 Welcome to Grand Rounds. Today our presenter is Dr. Alan Crandall who really needs no introduction. The topic is going to be from bench to practice. Good morning everyone. Actually you'll see why I call it from bench to practice, which is really our work that we do here with the people that probably teach me the most and that's Liliana and Nick in the laboratory and how we use data and questions that they have that we try to answer and then hopefully put it into some type of clinical practice. I also wanted to touch on one of the things that we tend to do or like to do is to be on the forefront, see what's going on, and change our techniques as more information becomes available. Nothing that this should be, most of this is not a conflict but I think we should see it. Most of these would be Alcon videos but of course I do AMO and the other videos as well and for the Guacoma stuff you'll see something that's included. So what's new and what do we do this last two years that's different from what I did a few years ago and why might we do it and why might it be BS we'll see and I want anybody that has a question the point of this lecture is to maybe bring up some topics, get some points of views about one of these and I'm actually going to start with the bottom one because I'm doing this now I've been doing it for two years and my reasoning behind it was based on OMIC data two years ago and what they found two years ago was that 38% of end ophthalmitis was MRSA which is kind of a scary and this is not hospital based MRSA, this is community based MRSA which means in actual fact that almost none of the antibiotics that we're using really covers it very well and based on that Doug Koch did a bunch of laboratory studies and out of that he came out with the concept that he should be using intracamal vancomycin at the end of every case where he looked at it in rabbits and all sorts of stuff and looked at toxicity with Henry Edelhauser and the ASCRS group and looked at potential toxicities such as retinal or corneal and in the dose that we're using there's really not much one thing that he's doing a little bit differently this year anybody that has glaucoma I haven't had this problem but he did see a number of patients that had pressure spikes using the vancomycin and so in those patients he uses bigomox right out of the bottle and bigomox doesn't have a great coverage for MRSA but it covers it pretty well so in a lot of people throw vancoin or any antibiotic in their bottle infusion bottle but that's really been shown to one not reach high levels and two isn't around very long time the intracamal injection some people have been doing it for years Jim Gills for example puts in a whole form of copia at the end of the case they've been doing different drugs in there's been doing that for a long time but has no data to support it no research but certainly I think this is a concept that we should be looking at fortunately enorphomize doesn't occur very often so as I mentioned I've been doing it here for about two years it took us a while to get through the pharmacy committee here but they finally agreed to do it so it is available and if you want to use bigomox you can just do it right out of the bottle bigomox does not have a preservative and that's the issue with intracamal so I think it's something to consider as I say MRSA is really climbing on the scale and it's nice to have it at the end of the case I was hoping Nick would be here because I think he did somewhere but Randy you might have some comments on that there's a stake in this to either argue with me or or whatever so Randy really any reason that's where that's where the OMAC data came from that Doug Cope was looking at apparently has a pretty high no sense at all that's what we've been doing and if you want to use the bigomox I don't know if FDA well all these are off-label anyway so it doesn't make any difference right now that was the biggest issue that I had to deal with with the pharmaceutical committee here the infectious disease guys they went through all the evidence based literature and there's no way with a small dose a single dose like this that you have any effect on it you just kill what's in the eye but we're not even touching we're not anywhere near that it actually took almost six months for us to get the pharmacy committee to allow us to do this there have been a lot on the chat line lately with that issue and there's still tons of people that are putting Banco and seproxamine and all that into the into their bottle and it's essentially nothing right that's the big issue so ours are made up by our pharmacy in the morning and in the afternoon each time so it's just something to think about okay yeah forty dollars per case yeah we're not that's the charge that pharmacy is given it doesn't cost anywhere near that you know I mean it's very very cheap molecule now let me ask you how many of your patients use it correctly pretty low it's pretty low you'd be surprised in studies certainly we probably have a better population than most but some of the studies done show that at least fifty percent don't even use it after day one and you know they forget if they lose it they don't use it we don't need it most of the time and so it's just it's a question of some of this is you know certainly to avoid litiginous issues for a very low incidence so that's why I bring it up the issue is there's cost issue there's a some people now are not given topical antibiotics they're just using intracameral stuff and they're not doing it and there's a couple I think Barbara was at the meeting well Randy we and you and I did one with one of those studies where we had the steroids now they have a capsule that you can put it at the end of the case and you get two weeks worth of released antibiotic that's in phase one studies now which means we'll see it in about eight years the reason it's sweet is because it's cheap now cheap actually yeah it's not Doug did compare those two in the MRSA case correct and then of course we all know the tough cases that we encounter why we need some of these new tools and of course here it's PXE PXE just a quick reminder we've done some Miyake views looking at the use of caps or tension rings I wanted to bring that up we have Miyake studies looking at the use of the OMED or the caps or tension segment in broken capsules and why you sometimes need it for stabilizing those types of cases and then some modified seonies I want to bring up a couple of the new things that are involved in CTRs so that everybody's aware of them as you know we use CTS's intravenously to support and I do believe I have a case for that then everybody may be aware of these but we have both sets available they're really critically in some of these cases the MST hooks are the two on the left I don't have a plan this is the MST so it's designed to fit in the capsule and the difference between these and the iris hooks sometimes I use iris hooks when I'm doing the capsule rexis because it can do support but it really they have a rough edge compared to these things and they can actually tear capsules they give you more of a point fixation so this is the McCool hook which has a little knob on it which is really machined nicely a Gucci Gawa I can't pronounce it correctly it's probably a better design but it's very difficult to get you have to go you have to send your money to Japan before you get they won't even send it to you you have to have a personal account with them they're kind of strange so I've been using mostly the MST's I'm very happy with those now this is a video that should have won the Academy Awards at ASCRS but it didn't a Liliana did it so this is the hurricane technique so for 20 years we used to teach that you'd strip to the center when you do I&A except when so the question is if you're doing it for all the tough cases shouldn't you really be doing it for all your cases and I think the answer to that is yes so that you see who this is this is not me obviously I don't use the metal things I don't think they're good because they don't form to the wound so you don't get as good a flow so we're going to call this the hurricane technique for I&A and I now have a lot of people that are doing that why are we thinking about doing that so this is some work that Liliana did with the guys from Brazil and why don't you look at the zonules up here we have more stress on the zonules when you strip centrally and you'll see when we do it tangentially how much difference it makes now if you can even really see it here since this is sort of a tangential strip on this side there's less zonular stress so anytime you have pseudo exfoliation which was what the parolibus a third of our cases or a quarter of our cases we should not be doing any stripping to the center we should be stripping tangentially you can really see that how much difference there is here in this beautiful view of this that again Liliana did with the folks and I've been doing this for about two years but this is the first time it's been done in bench work that really shows the stripping what it does centrally so now I certainly try as much as I can to not do central stripping and the other thing is incredibly more efficient technique you can usually do it in one motion all the way around cut down my flows to less than probably five it's about 15 seconds to do most of the INAs now and about we've been measuring some of the amounts that we use and it's really as much more efficient way of doing it so and you can see that it's much kinder to the system we've always taught that you do it on the tough cases why don't you do it on all your regular cases and we'll see in about eight years whether or not we get less of a of a late subluxation so this is radial again you can just see this is a technique that we that I actually taught for 20 years and stopped about two years ago because it really when you look at it in the laboratory it doesn't as much sense so sometimes you have to do a little bit if it's the last piece or whatever we'll show some examples and it doesn't matter what kind of INA here's this is a regular you saw there was a metal one bent one you can use it with a straight one you can use it with any of the systems you have but you'll see here how much more efficient it is as you go around you can do the whole thing basically in one maneuver and Liliana I do not understand why this one did not win I know but it should have wanted it should have wanted to ask you I know it won the real what the Brazil award at one international medium award yeah it's just a beautiful video really showing that and again so from seeing this this further made me think more and more that you gotta be able and I just put this this is the guys that came up from Brazil and did this this is some older work that we that we did you can tell from the video but it's still as valid one of the things is that it's not a free pass when you put in a you put in a CTR you gotta know where it's best you know where the where the defect is and use the good zonules to do that and here's you can see here that when you it's you want to be as gentle as you can the CTR M and wherever you can try to identify where the where the defects are so you can use the good zonules to help you put them in and I think you may have seen this before but I think this is one thing that certainly has changed how I how I remove fake or how I do remove pseudo exfoliations with where the zone where there's any issues or look at that look at that right up there so the most dangerous thing that you can do many of these pseudo exfoliation cases is actually the rotational motion it's and we've done this with this even with normalized now the reason we do we have a small rexus here and actually I think this was Nick do in this case as I recall but we do we wanted it on purpose because frequently you deal with small pupils and pseudo exfoliation so a lot of times you have a small rexus and the rotational motion is even more dangerous and so that's a good time to have pre chopping which we showed in another video the pre chopping in order of difficulty on the on the zonules pempto second ultra chopper pre chopper vertical chop horizontal chop and then the worst is divide and conquer in terms of stress on the zonules unless it's done each one in their most elegant fashion that's the that's the order that we found and so once you need to see it on the stretching motion here even on this pseudo exfoliation one you really don't stress too much on the zonules then this of course is the posterior view showing that there's really no motion posteriorly we're gonna as soon as we get our pempto we'll be able to do some of these with the pempto looking at it but I think you'll find the same thing that as far as we can tell that should be in terms of putting it into a divide and conquer type or divided nucleus type that the pempto second should be pretty good on the posterior zonules but again really emphasize that when you rotate anything now make sure that you don't push down because that clamps the capsule around and that's where you'll strip zonules and I think a lot of the times that there's some iatrogenic reasons that we're doing these things is we're not rotating elegantly make sure you have a great hydro dissection wave and make sure that you rotate following the anatomy of the back because that's these are times when you can you can strip it so these are again points that have actually changed and I'll show you how I've changed my paco in pseudo exfoliations some that rotate you can still do some that don't rotate I do hemisections now and bring them up because there's a lot of issues you could of course put a CTR in but what happens when you put a CTR in and there's still a big nucleus rotation is very difficult and it probably increases your zonular destabilizes your zonules even a little bit more I'm not sure what else I think I'll show it what I'm going to talk about is I'll stop this for just a second let's go back to that so one of the things that one of the questions we have is early data and the question is is it so biased that we're not really getting anything out of it and I'll let Nick editor of the journal and Randy talk about it but one of the things that is coming out at least early in some of the femtosecond data is that when you have a rexis that's perfect in whatever form you want to call that and you cover your IOL which we always try to do 100% that the effective lens position can be tighter and tighter and tighter you know this is some of this was Bob Sione's stuff some of it's slide stuff of course it's all right now driven by the companies in terms of a reason for using the femtosecond I don't think that's going to be the case the femtosecond is going to be good for tough cases I think as well decentered lenses it's great to do a rexis white cataracts it's great to do a rexis and that kind of thing so one of the things again that I'm doing differently based on that is making sure that I mark every cornea so that we can look at so I can get as much data as I can on exact coverage of our IOLs and see we'll see in a year or two whether or not it changes the effective lens position at all in hand down state and then we can compare it to femto once we get it Randy, Nick any comments on marking it's interesting because when a pupil's dilated it's a different you know high myopia, hyperopia, it's hard to sometimes get your rexis the exact size you want it it's a big difference right yeah I've done both of those with the femtosecond it really does it's unbelievable and to be able to yeah I think it's going to be a value for that so again one of the differences say this year last two years from say four years ago is to do that the other thing I've changed too is the rexis I don't lead it around as much I can usually do a rexis now with one or two three always but using one or two pulls using the Chinese technique again seems to be more zonular friendly and we'll be looking at that this of course is the use of the ultra chopper I think Mastel is now getting ready to make his available for all the machines if anybody doesn't know how the original was made in South America basically took a faker tip took it to his lab, put it in a vise and scrunched it down and then used that to cut with because he has cases like this all the time and so the advantages you can really get a beautiful crack and you still get those hard fibers posteriorly so you want to make sure you rotate around and then whenever you're doing these kind of cases make sure you understand flow patterns but that's something for different. Now I'm considering that you're using a lot of ultrasound of that inside viscoelastic which dramatically increases the effect of your math yeah I yes of course there's two things let me let me go back to it there's two things that you have to be very careful about one is to make sure this is a 2-2 wound and you want to make sure you get good flow because of that the other thing is you can, it's a cut it's a jigsaw it'll cut anything it comes so personally I have not had a wound burn but I've had some wound haze on long cases and we looked at the energy up at the end of there's just no energy that gets up to the endothelium so even though the numbers look big you know you're doing everything in the bag so I'm not worried there but you can cut the rexis so oh I know yeah you can do it yeah but I can screw up I can screw up with a regular fecal I don't have to have a I don't have to have a hand but I can I mean I think the again you have risk to benefit ratio the risk of a popping a capsule or doing something with these very hard cases is significantly higher and we've had no incidents of that even in even in we did a case last week where we had three Malugans in a 100% dislocated cataract and was able to get it output at CTR I know I keep talking now there's two reasons why they want to push femtosecond to the canal and not a lot of people know how to the reps don't know how to do it so that some people order it after they see one of our videos and then they'll get wound burn or they'll get other issues so you can but you can get a wound burn as you know with very little fecal energy because it's pretty damn hot but I think whoops oh crud let's get to the end here I still think that it's a valid thing I use it probably in my case is probably ten times a week something like that and then you can see the crack going through and then the other thing that we're that I'm doing of course we'll get past this here in a second is and this is going to be interesting this will be we'll see later is I'm trying to remove all the anterior lens epithelial cells this is a variation of the singer sweep so it has so you can actually go under it's really amazing at the end of the case how much how many cells we leave here you can't see it as well here but in with the enduroscope or with the Leica or the new zyscope you can really see how much lens epithelial cells are there and so now with the with the and myself for about the last six months we're doing lens epithelial removal on all those trying to receive we won't know for a few years but it may reduce the pymosis it may reduce PCO we don't know but we're looking at it and so these these are all things that are slightly different than what we're using and I just want to show this for those that sometimes when you're putting in a CTR because the bag is so loose it's hard to get the CTR around so what you can do is you can put a tenon, an nylon through the anterior through the islet and you can use that to pull it around so it stays within the bag and then use a second instrument through your side port either a kuglen hook or whatever to do that for that and I just want to do a couple of quick things on pseudo exfoliation and then we'll get wrecked up some questions a lot of questions about use of caps retention devices some guys use it in a hundred percent of their pseudo exfoliation cases to theoretically reduce late bag sub flexation but Nick we've got them in the lab there's CTRs sitting in the back of the eye so again there's a total impact there again you have to risk the benefit ratio and cost ratio so you know a CTR is 140 bucks you're going to add that to your case if you're going to add that to every pseudo exfoliation case that we do here that would be a third of the case so I use it when you need it and when do you put it in as late as you can but as early as you need it that's Ken Rosenthal's mantra and if you put it in early it's hard to get cortex it's hard to rotate if you need it to stabilize or center the lens do it but if you can add it at the last little bit it's a much better thing okay so just quickly what is the laboratory thing taught me to do now differently well you can see here this is your routine pseudo exfoliation case except it's nice because it has a big pupil so I do the first thing I do is I it's a hard fairly hard nucleus so I do a little ultra chopper and then I'm doing visco dissection to see if I can rotate the lens because the lens doesn't rotate well and you see it doesn't it didn't rotate very well and so what I'm going to try to do is I'm going to hemisect it sometimes I can rotate it about 15 degrees and if you can get one piece out it makes it a lot easier I'll show you there you can see even with visco dissection it isn't rotating very well so the thing is don't force it if it doesn't rotate well and you rehydrate it a good wave you know you can see a wave and you probably have loseonules you had wrinkling in your capsule you had a little deeper in the chamber as you go in so the trick here is to hemisect it bring it up use chop techniques above the plane of the or at the plane of the iris not up too high these are usually hard nuclei and we know that the endothelial surface in surexes is probably not as good as a standard endothelium so they a lot of times have or can have edema falling into your chamber fake us why don't flip these if I don't have to but point being don't don't rotate if it's difficult so that that was something that I learned very dramatically I think from our laboratory stuff it really just changed the way I do these surgeries and again we'll see if this makes a difference later on it sometimes is nice also if you have a little extra cortex you can't get to these these these goes in it's very nicely designed won't unless you I actually make a mistake here you can free up cortex really very nicely so and again just a couple of just the hurricane method so basically what you do is you just try to keep it occluded as you go around and don't strip to the center and this is not sped up so you can see that this that's an average time so it's really reduced the amount of time that we do here I'll just get to this is one of the new ways I do make one large central thing tear it around this is if you watch any of the Chinese guys they can actually do it in one in two moves and I average about three moves but again you just have to understand vector forces and it's very easy to lead it around and you don't get that cute little dimple at the end of your rexus by following because you go outside of it so the rexus is certainly different and then again we'll do I and A we have a few of these but you can see the average is now is about 10 to 15 seconds of I and A time and certainly less than you can do most including fecal cases with about 80 to 100 cc's of fluid so it really reduces the stress but more importantly thinking of the stuff that Liliana did you're reducing the stress on the zonules so I don't think we need to see 20 of these but I have these for another case now again CT I have a question about using a CTR in service again you can see as this is going around if you look in front of my tear there's a wrinkle that means you have loose zonules and there were wrinkles 360 degrees around so this is a case you know you don't want to rotate unless it's so easy it almost does it by itself because you're going to strip all those zonules so even though this isn't a very hard nucleus again I'm going to do a hammy section and bring this up because I know if I try to rotate this even minimally I'm going to have issues now here what I was after you crack it sometimes you free it up enough so I rotated to get those into two pieces or three pieces made it a lot easier to get it out and then making sure that we get the good motion here get to the CTR insertion also when you think you have loose zonules don't come out it's easy to pop a bag on the way out put your visco elastic in drop your bottle height and then you can go to zero at about 50 and the bag stays formed so you don't get flow you don't get issues and I even do that when I'm done with the INA because that's when things come up it's pretty easy to strip more zonules and it's pretty easy to pop a posterior capsule it's difficult to do with a silicone tip now this is the new mortures one if you haven't used it you should it's a very nice way to do it and I have a video showing what it is but watch the bag so you see the de-centration it's a pretty loose bag but it centers up nicely so what you're looking for is you wait 10 or 15 seconds if everything re-centers then you're probably good to go if it doesn't then add something such as a you could add a c-oni or you could do I'd use an ob-ed segment so this is the new another way to do that is to put a sinceky hook through your cycord and grab that leading loop so it's not pushing into the bag and then insert it or pull it with that 10-0 so this is the new CTR material is different that's why I like it it's a softer material it's more like the AMO material now so it's not as rigid and it's easier to put in it comes in this left and right gig it's not left and right for your eyes it's which way it comes out of the thing so if you have superior zonials you might want to use an L because it'll come out this direction if you want to use if you have total zonials it doesn't make any difference but it is a nice injection system and it does go easily through 2-2 very easy to get the material is different and it's a lot kinder now this is something brand new Gary Congdon a friend of mine from Pittsburgh is a great surgeon came up with this idea so basically it's a variation on the technique that I can I use published a long time ago for stabilizing these bags but it's really I think an elegant way to do it and really this is over here you can see this is a classic pseudo X with the single piece lens very phymotic capsule 360 degrees of that's dropped down so basically what he's doing is he's going two and a half millimeters behind which is similar to what we do grabbing the complex if you will and you can see there's a CTR in here and he's going to go through underneath it and the difference is we used to dot these bring them out and send them back this is a much easier way to do it and we don't care about the cornea it's just a window we'll just poke it anywhere actually we try to go from the different sides you'll see over here I'm trying to get it out so it isn't dead center but here's the trick let me stop mine for a second and now you've got this loop just like think of a seeps or not so rather than going back in all he does I don't like using this I prefer to use an MBR blade but he just uses a .8 thing and now we have upstairs we have in my set if you want to use it it's called a snare it's designed to go in for seeps or knots and for this and all you do is pull the knot through like a seeps or not so you only have to make one needle pass it takes this down from probably an hour procedure to 20 minutes 25 minutes it's so much easier and then you go to the other side and do the same thing on the other side so you get the point you go under through the bag through the cornea go through your MBR stab using the snare that bring it back out and you've got you've lost it so it's really an elegant way to do it we only have one snare right now I'm ordering a bunch I think we need three probably have you used it already? no it's brand new they've only made two one for Condon one for me but we have it here anybody that's doing seeps or knots or IOL repositions ask them to use the MST set that I have because it's got the snare in it and so what it does is the snare comes out grabs it and it's fantastic and it does 80 Gore-Tex and so these are just these are some this is a much more elegant way of doing an IOL reposition and then of course just a quick using the Gore-Tex technique and I won't make you watch Rex's even though obviously they don't need to be stained they have a tough case staying the capsules because it's a lot of times very difficult to see where these are and these are McCool hooks that are in there once you get the bag evacuated the reason why I wanted to show this is that the new if you look at the new C1 it's called a G1 it's much more flexible it's much easier to put in the standard one I try to get them to get rid of those and just use the G1 because it's much different materials much easier to put in and even in these cases with really loose bags it's much easier to put they only have it in a modified C1 modified so there are no new materials not in the two loop it's only in that but I prefer to use this plus an Ahmed segment for the really loose zonuals and that's Gore-Tex material that's all I've been using certainly in the kids these days it really is so kind and it doesn't break down we'll see in ten years but we certainly we have some out at least ten years with no breakage I think around 96 was the first time we used it in these Marfan's kids so with that I think those are most of the new things that I've been doing and one quick one even though this is a pretty looks like a pretty routine case so when you may wonder why I stained it but you can see as you tear around that the the Rexis there's folds in front of that showing that these all these zonuals are weak so in this case what I'm going to do is do the chase here and I'll use two segment one covers about 220 and then the second one down here and then at the end of the case you can just fixate those to the sclera sometimes I'll do that before I have at least positioned before we do that so with that I think we'll stop asking any questions or comments I think it's really interesting that the laboratory is so critical and the Miyake views that we're looking at really as I say the change is the way I do my surgery and I think that it's a reason to keep up at what Liliana and Nick are doing in the laboratory because it really has I think it will improve our outcomes in the future even if it's only a few percentage points we're already low on our complication rates but not having dropped bags and not having torn nuclei and stuff I think is a worthwhile topic any questions or comments no question and I think they improve our understanding of looking at these views looking at technology it makes us better surgeons if we watch them no question so we should really thank Nick and Liliana for what they do any other questions so try the hurricane everybody at my meetings now I got ten messages they love the hurricane yes sir no question and if I think I need to stabilize it I would do that but if I can get the nucleus out without doing that using an MST hook it's just much easier for me so the disco dissection was also a study that we did here with Liliana and Vasavadas and it's I should have shown that stuff too the nice thing about it it stays it actually stays there and you saw that I do disco dissect every pseudo exfoliation for that very reason in case you need to put it in one it's ready to go and two because I think it really does stabilize that posterior capsule so that's worth doing and I'm not sure it matters whether you use a cohesive or dispersive but I tend to use a cohesive it's a little bit better space creator in that sense great no I think it's going to change when people you know the issue right now unfortunately is that you that you have a very expensive tool that yeah someone has to pay for right and who pays for it premium lenses so the justification for people buying those now is really that but I think in the long run I think we'll be using it on these top cases we've done some de-centered lenses where we do a rexis it was perfect I mean instead of putting them foot loops and stretching and bringing the rexis down you know you can do that I know that Burkhard Dix actually done cases where he's put in a Malugin ring taking them over with his I'm not sure his is probably a Zeiss or Optometica so I think really it's a technology that we'll be using on these tough cases but right now it's hard to justify it if you only have one or two or three a month that you need it on so I think that soon as more of them come available that that'll start coming out and I think that's the reason for getting into it it's the tough cases we can all do an easy I will lens it's RLE if you want but it'll be great for the tough ones I think alright good work