 surgery minimized is so important. Keeping the relationship of tissue plain stable, I think is important. I was never happy about techniques that make you remove the nucleus from its space. I think when everything remains in its normal place, the eyes are quieter and happier. We want to coat delicate tissues and we have the advantage of the Arshinov softshell that we can use dispersive OVD and work within cohesive, which is my preference though. Certainly there are many ways to skin that cat. Keeping your hands light and not pushing the globe for resonance, if you're always seeing that you're constantly having to move your microscope XY, you're never in the center in your video, that means that you're influencing the tissue. If you're doing that, the tissue can't influence and talk to you. You want to be a little bit lighter with your hands. You want to anticipate and avoid discomfort for the patient. We have a nurse anesthetist I saw yesterday sitting by who rarely is needed, but sometimes vocal local is the most important part. I can talk for an hour about the psychological words that I've used given my background and my history for those patients. I have the same pattern every time throughout the surgery, which tells all the scrub nurses where I'm at and especially if you're going room to room, it really helps. We want to maintain visualization. Of course, we'll use triescence in a trachomy situation appropriately, or we'll use tripan when we don't have a good view. It's such an important part. One of the advantages that a disadvantage actually that you young people have is that you can accommodate. You don't really know where you are in the anterior chamber. As you get older, you've got to focus more to be in focus because you're not accommodating and it's always helpful to be in focus at the place that you need to be working. You want to keep large fragments far from the endothelium, and this is particularly true of the burnescent lens. For the burnescent lens, I developed a technique where I leave the nucleophied dense leathery epinucleus in place till the very end to protect the posterior capsule and keep the zonules expanded. This is the kind of cataract we're talking about. I practiced in Iowa and Illinois and we saw plenty of these. Once you get good at something, everybody sends it to you. Watch out what you get good at. Of course, there have been some ways to deal with that that are a little more old or newfangled. It's not unreasonable in your learning curve for burnescent lenses or even for any densely burnescent lens to go ahead and make an M6 incision partial so that you can always opt to that afterwards, but that does then entail having that above and extra incisions and so on. I think the my loop can be helpful, but it still breaks it up into large portions that need to be removed and can be challenging where you don't have a good view. Femto laser, you need an awful lot of energy to get through one of these lenses and make a big difference. I came up with something that I call circumferential disassembly. It's very controlled for burnescent lenses. It respects zonules as you'll see. It's ideal for small pupils because all you need, you're going to always be within the safe zone of the capsular axis. I never make a capsular axis different than about five millimeters no matter what the density of my lens. It's very endothelium friendly as you'll see. The capsular axis can be tailored to the optic, not the nucleus. The patient walks away with what we hope for, which is to cover the edges of the implant appropriately. It minimizes phacoenergy because as you'll see, we only use ultrasound to gain purchase in order to apply mechanical forces and then to assist aspiration flow as needed. One thing that people no longer use very much, and it's a real pity, in my opinion, is a burst mode, which still is on the machines. I want to explain that to you when what we're all used to using now is a torsional or ellipsoid type of pulse, which has a duty cycle. The linearity is related on your foot pedal is related to how much ultrasound power you're going to use. You're constantly going all the way through. Of course, you're throwing in a lot of longitudinal in a brunessant lens, so it doesn't clog because by definition you're going to be clogging, clogging, clogging, clogging until you get to enough ultrasound power to take the nucleus away, which isn't a problem in a non-brunessant lens in general. However, also it's wonderful for sculpting because you're making a wider sculpt. I hope people can see me on Zoom do my little hand things because I'm kind of into that. At any rate, you're making a nice wide sculpt, but the last thing you want to do if you're going to chop, and this is a chopping procedure, is to make a wide opening because your goal is to get in and hold on and then apply your mechanical forces. For that reason, burst mode is very helpful because you can set it at the panel ultrasound that you need, which may be 70 to 90% in a truly brunessant lens. Then what the linearity controls is the burst interval. It's like that on your foot pedal. Therefore, from the very first moment, you're not clogging your appropriate to your lens power. You can alter that based on how quickly it moves in, which you can control so easily because you can have one or two bursts and come up on your foot pedal very easily and not travel too far. If you go nowhere, you know you need to put your ultrasound up. For disassembly and chop, burst is invaluable in any kind of nucleus. Then for removal, then the torsional and pulse can be extremely helpful, though not necessarily so much so in the truly brunessant lens. Now it's become sort of the routine that everybody makes a one millimeter paracentesis, but Richard McCool figured out that 22 cc's a minute of BSS will be lost through a paracentesis when you have your instrument in there that is opening the little internal valve. Either we should reduce, certainly if it's going to be a longer procedure, we're going to use lose more BSS. Even if it's a short procedure, that's where the particles go because there's flow out. I know our newer machines kind of control this a little bit better. They'll increase the inflow. If you have a lot of outflow, but you'll still go through more BSS. In a brunessant lens, this becomes particularly a problem. Either a chopper that has a sleeve, like when we make our FACO incision, we expect it to be fairly water tight with the silicone sleeve, keeping it from leaking all over the place. We should do that in the paracentesis who are make a better paracentesis, a little smaller inside and bigger outside so we don't stretch it and we don't use so much fluid. A five millimeter greater pupil is all we need. Tri-pan is very useful in brunessant lenses. It looks like a red reflex, but it really is a brunessant reflex, and you'll see in these cases in the video that I show how we don't see the red reflex till almost the end. It can be very helpful to be able to see that capsularis edge. We must have a mobile nucleus for my procedure so that we don't stress on yields. Usually, this is very easy in a brunessant lens because there could be a little cortical capsular adhesion, but by and large, the fluffy cortex is pretty much gone. It's headed towards being hyper-mature and morgagnan anyway, so it's easy to establish that mobility. I like to really use that Oshunov softshell, particularly in this setting, and it's very important to retract the sleeve in a very soft lens or a very dense lens. If we want to chop, we need to be near the center of that lens in order to get enough purchase, and if your sleeve is right up at the tip of your fecotip, then you're not going to be able to, it's going to be the limiting factor to get into the lens. We like to retract that sleeve, not so far back, of course, that it'll get into the tunnel and shallower your chamber, but enough that we have a kind of a dipstick that we've performed because we know about how thick that lens is. We remove a little superficial, but we know where we are in the lens if we have our sleeve delimiting our dipstick and we can't go more than a half the way through, and then a fixed vacuum and aspiration. I don't mind vacuum being linear, but linear aspiration to me doesn't make a lot of sense because then it's going to be variable, how close you have to get to a piece before it comes, and that's not intuitively easy, whereas vacuum is very easy in a linearity. If I need more vacuum, I know I have to go a little further on my foot pedal, but it's very hard to establish what do I need to do for linear aspiration. I don't think my infinity settings are really significant, except to say that, but I have them here just so you know in the technique, but the main thing is to say that once I finish removing circumferential disassembly, when I finish removing the denser internal part of the lens, the endonucleus, and I start to fold the epinucleus in and expose the posterior capsule, I will lower my flow and my vacuum so that I don't have as much of a risk of any surge. Now, CHOP is poorly adopted by many, and it's so much safer and more efficient in my hands at least than sculpting because we're not wasting any energy and we're not at risk for suddenly occluding where we don't want to. There are several different maneuvers that are useful, most of the reason that people have difficulty learning vertical CHOP, and I'm not a fan of horizontal chopping because we have to go out of the safe zone underneath the capsule erexus out to the equator and then come in, and I think that even super experts sometimes will grab zonules or be in the wrong place for that capsule erexus. I want to stay within the safe zone at all times, so I've always been a vertical chopper, and one of the reasons that people have so much trouble with that is that as you go in, you've got to gain enough purchase and stay in foot position too in order to then dig in with your chopper and lift and separate. So the idea is that the sucked in FAKO lifts a little bit while the chopper sort of depresses a little, and if you lose foot position too for even a moment, you've lost your purchase and it isn't going to work, not only that, but in a brinescent lens there's a tendency for it to tilt because there's nothing really holding it in. It's so dense that when you chop it, when you hold on and chop in this direction and try to pull this up, the whole thing will tend to tilt, which is a problem, which is why I mostly use what I call cross-action chop, which I don't know has ever been described in the literature exactly, but what it is, is I go in in the same way that I would otherwise, but I take my chopper on the other side, and that allows me to just separate like this, almost like a pre-chopper, and you'll see a lot of cross-action chop happening here, which I'll show you in a moment in video. The other thing that's very nice to know is the back crack, and that is anytime you have any access to the bag, any crack that goes through and through post your plate or in the periphery, anytime there's any way you can get your chopper, not a sharp chopper, mind you, and I don't think you need a sharp chopper for the most bernessent lens ever, but you can take your chopper and put it through that little crack, and then bring it upwards to crack it, and that saves you're going out to the periphery. You know, as you kind of eat a piece, sometimes you lose the depth of it right up here, and then you're at risk for getting the capsule or even worse, the iris, and not being able to get it to fall in, so if you have any crack, you can make it fall in, so let's look at that. So this is my rose and splitter, it's a cheap instrument, it's blunt at the tip, and it has a slightly axe-like shape on the interior part that helps me use it, and here I'm burrowing in, and I'm doing a cross-action chop. This is not a bernessent lens, it's just to show you the technique. So I go in, and I cross-action chop, and I get rid of the little piece, and here I can do it again and make it an even smaller piece, and you see how very effortless and simple it is. Here's the back crack, so I'm down there, and I'm able, what happened was, I had a thicker posterior plate here, and if I just keep going to the periphery, it won't fold in because it was that center that was thick, so instead I just lift it up, and now I'm not at all at risk for being near the capsule. So here's a, I think you'll agree, a reasonably bernessent lens, and most all my videos are sped up here, so for the sake of time, it is, it does take extra time, where I'm maybe, I was an eight to 12 minute phaco time, this will be a 15 to 20 minute phaco time on a super bernessent lens, and you can see the bubble up there in the endothelial protective layer, and it's kind of a barometer that shows me that my endothelium is really safe, and what I'm doing is not trying at all to make a chop through the posterior plate. What I'm trying to do is I'm trying to open the lens kind of like a clam shell in order to get the meat inside. There's always an endonuclear plane, even though we can't hydrodelineate it like we would in a soft lens, there's that plane exists, and so what I'm doing is I'm opening the lens, if I want to crack all the way through the bottom, I've got to drag those two halves all the way to the edges, and I'm going to stress my zonules and risk breaking my posterior capsule, and there's no need for that. In fact, I don't want that. I want the epinucleus, which is thick, and you know it's those interdigitated leathery fibers at the back, the posterior plate that are really the issue with these lenses. I want that to stay intact because it's going to protect my bare posterior capsule, which has virtually no cortex to protect it, and most of the time the zonules are rather loose, so this keeps it all expanded. You can see I've made my nucleus mobile. I'm opening it, and you see how I'm using the second hand very actively to lice the little attachments at the posterior plate right there. You could see that little maneuver as I'm using that. You'll see it more, I'm sure, here, right here, and I'm feeding that in. If you would hear this, you'd only hear a ch when I attach, and then just to help the aspiration flow take that piece away. I'm in burst mode all this time, and therefore I'm using very little FACO. It's a little fatuous. You'll see that I won't even allow the whole piece of epinucleus to come. I'm going to hold that back because I want it to be the shoe tree in my shoe throughout this case, and you can see how unaffected the bubble is on the endothelium, and how happy my texts couldn't tell the difference between a 2050 cataract and a superburnescent on day one post op for this reason of protection. Now, as you get better at it, you'll less often need to replace the endothelial shield, but you'll see I'll do that in this case. Certainly, if I had a fuchs dystrophy or an at-risk cornea for any reason, I would do that even if I don't feel I need it. Pretty soon you'll see that bubble getting a little smaller, and I'm going to decide that I'm going to replace the OVD, which I want you to see. I always go into an on foot position zero into an OVD filled situation, and of course you always have to recognize that you must establish flow absolutely before you ever go into ultrasound when there's OVD in your environment to prevent a burn. You can see now we're being pretty uniform, and the whole trick is to just be patient and to just uniformly thin this lens. Then once that happens, and you'll see some more sped up things in how reproducible this is, you're just barely sort of seeing red reflex at this point, and see I'm not letting the whole thing come because I don't want to leave some really dense areas that may need to be then removed in the anterior chamber, because keep in mind all of my ultrasound is happening at the iris plane or below at this point. Here I'm just deciding I'm going to put in OVD, and I'm filling it into itself and put position zero, and then I'm going to come back, and now I absolutely must establish flow before I go into ultrasound again in order to prevent a wound burn. Now I know I have full wonderful protection for that endothelium it's rare that I have to re-add on an average brunessant case, but it's never a bad thing. And so now you're starting to see that we're getting to where you see how dense that center is, and this is why when you see people chop you see them like separate those halves like to Timbuktu, and instead now we're just starting to be able to take care of that endonuclear piece here, still I mean that epinuclear piece. Now you don't see the overlay in this one you will in some of the other videos where you'll see that it's about now or so that I reduce my vacuum and aspiration flow in order to prevent clogging, and of course in order to prevent a surge and the posterior capsule coming up. We have three choices for the last little pieces you know we can put more OVD underneath to blow the capsule backwards. I don't like that much because it comes out in little pieces and you never know when it might bring the capsule with it, or we can take our chopper out so that it won't leak but by now maybe it could leak slightly or we just protect the capsule. So you'll hear and then before I go I'll have the second hand instrument underneath. Now I always like to put BSS in the chamber kind of like a chamber maintainer when I remove anything so the chamber never collapses and you'll see at the end of the case everything is clear and lovely. And that's a very typical case in my hands. Here are a number of really more challenging cases. This is a black cataract because it was a retinal detachment from 10-15 years ago they told them just to leave well enough alone and never touched that eye, but the other eye developed enough of the cataract and had a retinal tear that I treated so we decided to do this eye. And it needed a Malayugan ring. It had a very floppy translucent iris because of the ischemia that it had had and you can see we're doing the very same basic maneuvers. It had very low cell count as well and it did take him about a week to recover to his best 20-30 macula but and you can see it's very dense. Same thing we're burrowing in and then we're trying a cross-action chop. You see how I'm on the other side of the chopper and everything is planar. I'm not allowing anything to tilt and I'm just slowly getting this open. This is three times you know the things so you know it's a 20-25 minute case but you know what the patient takes away is the important part. Somebody always needs to watch that you don't run out of BSS. You'll see there's not a lot of flow coming out of my paracentesis because I make it with a Triamon blade that's diamond and very 0.3 at the tip and then gets wider to 0.7 so I could make a small interior and exterior. And you can see that things are coming along just fine and I'm using that second hand instrument that Rosen splitter which goes in through the tiny opening easily and isn't sharp and I'm using the hatchet like inside part of that to sometimes sweep away the attachments of the leathery fibers. So hopefully you're not getting bored because I know it's a lot of repetition but that's kind of the point that this is so reproducible that we can pretty well count on it for every case I did not have to convert to an extra cap in a decade. And as you can see these are not trivial lenses. I did have one that was truly black and really challenged me and I was close to having to do something about it but it gave it gave in and it's a matter of kind of a labor of love of patience as you see here. So now if you'll watch the aspiration and flow you can see the rise. I don't like to use a rise time and you'll see at some point very soon I'll be lowering that aspiration and flow rate as you see now we're seeing red reflex and we're getting last little particles which as you see weren't really headed for my paracentesis like they would be if I had a one millimeter opening that was not occluded and so we're just making every effort you know to stay in in the iris plain and there now I think I'm about to reduce that aspiration and vacuum to 35 and 300 I think I'm 40 and 400 so there we go. Am I not doing it yet? I guess I still feel I have protection so we'll we'll flip that out now oh I'm going to add a little more OVD before I flip it because I think he had an 800 cell count. Establish that flow and now you hear your eh and I encourage you as Dr. Manilis does to work with your foot pedal on your sounds because it's all eye, ear, hand, foot coordination which nothing much else in life is like that and protecting the capsule as you see and you see we have our aspiration and flow down to 32 and 320 and then it never looks like there's cortex but these hyper these very mature lenses always have cortex it's just not in the center so we really need to go hunting for it with a little vacuum setting and always trying to get from the anterior edge so we don't move little fibers behind. Here I'm enlarging the capsule rexes because it was such a marbly kind of a cataract that I had made it rather small and most of the time I'll enlarge after I have the lens in but I thought it was even small for that I guess in this case and we'll get that all centered and nice and and then I always like to remove the OVD from the posterior chamber and then take out the ring and then remove from the anterior chamber the OVD and you can see it was a transillumination type virus now that was certainly a very difficult case but you'll see it's so reproducible in here I've really sped it up to help you out and then I'll show you a case and then I'm going to show you another another case and so another issue after this so I'm going to I think this is the last one in the interest of time first of all take any questions while this is going on yes yes oh thanks it seems like all your settings are on panel mode on the overlay I find that I have better control if I keep something on linear and I usually keep my vacuum on linear and keep aspiration on that makes lots of sense as I told you earlier I think vacuum linear vacuum makes some sense but all I want to think about in the burnescent lens is is my burst interval and and there's no need to vary the vacuum for that I vary the vacuum a lot for INA but I do see your point as I made the point I really don't like aspiration to be that way aspiration flow but you make a good point and there's nothing wrong with linear vacuum aspiration you just can't intuit what's going to happen it either happens faster or slower or you get this close to the piece and it works right now but then you change your aspiration flow rate and have to get that close to the piece for it to come so that's why I'm not a fan let's see if we'll skip a little further along I don't know if I have a ability to do that I wanted you to see the no I guess I don't I wanted you to see the colabominus eye because it shows also how very or did you already see it I took my eye off okay so we'll just go to the next thank you it's so zonual friendly that we don't need to hold the zonuals in that colabominus eye and it was a very shallow eye and still the cornea did well so establishing flow before engaging FACO removing superficial cortex for a view bury the tip into the nucleus maintaining vacuum at depth and then place the second instrument and dig in allow time for propagation you know the the concept that this is a chop it's not really a chop we're we're actually needing to propagate a fault line and that happens really fast in your nice two plus goldilocks lens but it doesn't happen fast in in a brunessant lens and so you have to allow that fault line to happen and we just repeat that and then reduce the vacuum and AFR protecting the capsule from surge with the second hand instrument so I'm going to add a new wrinkle to things in this case and I wonder we have a nonverbal 65 year old intellectually limited white male who stopped participating in any activities can't find his food and they finally bring him in to see us and we can get close enough for retinoscopy and maybe a little kind of a slight indirect but not really and he's got black cataracts and just the glimpse of the fundus shows us that in fact the view is consistent with his function he's got close enough sweet talking to do a little finger tension you know a block meant you know the globe so he's not extreme in his pressure in one direction or another so what would be our plan um so the surgical plan is needless to say you know exam under anesthesia and we make measurements right away and we talk at length to the family because if this man didn't get brought in for his cataract until he couldn't find his food do you think he'll ever be brought in for his yag capsulotomy I rather doubt it um and um and so and no way he's going to sit for a yag so that would have to be a general anesthetic for the yag as well and so after a long conversation with family how am I doing on time okay I see somebody looking after a long conversation we decided not only to do his berness and cataracts but to do a sequential same day surgery as well as posterior optic capture with a planned posterior capsular axis for both eyes assuming all goes well with the first eye we were going to do this same with the second uh all the dictates of the international society of bilateral cataract surgery uh was you know was uh followed and most particularly I used uh intracameral moxifloxacin bigamox actually uh from 2006 I think is when Arshnoff described it and had a thousand cases ahead of me uh and for every case so I certainly would for any complicated case and it's necessary I believe if you're going to consider a same-day sequential. So let's show this to you. I've left some sound here all from the second eye this is the less bad left eye we do the right eye first it wasn't simultaneous like this it was sequential of course um and then right and uh and so you can can have uh a little faith while I'm applying but the sound hopefully you can hear this here there and so I I think I've never gone above 40 seconds in the blackest lens and um you can see that we're going to uh go ahead and make our way through this lens in the same way that I just described uh the left is a little bit less dense so you'll see that I'll finish ahead on the left eye compared to the right eye it's so reproducible that uh uh in fact uh just uh chop in general I always go down all of my uh seated in order to be able to get better and better at things more uniform I got you know you get you understand the locks to uh nuclear sclerosis and if you're a three plus nuclear sclerosis I knew that I was going to be you know uh five you know or six seconds of of uh cdb and as you see that getting more and more consistent you know that you are more and more consistent so um general anesthesia made this kind of easy because I I didn't have to worry I usually had the family watching through the microscope in a remote room uh so I talked to the family and tell them what's going on and I talked to I actually uh used that as an excuse to talk to patients and tell them what's going on and be very relaxing to go down. Any questions while I'm sort of getting to the point here of the posterior rexus if not let me just talk a little bit about that so uh one of my real areas of interest is optic capture and particularly primary posterior capsular rexus that's hyloid scaring and I believe the hyloid is really causing the two chambered eye and we know so little about the rexus sadly which we'll talk about well I have a whole two hours to discuss that thanks to Marie-José Tassignon some of the work that was done in the 1800s on the anatomy of the retrolenticular space is now becoming known our imaging of that area doesn't work very well we're starting to talk about a subspecialty of middle segment surgery that affects a lot of things so now that I've finished uh with the last and you'll see that I'm protecting the capsule and getting any last little fragments and what you'll see in a moment is that I'll get ready to get my posterior rexus and what that entails is putting some OVD into the sulcus in order to flatten the anterior and posterior capsules together and once we once we have a nice flat plane then we go in with a 30 gauge needle as you see here ski up the posterior capsule which as you know is four microns thick I'm here to 14 microns of the anterior capsule and make a little opening and it's because we don't know where the anterior hyloid is it's right behind it or it could be a real a real space versus a potential space now I'm placing cohesive OVD through that tear in the opening of the posterior capsule and it's kind of pretty much filling into itself I felt that I had enough down there and I'm I'll only do a posterior primary posterior capsule rexus if I have an anterior capsule rexus that is capturable because then I can always put a sulcus lens in anterior capture or reverse optic capture I have many opportunities to keep this from being a difficult case now I'm just using more of a centripetal force uh and uh because it's more elastic I'm following the uh the capsule um the anterior capsule out of me and I made it a little small I decided I'm just going to gild the lily a bit and make a little opening in that capsule again make a little tangential cut and make it more perfect and you can see it's so controllable that one can do that even for that posterior capsule and now I put OVD into the sulcus of the bag so I've opened a big landing spot for my three piece lens and the anterior haptic the leading haptic goes into the bag uh I never want to put it under the posterior capsule rexus into burger space of course uh and and we rotate that into position and then we're able to optic capture uh it doesn't always just pop into place like it does for an anterior capture sometimes we have to walk it from haptic optic junction to haptic optic junction and we get that nice football shape and uh so you can see here this is on the table immediately after that picture on the right isn't so lovely but it's foggy all over as you can see um anytime uh and in this case I use triessence uh and moxie because we didn't know if we'd get any drops into the guy but he became tremendously uh able to do many things afterwards and cooperate afterwards whereas before he was truly blind so here are some resources for you I've included uh and I'd like to talk about another a completely different case since we have extra time and I thought enough was enough with a burnescent lens would anybody like to have any questions about the burnescent technique I I've had difficulty I really described this in 2005 on uh Osher's video journal and and I've written in textbooks and I've actually lectured to whole departments and I'm not sure if anybody's really adopting this and I don't know why because I watch these these um my loop cases and you know these giant four pieces you know are just floating around and up near the endothelium and that's if you know they don't get it stuck somewhere uh and and certainly I think femto is you know not the revolution it was meant to be uh and uh so flax is really not the answer uh I think many people I hope that extra cap has become a thing of the past and then m6 is now uh taught but there's so many residencies where it isn't which is really a pity uh because that's certainly a viable option how do people feel about this and uh is it something that you would what would be the barrier to taking this on I think Jeff's gonna say something here in a moment he's getting the mic uh that was just an MA MA 60 you know Lisa beautiful surgery it it's really lovely to see and yeah I think adoption adoption of techniques is a really interesting conversation you know why things kind of some take off some don't you know for so long you know it was you know Alan and Randy and and Nick as our primary surgeon so you you kind of had this you know almost like a family tree of surgeons underneath them that certainly operate with certain techniques you know pre-chopping certainly one that that's carried forward you know I I really really like the technique I think it's really thoughtful very meticulous sometimes I think we we just might be in a hurry and want to see those big quadrants that you can get with a my loop a specific question about the technique is and I can hear Nick Mamelis talking about the leathery plate behind an innocent area where you're dividing and you're left with that just just kind of dense shell just kind of tips thoughts about how to manage that shell because that that's a tricky one that's a good question by the time you get that endonucleus debulked you've pretty well gotten rid of most of that leathery thing so sometimes it'll fall apart for you you can just you can just actually you know it'll be you can just split that epinucleus and take it piece by piece or else it will just roll in and when it rolls in then it's fairly easy to take care of because now you've got all this space you know that you're working with so if you if you look at participation of different techniques and approaches and we've done a couple of those surveys and published you know just probably time to do that again see how that's evolved is what what I see you doing is something that is clearly you know a focus on mechanical disassembly and always trying to have small controlled bite-sized pieces and then use your second instrument to help mechanically to hold it in place so that you minimize the amount of ultrasound I think that's there's real good evidence and there's good studies you know that we've done as well that show that that minimizes endothelial damage and if you use short little bursts of ultrasound energy that from the work we've done in regards to wound burns it's impossible to get a wound burn you really need a relatively long run of a lot of ultrasound to get enough heat to cause a burn with the single exception if you do it inside of an eye full of helon 5 you can't get a burn in about three seconds we've seen that on videos we know that's documented we've seen that happen under you know experimental conditions so um you know uh David Chang and I taught a a chop course uh with skip neckamon for years and years and years uh and uh I think that chop course is it still going I think is David still doing it yes I think he is yes you know I finally signed up nobody does cross action shop right you've never seen it there's that is one variation that was part of that course that we chatted about and talked about you know that is a possible variation moving forward talked about you know a lot of the different features you have so if you look at participation overall in mechanical disassembly so let's just take that this is a variation in mechanical disassembly and um you know the classical grooving technique and then splitting into four quadrants has been the majority but it's been less and less and less as time's gone on and then chopping has picked up more and more and the last time we looked at it vertical shop was about and oh my gosh this is now been 10 years so and I don't think we've had no good papers been published since that in regards to where techniques are across the country but at that time um you know vertical chopping was about 22 23 percent horizontal chopping had dropped off some I think for the reason you say I I've used both I think they both can be very effective but you do have to be really careful that you don't get on top of the anterior capsule or you'll just rip the zonules obviously uh and that was about 18 percent but uh different variations either you know stop and chop which was still uses a lot of mechanical energy or the regular was still represented about you know 60 percent of those that were done and so I think so much of it has to do with what's being taught uh well all of the people here have had enough of different variations of chopping I don't I mean I I'm I'd be surprised if anybody's carrying on their technique after leaving here without some element of chopping interesting the one thing that uh a less experienced surgeons run into and this is coming from the course when you have these black cataracts by not trying to get that early split through that posterior leather leather plate is that uh due to timidity and as I watch as you did it I mean you were making sure that you were getting the core elements of that leather plate as you went around if you keep being too anterior and then all of a sudden you leave yourself with everything removed but a leathery plate and it's still pretty darn stiff and then how you get it and uh you know there's just a lot of people in the course of the one that that's when they break the caps they're trying to get this that's nothing's left is a leathery plate down there and so um sometimes that's a confidential disassembly it's so nice because the leathery fibers come with them so I'm but you've got to make sure you're getting at it and I watch you and you're getting at it and if you're not so that's part of the reason I must admit of course we emphasize it makes sense earlier rather than later that you're starting to split through that leathery plate and so that you you don't you aren't left with this large flat hard area that will is not malleable and stuck there on the plate makes sense and again another one that that I saw that you know I've certainly always recommended in all the courses I was involved in is that when you're getting towards the end is that make sure before you use ultrasound that you know that you have your chopper in the same position always just under the tip so if the capsule comes up it's going against the chopper and not against your tip because it's the combination of aspiration little post occlusion surge contact any capsule that's absolutely absolutely and it's easy also when you have the sleeve back like that which is necessary for the really dense lens it's easy to withdraw into the tunnel and let things collapse you have to really be mindful not to do that that's another place where I've you know once in a while I had an issue so can we talk about this next oh another question yes oh no okay so I have a this is a case that I'm very proud of it was a very challenging case an 11 year old boy presented with near total hyphema after a BB gun hit theoretically his closed lid of his right eye he had a hand motion vision with good projection and an IOP of 30 there was no reverse aphrodite pupillary defect which you know when you don't have a pupil on one side and you do on the other you need log unit neutral density filters in order to equal it out in order to look at the only the pupil that moves in order to see if there's an afferent defect I was a disciple of Stan Thompson so I'm that's a big he was Mr. Pupil you know I'm sure you'd remember and at University of Iowa and he he met we managed him conservatively whenever it's possible to control inflammation in a trauma where the lens is involved and to control pressure it's a good idea to wait for the eye to be less hot to wait for fibrosis which makes the any break in the capsule more less likely to tear and the eye did quiet and we were able to wait two months before surgery now all the risks were discussed with the parents it was a possibility of retinal detachment and corneal edema infection permanent glaucoma they were very aware that they had to be followed for life for glaucoma regardless for traumatic glaucoma there could be glare and irregular pupil they were prepared to be a faking and need another surgery based on that but we did calculate the lens based on the fellow eye there was a potential need for more than one surgery and of course the general anesthetic risks this is what the eye looked like when it quieted down you can see there's a hundred and eighty degree order dialysis anterior capsule rupture B scan was normal of the post-hair segment um probable zanilla lysis unknown post-hair capsule status anterior and posterior synechia and so I'm going to show you our first surgery does anyone want to talk I want to get through it so does anyone want to talk though about how they would handle the case or anything specific there's a much more interesting inflection point a little bit later so perhaps we'll move what's that delicately yes that's a good idea so perhaps uh let's see why is this not going there we go so uh my goal is usually not to create any turbulence at all and so I'm going to do everything manually and you know you're you're seeing that I'm I'm taking advantage of manual quite a bit uh I make sure that his pressure's okay before I enter I put in tree essence and didn't see any vitreous forward I put in try pan blue because I'm looking for where the heck is that capsule um you know what's happening with the anterior capsule and I'm doing everything with just uh just a syringe and the eye is full of OVD so that I keep it normal intensive throughout the case I have to replace it you know and this is not the time to you know to to be measuring how much OVD you're going to use and now I need to establish the appropriate planes so preferably by uh by blunt dissection but sometimes by sharp dissection it's necessary to break these synechia these uh uh posterior synechia uh and to establish a free iris again and so a little bit of sharp dissection trying to spare the iris rim as best I can and with more try pan uh so I'm just starting to uh to be able to visualize the the visual axis here and uh with more uh more help from plenty of OVD and a little more try pan here and there which I like on an osher cannula which is just a cannula with the hole at the bottom instead of at the tip that allows you to paint try pan very accurately where you need to uh under OVD and so now I'm just I'm removing the flocculent lens material and you know this is going to be a long case if I want to make it a short case then I'm going to use the equipment you know INA and but but I'd rather keep everything in its place since I just don't know where anything is and so now I can see that I have some anterior capsule above and I'm breaking the posterior synechia of that upper area of the iris uh and I don't know what's going on below really I don't see any hole in the in the posterior capsule as yet this is highly edited of course so I may have used some treasants in between I'm not sure but of course we're filled with OVD so it's not all that helpful uh at that point it can block your particular identification of vitreous um that's why I put the treasants in first before the OVD uh and um and so I'm trying to uh to establish my planes and remove any flocculent lens material that I possibly can and uh that's a little subconge epi lidocaine epi even though it's general anesthesia just to try to get some hemostasis which you'll see didn't work too well um I'm doing goniocinicae lysis now I decided not to put a goniolens on just I need my view more than anything else so I didn't think I would do anything different than what I'm doing anyway even if I viewed it but the goal is to try to open that angle because it still might be functional uh now I'm going to use a double arm tenno uh in order to two double arm tennoes is what I'm trying to decide now in order to deal with the erdo dialysis uh and these lovely little uh uh forceps from MST are just so fantastic I here I've got a straight needle I always have the scrub nurse I have no financial interest any of it by the way I always have the scrub nurse uh follow my needle tip because it's a very deep uh orbit orbit in this little boy and look I go through the drape and when you do that you need to get the needle off the tray uh and uh so I have somebody else watch you know you're too busy uh to watch everything and so I'll watch if I've uh I've invaded my um my uh drape and that needle is contaminated uh and cut it and get rid of that so here I'm of course when you do an erdo dialysis you don't want to make it tight uh tenno is fine I do have a paper with Boris Malyugin where we showed that even the nine oh can uh going through a um uh an eyelet will get cheese wired and that's really not so much the dissolution of the land of the of the material but more that it cheese wires through an eyelet so you don't need a nine oh if you're going to be having no eyelet and sewing iris just tenno is fine I decide that I have enough anterior capsule that I'm going to put a three piece lens I didn't think a one piece lens would be okay because I couldn't see any capsule for over 180 degrees so I wouldn't allow the uh one piece haptic to be in the sultas or near the iris and I decided though that I had enough coverage to place the three piece IOL which I did and I looked everywhere for any possibility of of of any vitreous and didn't see any uh and uh there's my last treasance dilute treasance and at three months post-op uh he uh he was 2060 so we waited three months to do the yag laser because and there was this interesting hole here in the anterior capsule and this is this is the rest of the anterior capsule and so we waited and we did the yag and and then he was 2025 uh uncorrected actually amazingly enough and uh with a quiet eye and off drops and this is what he looked like same day post-op and then we we quieted the eye we used a fair amount of anti-inflammatory topically I left some treasance in the eye at the end of the case for the first few days we followed him closely he really he did he was 2060 on day one but he did come around and we gave him polycarbonate safety glasses even though he's plain on the other with a progressive ad and eventually we had to let him go back to dodgeball and he returned having been hit in the eye with iridus and and the question was what to do because look at this the haptic of the IOL is sticking through the iris which is why I didn't I thought the lens was dislocated uh and had to be and I had to go back in so the plan was to go back in an unsustainable unsustainable situation uh and I presume the IOL was unstable and here's where you'll see that everything is not what we think it is and I just have a few minutes I have three minutes it looks like on my watch I'm sorry that it's almost over because I'd like you to see the end uh we're going to use a trocar uh system to uh do the vitrectomy because my plan was to do uh take care of vitrectomy uh one port par's plane of vitrectomy and a posterior capsular rexis after uh to enlarge the enlarge the yag into a with a vitrector rexis into something that was capturable for the optic that was my plan but you'll see that things don't turn out as expected at all because when I go in there to start doing this it was very hard to get a hold of the uh the capsule edge and what I started to notice was that that lens was just stable as could be and I I just didn't see any uh here I'm starting to enlarge the yag uh but uh the thing was is that I was so surprised to see how stable that lens was and yet the haptic is up here in the iris and uh so um I'm going to come out and I'm going to explore and would I decide and I'm uh that was before valves in trocars so I put a plug in the valve uh always want a closed system and we're going to explore and what I'm going to find out is that that lens is just stable as the day is long and beautifully centered so I don't want to mess with that uh and uh now I have a nice opening but what am I going to do I'm not going to leave that haptic there so I'm going to untangle the haptic and um hopefully I can't speed this along unfortunately and I think I'm going to be about three minutes late so my forgive me uh we had some good discussion now along the way I'm going to untangle this haptic uh I'm going to find it here and I'm going to release it from its attachment to the um to the iris and that's you know our sutured iris there that's the iris that was had the iridialysis and when I get a hold of this thing what I'm going to find is I'm going to give it a shake and this thing is just that lens is so stable uh so I decide the haptic isn't doing any good and it's just causing trouble and I decide to amputate that haptic and then to bring the iris taut uh so that he has with time he got more and more of a bigger pupil uh and so I'm going to use a seeps or a modified seeps or not you know and uh uh this um uh technique to make the pupil a little bit more physiologic and taut away from the uh capsule and the lens and uh this shows a very good lesson at the end uh so I'm I'm hoping that you'll stick with me for another two minutes um and and that is that I'm going to remove the OVD with the protractor since I already have it out and my last maneuver is going to be to put in treasance and uh you'll see the shocker that happens when I do that because everything looks so stable and so perfect and that's the first time I saw vitreous present and whether it was there all along or whether it was that I stirred it up I don't know but I didn't take the truck car out until the end and so I was able to go in and and call home that prolapse vitreous out of the way and uh ended up with a wonderful situation and then finally leave some treasance and everything is nice and stable put a stitch over there and this was sutralis you want to tamp it shut like any scleral tunnel the floor and the ceiling have to come together and then you need to firm the eye to see do you have any bleb of any sort if you did you would take down that conge and you would suture it uh which I didn't need to do and uh that was the end of that case and here this is two weeks post haptic am amputation and uh he was off all meds for four months uh after four months and everything went great I have ten-year follow-up and uh and he requires one drop for glaucoma at the present time so hopefully he'll be a candidate for some sort of mig someday and and have a very happy eye that is only missing its presbyopia ability and maybe we'll have some ability to do femto index shaping at some point and give him a better near as well as distance so thank you so much for your attention and uh uh just to sum up avoid irrigation and turbulence identify structures maintain the chamber compartmentalize exposed to regular mesh work avoid cotterie prepare the patient for more than one surgery thank you so much for your attention I hope this was great it's my privilege and pleasure to be an adjunct professor here at Utah and I'm always aghast at the wonderful things that you're doing here so so glad to be part of it thank you I'm here for questions if anyone has time and any questions or wants to see any surgeries I even have my computer along