 We're well over a decades and I did have an interesting arc of my career in that my husband and I started a mom and pop group in the Midwest where we were needed in Iowa and we grew to 22 docs and nine locations in two states and all the subspecialties. In the first ten years, however, we did everything together. I did buckles and PKPs and trivaculantides and open eyes and plastics and you name it and all the pediatric cataracts and then my husband was a pediatric ophthalmologist but felt I was better in the eye so I was his technician for that and that led to quite a broad understanding of the eye and different specialties and as we got more and more subspecialists to join us, I no longer did this or that or the other and have sort of settled the last 20 years of my practice into enter segment reconstruction and complex and refractive cataract surgery. We had a 30-year plan. We have four children. We now have three grandchildren. For the last four years, we job shared every other month with Paul and Priscilla Arnold. He had been a resident with me. You may have heard of her. She was president of Ascrus for a while and decided we all like the months off better than the months on and I have retired from patient care though I seem to still have some things to teach and as long as people feel that I'm helping out, then I'll continue. So it's an irrelevant, I believe, to this talk, this minimal financial disclosure and you know, I'm coming to a great residency so I may be telling you a lot of what you already know or maybe some of it will be slightly counter to what you are taught and it's up to you to put that all in perspective but we must maintain a normal tense of globe as much as possible if we want the eye to be a happy eye and certainly when the globe changes pressure dramatically that predisposes to supercarotid hemorrhages and that the little vessels are anchored and it also increases inflammation and I believe it harms the anterior vitreous attachment which we don't think about much with Weaver's ligament as well as zomials and so maintaining both a normal tense of eye and keeping tissue planes in their proper relationships I think is very helpful to having a quiet and happy outcome from cataract surgery. You want to coat delicate tissues that's no surprise if you don't already know all of the nuances of the soft shell technique that Arshinov taught us it's well worth understanding and knowing and I believe that although there are many OVDs out there it is very nice to routinely have both a cohesive and a dispersive viscoelastic at your disposal for their appropriate best use highest use we want to respect tissues keep your hands late I assume you get to see your own videos and if you're always out of out of the the right place but you start in the right place that means you're pushing on the globe you push on the globe you're not going to have the tissue tell you what it's doing and you won't be able to isolate your activities and won't be as effective and maintaining visualization of course with try pan if necessary or tree essence if necessary and being aware that you should always focus there's one disadvantage to being young in eye surgery and that is your ability to accommodate and that means that you don't really know where you are in the plane of where you're acting and people who have a lot of edema day one post op generally are so fearful of being close to the post chair capsule that they're unknowingly really up near the endothelium and so I always tell people to be super active with your focus and be and that will allow you to know where you are in the eye now with great accommodation you have such a broad range of focus that it's a little tough but just keeping being mindful of that is helpful thorough removal of lens protein I do not believe that the enemy of good is of better is good or whatever that horrible statement is that you should just leave well enough alone and sometimes leave stuff behind cortex is has been shown to be one of the best media for growth of bacteria and certainly it increases inflammation as it's super antigenic we all know that the embryonic lens material is never exposed to the immune system and so it's foreign body and always be prepared for contingency because the only way to keep out of trouble is to not operate and it's kind of your job to not lose vitreous the same way twice not to not lose vitreous now it takes a village I really recognize this and you all have a privileged opportunity to travel and go to different places to operate and and I when I first went to India many years ago to help set up the run a diet thing which actually is a desert foundation beneficiary the safety started something in I think 2003 I was there in 2004 to help them brought texts well the first year I went I thought oh well I'll just show them how to operate you know and they knew lots of things but there were holes in their knowledge and there were so many holes in their knowledge that the next time I came with a tech and a scrub nurse and you know realize that that it isn't just what you do you have to control what's around you as much as possible and certainly you're aware of the new the guidelines for ophthalmic instrument cleaning and sterilization which is very helpful that we have now the pilot checklist positioning when you go to a new place to operate the very first thing you should do is have somebody lay down as though they're a patient and work on how the headrest should be for you you know if you're short-waisted if you're tall if you're long-legged you need to be comfortable not only to do better surgery but also for the ergonomics of your lifelong activity and not to end up with cervical problems and and back problems and thoughtful choice of instrumentation there was I tried 15 speculums before I decided which one I thought was the one that applied the least pressure and then went from there so you know so many people will just use whatever they were used to using but sometimes it's really helpful to look at that and then anesthesia I believe we shouldn't be all topical we shouldn't be all Perry Bulbar we you know we need to choose actually in the operating in the in the office what's best for an individual patient I did about 97% topical but there was 3% that work appropriately I believe Perry Bulbar and and then of course there's the occasional general that's necessary a good meta-analysis was very interesting lately in ophthalmology management of all places I know it's not a place that you know we're supposed to quote but it was very interesting in showing that oral sedation is probably the most cost-effective rather than no sedation or IV sedation anyway it's an interesting thing to look at but the main thing is when you shut when you ask your patient you're doing an indirect and you say look up look this way look that way and they just squeeze and you got to squeeze their pull their eye open that's or they can't fix it on your light at all that's not a patient to do topical because you'll have to snow them and that's going to lead to a non-cooperative patient and a potential complication talking to the patient is so important can you go as nearly as your eyes still and steady straight ahead as you have it now even if the light seems to move you just want to do your best not to move your eyes around just stay pretty much where you are unless I ask you to change your position you'll see light and motion and color nothing distinct or disturbing we've begun you might notice a slight sting for a moment if you do it will just last a moment it's a little extra anesthetic for your comfort a light might come and go or change color that's normal your patient and what I did was I kind of developed a pattern ecology family background and every every word means something to that patient and they're hyper aware of what you're saying and so and the pattern might seem boring to you if you get to say the same words every time but your goal is to make every eye behave the same way even though every eye is different every patient is different and if there's consistency in what you say to the patient that's helpful to help them cooperate it also helps your staff tremendously because not everybody can see the monitor all the time and they know there's more or less saying the same thing just where you are in the case pretty colors as we use this gel to coat the delicate surface inside and out keep it smooth and comfortable throughout the case look at the light please kaleidoscopic effect here visual highlighted a surgery last to the annoying eye drops when you go in with your fake oh sometimes the light the patient be fearful or else everything they feel is pain that's just how the brain works as I never was the fastest surgeon I was an 8 to 10 minute surgeon but I was one of the safest anywhere and my patients regularly said can't wait to do the other eye you know this was the most exciting experience I mean people can be happy about this kind of surgery so speed does not equal efficiency because every time anything goes awry you lose many more minutes than if you make it go slowly protecting the corneal epithelium as well the as the end of the line makes for a faster recovery and patient and then the odd patient of course who can't recover their epithelium is protected you want to protect the macula both the patients and yours and you know everybody starts out with this shoot the brightest light the microscope can provide you don't need that for perfect visualization so each time you sit down to figure out where you like to be you know just turn it down a little bit and see if you still see the same and also use something to protect the patient's macula when it's not necessary to have your view and look towards the light kind of fight to look towards the light that's it keep doing that if you can comment like things will brighten up as the lens goes inside was folded into a little tube if you go through this small opening and springy arms will open to keep it centered and secure within the bag a little housekeeping and you'll be out of here cool feeling for the last time perhaps look at the light now rinse to be sure nothing could have hidden out and enough for cranny abating our attention certain water tight without a stitch by being sure there's no gel between the lips of the incision finishing with a little antibiotic to foil any germs that could have escaped all that cleaning I'm adjusting the pressure than normal you're a great patient things have come without a hitch you may stoop lift and bend and use your eyes just don't rub it or get anything in there 40% chance to see just great today 90% chance it'll be clear by tomorrow 10% take a little longer to see their best and that's where they turned off the faster than you are no harm to ask me the question when we're done just in case that catches in your throat again is that when there's a first of all we always inform patients we have to cough let us know but really most of the time they don't know until they cough right and then they become super fearful for one thing and so you can assure them if everything was okay afterwards that you were faster than they were no harm done but most importantly I believe that in addition to telling patients to warn us if you can that you tell them but the most important thing is just to not lift your head and then my scrub tech or nurse was instructed to always immediately and I don't like to strap people down because they get claustrophobic and it just isn't necessary most of the time so their job is always to just put their hand firmly on the forehead to keep their head down on the cart and that means that you don't have to pull out when someone has a Valsalva because if you pull out when someone has a Valsalva you're gonna lose chamber and possibly everything else too okay and as long as you stay put on foot position zero or one and just attach yourself to the patient's head nothing untoward will happen this is voiced over this has to do with keeping tissue planes the way they should be everybody knows when you have a high at my opa the trectomized eye that you're gonna get a retropulsion of the iris you know with a reverse pupillary block and it goes and the page goes and your zonules go right and so everyone knows that when that happens you just go in you lift the iris and you push down the anterior castle and you resolve it right now people who don't know that they're gonna be operating at this angle until it somehow breaks which is unpredictable and then all of a sudden they should have been at this angle there at that angle they have a complication but I submit to you that you know who this is gonna be by the time you do your capsule or exis in your hydro dissection you know you can feel that plus you know it's a my opa you know it's a detracted my die ahead of time why let it happen so what you do is you go in on foot position zero with OVD control with your second-hand instrument lifting the iris a little and then you go down into foot position one and everything stays stable the whole time because you've allowed the fluid to distribute between the anterior and the posterior chamber so that there's no retropulsion of the iris so that saves the patient pain and it saves stretching the zonules and having complications as well and then the second part so this just shows this in kind of slow-mo and the second part is is that you don't want to let the chamber shallow and so it's unless you use a chamber maintainer all the time which really is not a bad idea although it's you know that's extra bottle something to think about an extra incision which is why I didn't do it I used a poor man's chamber maintainer and what I mean by that is you're at risk whenever you have irrigation in the eye and then you come out of the eye and many eyes will stay the same but many of them will shallow because you always have stuff between the lips of your incision so it doesn't truly seal as you as you withdraw and so I always exchange my second-hand instrument for VSS and irrigate into the eye as I come out and then I may need to continue irrigating till I get my INA switch you know my Fego switch for INA or most of the time that's good enough and it'll seal similarly when you do this get rid of the INA and switch for the OVD you want to be irrigating some some BSS into the eye to keep the chamber stable and I also as Osher most popularly showed people you want to irrigate your incision nicely before you remove the OVD for the last time after the IOL is implanted so that it has a chance to really seal when you come out with your INA and there's no more OVD in the eye I believe that eyes that have the tendency to shallow like crowded chamber eyes hyperopic eyes people with PIs and so on when they shallow like that and then you go in with your fire hose with the next instrument that's when you get misdirected aqueous and hard eye because the way they're set up is easier for the fluid to go through the zonules then it is really for the eye to deepen and so almost always that sudden hard eye will come after you've allowed the eye to shallow and then you redeep in it like crazy with with with fluid so this video just shows that and the voiceover is not too important since it isn't loud enough and so you see I have the second you're on foot position zero over here I only go to one once I've lifted that iris and everything stays in a nice stable position and now I can raise and also you can start by lowering your ILP or your your bottle and then here is just showing I finished the faith so I'm going in with BSS on a you know 5mm syringe or 3mm syringe and irrigating until I'm ready to go back in so that the chamber never showers and I think you'll find that your eyes have less inflammation the next day then patients are more quiet that this really makes a difference and then once again here I'm irrigating the incision before I go in and I'm getting some of the OBD out that way and now I'm going to go in and can't to leave her under with my it doesn't shallow when I come back out finish we'll talk more about the one later okay so iris prolapse you probably all know what to do but you know what I'm doing here is I should be irrigating into the roof of my incision instead I'm irrigating into the incision in a floppy iris or a crowded chamber and your job is to see the iris prolapse to the internal decimates incision not all not wait until it gets out the tunnel because then you will never lose pigment you'll never have an iris and you'll be able to have an intact stroma and epithelium both so that you don't have a floppy floppy or iris every time it comes out and then of course you know you've overfilled or there's too much pressure so the first thing you do is go to the paracentesis and release all the pressure to get the iris to go back in any time I touched an iris I knew that I'd have more cell and flare the next day so if I used a male ugon ring for example or hooks or had to manipulate or do postures sneak yet in my later years I would put a little puff off label of treasants in there at the end and that I look the same as every other eye on day one post-op because when you touch the iris that eyes gonna be more inflamed now maybe you can tolerate that little bit of inflammation and so will the patient and you're clobbering them with steroids anyway but why allow that so this is a high pressure and you can see that the moment I open the moment I open that incision see the iris is ready to come out and it's a crowded chamber shallow chamber and so I'm putting OVD over that protect that iris I'm putting a little cohesive and in these very crowded chamber eyes I virtually never I really dislike the idea of dry vitreous tap though it is a last resort and instead of use a heavy cohesive OVD like a hill on GV and I prefer not to use five in these cases I think five should be very isolated reasons and then use dispersive as well like a viscota and a coat then you can constantly protect you can you can deepen things with your with your heavier visco elastic and make it flat enough and very and then protect the iris closing the door with a little dispersive and then very carefully start a smaller Rex's to me I would not pinch such an eye with it forceps because you never know that that pinch might go straight out and always keep the right angle on your Rex's and go slowly so that you can always deepen now here you'll see that the iris is just starting to come out you see and I'm very aware of that and I know you could go through a paracentesis with a different eutrata type you know the ones that are that don't open the wound but I didn't find a separate instrument necessary I just might have to go in with a little more OVD and make that iris happy again just a little we're talking a minima to because if you overfill and never feel distilled to proximal you're only feeling proximal to push things back in if you go distilled to proximal you're going to push the iris out also in cases like this never exit on foot position one on a irrigation to me one of the biggest enemies of great surgery is continuous irrigation I don't know if you're trained to do that or not I think it does save some complications and problems because you don't want to be in foot position zero when you shouldn't be right and stop irrigating when you should be irrigating but once you become facile with your foot positions why would you always want to be irrigating for one thing when you go in and you can keep watching the video here and you see I'm never allowing it to come out never never maybe into the tunnel because I can't help it okay and then the slightest little little bit of hydro dissection we're talking a minimum or two and hydro dissection I'm just going to stop that for one second hydro dissection is not irrigation hydro dissection is irrigation with slight volatment because in my opinion because if you just irrigate yes you're going to get a good fluid wave if you have a perfect normal eye then everything goes great and it's very efficient but you have the two risks when you when you do this one is blowing the iris out because the lips of the incision seal behind you because of OBD and and so something's got to give okay and the other is blowing the posterior capsule out because you get a ball valve effect of the nucleus and the capsule right and you put fluid in and there's nowhere for it to go so it blows the posterior capsule out so you don't want to allow a ball valve effect or a totally confident incision the fluid has to go somewhere and you want it to go around and out right so as you're irrigating you're subtly volatting to push the posterior lip of the incision and the nucleus downward away from the capsule and you will never ever ever in your lifetime blow out a capsule okay I never did 30,000 cases or so over 30 years so once again I'm just showing you how deliberate we are you know with that this is maybe a 2.2 chamber to start with okay 2.2 millimeter deep chamber and I like going in on foot position zero most of the time though you have to be very aware that you have to go to foot position two and establish flow before you go into ultrasound or you'll burn right but when you do that you can see decimates as you go by it the patient doesn't flinch you have total control unfortunately I had a few bubbles in there but a couple bubbles aren't bad because they're your barometer when they stick up into the endothelial protection and your OBD they're your barometer that you're having no impact on the endothelium this is a little I did this in real time because I want you it's a little like watching paint dry I mean look how we couldn't get a lot of hydro dissection in there so I'm being very gentle with my with my rotation and it's a little edit I want to show you that I got into a little trouble trying to get it from peripheral so you just get it from the center a back crack is what I call that and we'll talk more about that when I show you all FAKO stuff in a video which hopefully we'll get to because I have like two hours of information and you know whenever whoever can stay I can stay so at any rate you'll just see that we're we're we're debulking the nucleus from inside and doing everything almost in situ until we're getting the epi nucleus out and then it's really important of course to replace the secondhand instrument which for me is always a rose and split or no matter how dense the lens which is a non-sharp old instrument that last 30 years and never needs to be replaced it's got a non-sharp outer edge and tip and then it's got a slight wedge like shape on the inside so it works in so many ways for me and and then we'll complete the case and sometimes you'll end up with these eyes that have a marble like cataract with a little small rexist just make sure it's big enough for your FAKO it's always easy to enlarge also I like to tailor certain drugs for patients patients with at-risk nerves patients with really shallow chambers pseudo exfoliation really dense lenses glaucoma ocular hypertension as long as they had no sulfa allergy I would give one diamox sequel on discharge and virtually never have a significant pressure rise the next day since it lasts and here you can see I'm really spending some time and energy to make sure that I have a watertight incision and so FAKO machine settings and parameters don't set it and forget it you know so many people out in practice now that I'm talking to the speaking to the choir here because you know your institution has published some of the best articles in the literature about proper machine settings so you're probably much more wary but so many people out there though they are supposed to be captain of the ship and the ship includes the machine we'll just delegate that to the rep or the scrub nurse and so on don't do that so understand and Barry Seibel's FAKO dynamics textbook is a great one is your eyes time too high you know is there things happening too fast once you occlude because the pump speeds up you know do you need to decrease your flow rate I'm not a fan of linear flow rate it makes no sense to me because the whole concept of flow rate and that's assuming you have a peristaltic pump and you can set it separately not a venturi pump the whole concept of it is to know how close you need to get to something before it comes to you besides speeding up the procedure because it comes faster so if you have a linear aspirational flow you see linear vacuum makes a lot of sense especially for INA because you know when you want to pull a little to make sure you have the right stuff and then when you want to just evacuate and pull a lot but do you know that you want a variable distance of how close you have to get to a particle before it comes to you you can't do it that as you go down so I'm a I'm a big advocate for panel set flow rate in peristaltic machines um also I just want to point out that cataract surgery is really kind of unlike anything else we do in the world and then it isn't just high error hand-eye coordination is hand-eye your foot coordination right and uh so you have the opportunity to become great at that because you don't need a patient to practice with the foot pedal and to listen and you can just go in when the bottle's still hung and you can you can pinch the tubing in here ding ding ding and you can know and you can watch and see when you're in foot position one two or three and of course you can put a detent in there early uh you know when it gives you that buzz in your foot you know when you're learning uh to know when you're switching foot positions and if you're heavy-footed you can have more range in in foot position two and less than three and light-footed the other way around so become a master of that foot pedal because there's very little that we do that involves both the hearing and of course in a peristaltic pump you don't get vacuum really until you occlude so that's something that you hear so there's no point in using ultrasound unnecessarily ultrasound is strictly to um to borrow into things to apply mechanical force in my opinion now I never sculpted an inch I I started my residency doing intracaps finished my residency during doing extra caps and we did an occasional faco on a young person at that time uh and kind of learned it uh mostly from gimbal in my opinion he was really a great mentor to all of us but the point is that ultrasound if you don't I mean sculpting to me is such a waste of ultrasound though granted you're kind of deep you know so it's not too bad for the endothelium but your goal is to be inefficient right is to lose most of it and just to sculpt whereas chop techniques and particularly I'm going to show you more of mine use every bit only to gain purchase so you can apply mechanical force and then to assist aspiration flow okay uh with a little so you will keep your cdrs or cds or whatever ept's or whatever machine you're using very nice and low if you keep that in mind that you're not there to use ultrasound on the thing you're there to use mechanical forces and your uh hydrodynamics and just to assist that with your ultrasound um so practice with your foot pedals without a patient now uh here I just wanted to stress this business of being gentle and this is an eye that that's maximum dilation for the eye so we're gonna sort of gently do a posture synecialysis here and sometimes you have to go a little further out in the periphery but I'd prefer to do that with a little ovd a little um viscometriosis uh and uh this is just a kind of a combination case now never stretch a floppy pupil but the two point fry stretch is quite gentle if you think of it like the sphincter of some of you are interns like the sphincter of the cervix you're not trying to destroy the cervix muscle right you're just trying to dilate dilate dilation and curatage so gentle gentle I never go bam out to the out to the limbus and I don't like the bealer because it's a little less controllable and now we're going to do a little viscometriosis uh in order to be sure that we're free and then with my technique of vertical chop I only need the uh pupil to be big enough to do an appropriate capsular rexis although some people will do a capsular rexis under a really small pupil I won't so as long as it's five millimeters that's good enough um sometimes you need to make a little snip especially if there's an inflammatory membrane you make a tiny little snip not through the sphincter just through the membrane and maybe the little bit of rough and then sometimes you're lucky you can just pull that all off and the pupil gets to be seven you know millimeters eight millimeters otherwise you can make tiny little sphincterotomies all the way around uh per you know away from you and then if there are scissors that go uh uh backwards I think they're mst osher scissors I've no financial interest in any rate usually that's not necessary and if you do that and you treat the pupil with care uh then you will have a functional pupil better than it was before and not all stretched out and uh with transillumination defects uh if you keep in mind that your goal is just to tease it into the right position not to force it there I think it's really important I mean I I wanted even before femto uh and I got a femto and did quite a few cases with that before I quit um but I think it's really important to try your best to make the appropriate size capsular x's that just covers the edge of the implant I want everyone of mine to look like a femto did it so in order to do that you need some frame of reference and I just wanted to mention here let me stop for a second so what I did you probably saw is I just like to hover over with my caliper at five of course there's parallax so it's not perfect um and the best thing now uh is a really interesting uh thing maybe one of the few purposes of femto laser uh with the lens are they've added a little divot you know that they can put for uh uh for the uh lining up um your toric lenses and uh that's an additional benefit to just knowing exactly what size your capsular x's is going to be and I was impressed with that because there's no parallax that's the reason I brought it up but some people will use a uh an old rk marker you know or a marker to mark five millimeters on the don't do that to the end of the epithelium you know I mean that has to heal right if you can see that mark for a little while that has to heal so I just hover over because the idea is the only thing that stays constant is the radius so that's the only thing you should pay attention to at the beginning is the radius needs to be the same in every case because you have white to white that's different the pupil size is different so it's very hard to judge how big to make your capsular x's without some reference or being great at knowing what your radius of curvature should look like for a five millimeter rex's right and uh so I like to hover over and the reason I have this video in here and I won't belabor it uh too much is uh that you saw me hover over and now I'm going to just double check where I am okay um I did it at the beginning because this is a huge myopic eye almost a megalocornia you know it's not a megalocornia but it's a big myopic eye and I want that capsular x's to be perfect so often in big eyes you end up making the rex's too big too small and in in small eyes you end up making it too big if you don't have an extra frame of reference and it's this dimension this radius right here from the center to the periphery that uh that is constant in every eye so you see it ends up just right okay I hate it when people relax there when people make a relaxing incision in their capsular x's and I only show this it's really gilding the lily firm very early restore uh but I wanted to show this tangential snip that if for some reason you need to make your capsular x's bigger you have a complication and you have nucleus still there or whatever just don't sacrifice the potential for optic capture okay and uh just make a tangential snip and uh pull it around and you'll do that in your um uh most often and in two messing cases because you want to make a really small thing to begin with and it may not even be big enough for say Faco you'll want to do that when you if you use crystal lenses at all you know you I liked it to be outside of the optics so I might enlarge it at that point um and so on it's just a really important technique to have in your back pocket I don't do you do facto here you do a fair amount don't you okay so uh I wrote an article uh the lead author with Burkhard Dick here and he's just showing how dimple down technique is a great way uh to take advantage of the little technique um you know of pulling uh your Rex's uh Rex's rescue uh with Femto uh so this is an eye that had I never would have attempted it but here's an eye with a corneal scar and so he's pretty sure he hasn't got a complete Rex's and what he's doing he's stated just so you could see uh that's not really the point but the point is is that rather than grab it anywhere to remove it if you push down in the center since you really don't know um you really don't know where your problem is unless you have a corneal uh uh opacity you really don't know where a tag might be so you don't know which way to pull backwards if you just push down in the middle that essentially pulls everything into the center which is the little rescue technique I see some uh quizzical looks on faces you have a question I've not made myself clear so if you um if you have your uh incomplete Rex's and the tag is here right it's still attached here if you knew that you would then pull in from here right you you know what I'm talking about the little rescue technique actually I understand Gimbal described that about 15 years earlier but little has taught it Brian has taught it so very well uh and it's become uh his eponym at any rate you would pull in that direction now if the tag was here you would pull in that direction right well you often don't know with Femto if there's a tag at all of it isn't free floating right so if you just press straight down what we're calling dimple down central dimple dimple down in the center then it pulls everything into the center no matter where that tag is and uh Burkhardt who's done thousands of these I didn't do that many um says he's never had a a a capsule of run out um using that technique you're doing that with your viscocannula yeah you do it as soon as you can you know it's uh the moment that you're able you know before you lose chamber is the point so yes with your viscocannula or with anything that you could just reach in it once you have your OBD in the eye then you if you're gonna you reach in whatever you would have used to pull the capsule out with don't pull the capsule out don't lift the capsule up push it down in the center yeah uh of course if you have a tag and you lose chamber then you're likely to have a tear right so the point is not to lose chamber and to push down and dimple down the moment before your your you might lose chamber any other questions about that okay there's a nice article uh I forgot the reference but it's in JCRS I believe okay so this is old admittedly old video but it's it's the best one that I have to demonstrate how uh a vertical chop technique you know which is chop is a misnomer all together because um we're not chopping anything we're creating fault planes um it's uh so uh horizontal I believe although it's effective it's not a good technique because you must know exactly where your rex is you must go out to the equator you don't know where your zonials are or what you might grab or if there's a cortical cleaving you know a cortical uh uh capsule or adhesion and so you must go out and come back in with vertical chop you're always within the safe zone within the five millimeter rex and um the reason that it's so difficult for most people to learn is that it requires exquisite control of your foot pedal because your goal is to burrow in and by the way I believe that burst is definitely best and non non uh torsional non ellipsoid although I don't know if you have a machine that'll do this for you but the point of those things of course is to make a bigger swath and your goal is to make the tightest tunnel you can so you have something to grab onto and if you eat what you're grabbing onto then you have no purchase right so you don't want a nice big swath of a tunnel when you go in you want a nice straight one right and you uh i'm doing some hand motions which unfortunately won't be recorded but um at a rate um uh you also uh only want to go in to get enough purchase and it varies depending on how soft or hard the lens is to be able to start your fault plane and then in classical vertical chop you need once you get in and the nice thing about burst is that instead of being the whole way through on your you're able to your linearity uh applies in a controllable way your faco and you can set your ultrasound power to be just right for the particular nucleus so if you have a five plus you might set it at 70 percent or 80 percent ultrasound if you have a two plus nucleus you know maybe you need 30 or 40 percent ultrasound but when you you're using pulse you don't get there until you until you use too little and then just right so you have a big opportunity to clog also and not really be able to gain purchase that's one issue so when you go and and as you in burst when you come down in foot position three the linearity is how close together the bursts are right so it's like that right and so you can really watch so when you start if you go nowhere you need your ultrasound up a bit when you start if you lunge through with your very first burst you're very unlikely to get all the way through though i did have one complication because of a high rise time that as soon as it occluded everything built up and it was a soft nucleus and the capsule came right up but by and large you know that your nucleus is about what four point your age you know your lens depth and if you have your your sleeve back and you should measure your sleeve should always be back the same amount not so much that it gets the irrigation out into the tunnel but not so far forward that you have no place to go because it's the stopper when you're trying to burrow in okay and so it should you measure with your with your um caliber in the beginning when you get the feel for you want to have it fairly far back and that's your dipstick so you know that if you have someone who's 80 by and large it's a four point eight millimeter lens and you've already removed a little bit of the cortex on top so it's a little less so if your uh if your sleeve is about two millimeters back um then you know you can't go because it basically stops the travel okay at least in a dense lens you can't really go all the way through so if you're not going anywhere with your first then you turn your old just sound up a bit and then you go now you have to stay in foot position two once you come up because if you go into three you eat what you're holding if you come up into one you lose your purchase right you lose your vacuum so while staying in foot position two you've got to then take your other instrument uh burrow down slightly in front of it and then you raise the one and sort of lower the other now to my way of thinking that's one important technique but not the best technique for all cases because if it's a very dense lens it's going to cause tilt of the lens and you want everything to stay planar and if you should lose foot position two you have no purchase whatsoever no ability to chop whatsoever so I do something called cross action chop which I use a lot I use multiple techniques straight vertical chop just as I described cross action chop uh back cracking and circumferential disassembly and I'll try to explain that to you I don't know how far we'll get in this lecture I could really talk for a long long time but each thing is a different case and I I hope it's useful so uh you'll see that now the whole trick of of doing and this is going to go from a one plus lens up to a five plus lens and then I'll show you a really dense what I call six plus bernessant you know what we call berness and this goes more or less to bernessan so uh the whole trick with a soft lens people say you can't vertical chop a soft lens no it's just all about hydro delineation that's the whole secret to a soft lens as long as you hydro delineate you may not chop at all you'll just eat the center or maybe you'll get it in two and it'll be gone but you can still use vertical chop there's no need in my opinion ever to sculpt any lens so here's a whole bunch and uh of uh and I'm almost inclined to let it talk for me you barely a one plus nuclear sclerosis where we don't truly need to use any ultra volume up because of the fluidics of the infinity we are in here to along with good hydro dissection and hydro delineation simply aspirate the lens material in a very efficient manner if they can hear it's fine a two plus nuclear sclerosis requires a little bit more effort I do vertical chop and all of my lenses no matter how much or how minimal if chop across otherwise they just show that again yeah aspirate you'll see it over no previous but what I want I should I forgot to shine it to you first you'll see it over and over and over I don't have to back up so cross-action chop is a combination between the benefits of vertical classic vertical chop and a pre chopper because you go ch ch ch and then take this to the other side not here and raising but just stay here take it to the other side in opposite directions and you don't need a sharp chopper even for the most brumescent black cataract because your goal is just to make a groove enough with that thing that you get in enough that you can sort of push it to the side so what that does is it doesn't tilt anything it's not as it's still more effective if you stay in foot position too because you're really holding on to that piece better but you actually get the ability to use that as a sort of a pre chopper okay you know what i'm talking about agahoshi's pre chopper that goes in and does that okay and so i use that most of the time especially in dense lenses and you'll so you'll see it over and over you can see that we're able to have excellent holdability and followability even though this is rather a soft lens we were able to chop you'll see that there's an almost magnetic effect due to the fact that we're using very low faco power and 20 millisecond bursts and with the burst the linearity has to do with the frequency of burst so that we can have bursts very few and far between or closer together as needed and reduce chatter significantly because the stable the chamber is so stable we're able to remove epinucleus and sometimes even cortex with the faco handpiece alone without having to go to every new set this is so this is direct this is a three plus nucleus sclerosis i've been showing you the this is all direct this is the usual type this particular before each case you'll see a cross action for this denser lens we've increased our dynamic rise to three which means that it increases by 50 percent of the preset aspiration upon occlusion to help the efficiency of the case you'll see that the material aspirates into the faco tip very quickly and efficiently and because it then quickly comes back to its original aspiration flow rate there's no surge and the chamber is rock stable one of the nice new advances in this software and this technology because this is a denser lens we're breaking into more sections and we can cross action chop there can direct action chop we can back crack and these are really the easiest lenses these somewhat firm meaty lenses that don't have a lot of fibrosis and aren't soft therefore tend to come away easily puzzle pieces come away from its attachments to the puzzle as a whole without difficulty i want to point out one thing that the faco tip is pretty much never moves i mean it'll go out to get something slightly but no ultrasound is applied except for lollipopping and then everything happens in the center and if you're not good at ambidexterity get good you know brush your teeth with your left hand eat with your left hand try writing with your left hand or your right whichever is the non-dominant you know i mean the the benefit of using that second hand instrument is just so great because that allows you to just go ch ch ch and you keep here in you know and you don't need to to go into ultrasound until you have some inclusion and you can help to break up and feed the pieces with the second hand instrument and remove the epi nucleus on the same setting though when things look like they're going a little quickly i'll switch to an epi nuclear setting i frequently won't bother to use the foot pedal to achieve that this is a four plus nuclear sclerosis and once again we're going ahead with a chop not get all the way to 180 degree crack centrally but we'll get there as we turn the lens the nice thing about this tapered tip which is new from our constant is that um i i just i want to point out um that in a truly bernese this isn't a truly bernese lens i'll show you one that is truly bernese lens direct chop just doesn't work well because you can't get the the thing to split all the way down in fact if it splits all the way down it simply is a bernese lens and you've seen people try to get that 180 degrees flip uh split and they go like that where you have the risk of stretching your bag even breaking your bag i don't want to do that because the bag has no protection right it hasn't got a big cushion of cortex or epi nucleus it's all nucleified epi nucleus and so i don't want it to split all the way through and you'll see that in the really dense lenses i want to debulk from the center because the fact is that um that uh fetal nuclear plane is still there of course you can't hide it a little delineate it in a mature lens only in a very soft lens but it's still there so we can take advantage of that by opening like a clamshell shallow little little um little uh chops and then going in and you'll see that much more definitely in the next in the really bernese in case then going in and pulling out that endonucleus and you may need to go around multiple times to thin thin thin thin but everything happens all the ultrasound happens at the iris planar below when you debulk the nucleus this is what i call circumferential disassembly i described it in the video journal about the malady in 2004 if you're interested osher's video journal um i'm not a big article writer i've been too busy being clinical um and um that's why i make a good adjunct professor perhaps and not a professor at any rate uh the the point is to debulk it from the inside leaving the shoe tree in the shoe so to speak the epi nucleophied epi nucleus the nucleophied epi nucleus protects the posterior capsule keeps the zonules expanded which are almost always loose and you debulk everything that's dense first and then allow either to pick it up in the center and cut it in pieces uh that went off but this didn't okay uh and uh or to efficiency by having a lighter opening but because it is correlated in our own neck and gradually tapers there's much less potential for clogging you can see our barometer bubbles under the endothelium remaining quite stable and we're able to feed these little pieces in with the help of the second hand instrument holding them nicely in place back chat uh back crack and taking the piece from the center in the back when things aren't perfectly hydro delineated I'm a whole two hour lecture on President Lenz's nice thing about the taper tip additionally is that uh we're able to have the sleeve rotated backward quite a distance on the tip since we're not so worried about the abs hole which is placed further back and then this fake o'neill compared to the flare tip because i want to prevent the chamber shallowing at all times i will irrigate through the paracentesis before removing my fake o' tip from the eye in every case some eyes will stay more formed than others second there are two ways to uh keep the posterior capsule from jumping up at you with those last fragments you know when you no longer have protection one it well there's three ways really one is to put ovd in and push it all back i i think that's crazy especially the dispersive comes out in little chunks like macaroni and it may bring the capsule with it um the second way is to uh protect make sure you hear that after you hold the capsule back okay and that's what i mostly did and the third that makes sense but i didn't do it is to pull your instrument out so that you don't get leaked through your paracentesis um because you have an instrument through there and that keeps the chamber a little more stable while you get that final piece but i submit to you that most people by the time they finish a dense lens will have stretched their paracentesis enough or there's a little particle there or whatever so it doesn't actually close when you take it out so i always prefer to actually hold the capsule down with the second instrument one of the big advantages to not having a sharp second hand instrument so i want to at least get to the really dense one here so maybe i'm going to leave this one because i'll talk through this next and uh just nuances keep incisions tight to control the chamber and minimize turbulence you know everybody makes a one millimeter paracentesis that'd be fine if we had a one millimeter instrument we were putting through it with a sleeve but really you just want the smallest paracentesis that gets your instrument in because uh we'll measure 22 ccs a minute a bss rushing through the pair one millimeter paracentesis one you have an instrument in there uh and uh tailor the procedure to the anatomy and adjust ultrasound density as we discussed and try never to lose pictures the same way twice learn from mistakes video but i i know we're running out of time so i'm going to go ahead to uh one last since we're on the subject of brunessence here uh and this is a case and here you can see the cross-action chop and how it kind of i'm only going in a shallow uh for a shallow chop oh i forgot to start this one this is a same day bilateral sequential case under general anesthesia with posterior optic capture to make it one anesthesia for the entire life of the patient all cross-action and i'm not trying to split all the way down and you'll see that what we're doing is we're trying to uh gain purchase and just kind of open things up a little you see i'm not stretching way far i'm keeping everything in its proper tissue plant there's the first time i got a bit of endonucleus do you see that um so here uh as i open it and i can gain purchase on a piece and i've sped this up because it is a labor of love to do these really dense lenses this way it'll take me say 20 minutes i've never gone about 40 seconds of cde ever and these corneas look as clear the next morning as the california cataract because everything is done under a soft shell of dispersive and tight incisions make it so you don't have to run through a lot of bss and what we're doing is you can see we're debulking the endonucleus you see how i'm pulling out i'm peeling the endonucleus out of there can you see it well enough uh and and there there's a good piece and i'm using my secondhand instrument sometimes to strip the leathery posterior fibers uh and uh as so that they'll be free to be aspirated and you can see we're up to 19 seconds of cde right now not much at all and we have our shoe tree in the shoe we have what i mean by and you see i i've got 90 of phagopower for this ultrasound so every time i go it's with 90 ultrasound all right but i'm using such little bursts of it just to gain purchase and then to assist aspiration flow and you see how we're starting to see a red reflex finally of course you're going to use tri-pan for these eyes because uh what seems like a red reflex is really just a pernescent reflex you're just seeing it now and my goal is to try to uniformly thin it until then i can begin to take out the epinucleus and when i do that i lower the aspiration flow rate in vacuum uh because i don't want that floppy capsule now to come up so now uh and you can always replace ovd which the other video showed up just up to my time limit now by just sitting there with your faco go to foot position zero come out with your second hand instrument then irrigate the uh viscote into itself then be sure that you and look how i'll protect the posterior capsule see with the instrument down and it's so consistent that i i did in iowa people came off the farm with these kinds of cataracts all the time and i did all of them nobody wanted to do them uh and you can see that the the left eye was a little less dense than the right so i got that one done first it's faster uh the one on the the one down below on the right the second eye i always do the worst eye first and if there's any complication they know i won't go on to the second there are dictates of appropriate uh techniques for uh same day bilateral surgery there's a whole society that you know we have all different uh now i'm opening with what i did was i put ovd in the sulcus and then i use a 30 gauge bevel up needle to open the posterior capsule and then cohesive ovd through there to actually form burger space is another two hour lecture but um then we can very nicely because we have a nice planar surface because the two capsules are together with ovd in the sulcus and we have the uh hyloid protected and posterior because of the ovd that we put in there and there was a little fibrosis so you can see uh on the second eye it goes a little smoother on this first eye i'm a little bit chicken all i'm doing though is making sure i have the appropriate size anterior rexus before i even attempt to posterior rexus and uh you'll see that i'm a little chicken and following that cookie cutter so i'm even enlarging you see i didn't you don't really have to that might be a little overkill but i'm enlarging on that first eye the posterior rexus so that it matches the the anterior rexus beautifully but it's a little smaller because the posterior capsule is so much more elastic it doesn't have to be so big here we're taking a three piece lens and putting it now in the bag so i've put my ovd instead of in the sulcus now in the bag and i'm going to rotate this lens entirely into the bag and then we're going to capture the optic it's fairly similar into burger space it's fairly similar here i'm capturing fairly similar to how you capture from the sulcus into the anterior capsule into the bag except that sometimes you have to walk it across from optic haptic junction to optic haptic junction because it's just four six millimeters thick and it's very elastic so this patient now will never require another surgery and i'm just going to summarize by saying customization communication visualization concentration don't be talking about sports when you're in your cataract surgery do it of the shrubs and scrub sink maintaining physiologic tissue planes and normal tension and respecting the tissue and that will give you a very lovely and consistent result in all types of cataracts and happy happy patients and thank you for your attention and i value the opportunity to teach in any opportunity and if there was a bigger and a better one where i could have some hours to teach i'd be more than delighted to come out and do that thank you