the last quadrant decrease that to 20 or 25 so that you have good control of the pieces and I'll often change the amount of time on 90 milliseconds average sometimes 110 gives you a little bit more of a stroke pattern and Randy can probably talk more about this the efficiency of different on-off patterns on that you want to go ahead and say anything about well there's a whole series of work and right now the way the centurions set up for that point it's a 30 pulse per second on-off with about six seconds on you can obviously alter that based on what you want so trauma if you're doing traumatic cases if you see six millimeter or six zonules you add two on each side because they're probably weak out there and you can use these beautiful devices the again those were MST hooks they allow you to do lots of different things I did want to show one other one other interesting case this is just using not this one so I want to present this case this was an interesting case this patient was referred down from Idaho what had happened was the surgeon had planned on doing a PECO I step this is a case of pseudo exfoliation not self exfoliation I still don't know the problem but he had bilateral zonules so when the surgeon started the case the lens moved and he decided he didn't know how to finish that so he just sent him down this is actually the second eye the first eye was more interesting and so you'll see here as I just go in here in this case the femtosecond I have a great video to show that the first eye I thought I could use it to chop it but the lens moved so I had to abort the lens X portion of it because you don't know how far down it could have gone out but it does the rexis so it does a beautiful rexis in these kind of cases you can also de-center it for your Marfan's cases so you get it widely dilated de-center the nucleus then you can set it down to four millimeters three and a half, four millimeters, whatever you want to have and so this is post lens X and you'll see here so I've moved him back into the OR let's get the thing going there we go so just to show you what what that allowed is the rexis is often one of the most difficult things to do in these cases and so here you'll watch the as I put the viscoelastic and you'll see the chamber you'll see the lens move back so you really should not totally out of out of the difficulty here but even here I still very careful not to pull central because you want to make sure that you have a free floating one so you can do the necessary devices and so in this case because I'm going to end up doing a trap at the end of this but I don't remember whether to do a straight trap or whatever but these are good times to have those MST hooks available in these other cases because these are kind of difficult to do otherwise let me just move ahead just to show you sort of as we get going so here using the MST hooks again putting those in allows you to really basically do the same case you have to watch your flows because remember the bag is relatively free well it's not relatively free it is free and in this case at the end I did two Ahmed segments to the sclera because I was going to do glaucoma surgery so I have one case that I wanted to show from yesterday to show you how to screw up so this is turned out okay but it was well actually let me show this one this one I would have I would have that's the end so this is this is the wrong guy sorry I'm sorry that was another one from yesterday where did the other one go it's a very interesting case that I thought would be kind of interesting to discuss where is he, does anybody see it talk amongst yourselves say something while I look for this damn case we haven't been doing that a lot till recently and I've seen a few but not all Nick you want to discuss that I think it's still here I'll find it in a second let me just show you this so this is I thought this was an interesting case because this is a one-eyed gentleman who has end stage not end stage but glaucoma he was referred down and of course he was as you might guess a little bit nervous and so they waited until the case was a fairly hard rock so I just this is unfortunately this was yesterday afternoon so I haven't had a chance to edit it now you say that's a great pupil but this is a very hard cataract so what I'm going to do here is I'm going to use a Mayugan because I want to make sure that I have a bigger enough space now that's great but the problem was I should have used the 7.25 Mayugan so what I ended up doing was I had to cut this out to really bring some of those pieces through towards the end of the case so I get a fairly nice Rexus there and then I'm going to do the ultra chopper and then I'm going to bi-manually rotate with the ultra chopper to make sure that there's no zonules so this part's good so I taught myself something we'll get through to the I'm going to go to the very end and you see I get a really nice crack and so I think this is great able to bring these pieces forward but in actual fact what I hadn't done is I hadn't gotten all of the fibers in the very back to debulk a little bit more to get this to come out and I want to go to the very end because the rest of it is just a piece of cake but you see here I'm struggling to get this through out these pieces these pieces are large pieces and I want to make sure that I don't flip or bring them forward so they're still on the attachment posterior to that so then I end up at the ultimately you see dislocating this piece at this point you just got to stop come out and I'll cut that cut that out take it out of the eye so then I can complete the whole thing so I should have used a 7-2 or it probably I may have been okay without it because the so make sure when you're coming out don't try to pull it out in your normal technique because it'll move things all around and then the rest of the case was relatively simple and the new machine is very efficient on this type of device it's like we have time for one quick thing I still can't find that one I just wanted to know what everybody else would do with this gentleman's eye any questions or comments before I yes we don't know we'll know that the next time around these were this was the first time in that region it's a region of 800,000 people they have one ophthalmologist for 800,000 and all of the Mayan subgroup that we saw which you know mixed between Spanish and Mayan those the ones that we saw were in fact pseudo-acts and many of them very very very rock hard eyes we didn't have any complications by the way those of you that saw the Sunday Meet the Press the numbers they gave were in fact correct our team did 200 and I'm not a mathematician but I might be wrong but I don't think that 10 means dozens they said Dr. Paul did dozens cases 10 was dozens okay I cannot I just have to make that statement but we did do 200 and we had a really successful trip and we'll be going back there more often and I promise I had that video somewhere and it's hidden because it churns down it's a very interesting case I'll show it some other time so any since almost time for clinic any questions or comments I think that these are kind of cases you have to think in advance but if you train yourself to do the correct thing on the easy cases then you can deal with the hard ones from the resident standpoint that's why we bitch and moan about hand position, foot position and understanding everything that you're trying to do because if you don't do it well on these ones you'll never be able to do anything on these more difficult cases so just watch carefully for the second year residents let me make a suggestion go to the OR and don't look at the video watch how they're holding their instruments don't even look at the video you know what the fakle tip is doing it's moving one millimeter you want to know how that person is getting their control of the hand piece and the chamber depth and all other stuff watch their hands don't watch the fakle I don't want to do an advertising of that big thumb that comes out and Larry lacks sorry I was a little disorganized I didn't know I was doing this till last night I didn't organize it this morning sorry thank you guys Jeff I gave you some props were you here when I said talk about it thanks have you actually used it yeah it's going to be yeah could you sell it no I did how can we do more with that patient having a choice so looking at systemic associated disorders so elastic disorders what are you talking about so you realize this is a totally agreeable