Lecture: 1st Annual Crandall Cataract Conference

Dr. Chang: Well, hello, everyone. My name is David Chang and I’m delighted to welcome you to the first ever Cybersight cataract conference sponsored by Orbis. And dedicated to the memory of the late Alan Crandall who we tragically lost in 2020. A giant in the fields of cataract surgery and global ophthalmology. While Alan was an extraordinary surgeon, it is he was passion fore teaching and improving global eye care that set him apart. Hunter Cherwek wanted to honor Alan’s legacy of teaching and teaching so many of us to improve our surgical skills and decision making. Alan Crandall embodied the humanitarian spirit. And though we’ve all lost a special friend, we remain inspired by his commitment to helping and teaching his fellow ophthalmologists. The six distinguished member of our faculty today were among the scores of residents and fellows and colleagues that Alan mentored and trained. In large part thanks to Alan, they are all great surgeons and also masterful teachers. We’re going to have each of them present a teaching case or two followed by a brief panel discussion. And we’ve set aside time at the end for you to pose questions to our faculty by using the question function of Zoom. Our first speaker, Susan MacDonald, was a resident under Alan at the University of Utah and then was on the faculty and the residency program co-director at Tufts New England Medical Center. A past President of women in ophthalmology, and runs ICoR to stop cataract blindness. Susan.
Dr. MacDonald: Thank you. Delighted to be here today. I’m going to share my screen.
There we go. Does everyone see that?
>> Yep, we got it.
Dr. MacDonald: Okay. Fantastic. Sorry. Start at the beginning. I’m going to talk about anterior vitrectomy. And the lessons I have learned from Alan. They are going to be scattered throughout the talk, I have known him for 30 years, that’s my privilege. These are my financial disclosures. And this is the guy. When I first met Alan, I was a resident and I had a meeting with him and I walked into his office and his feet were up on his desk with his cowboy boots and his bolo tie and he was leaning back. And I was a little surprised since I had come from Massachusetts. And we’re a little — have a different proper attitude about how residents and attendings would interact. And so, I started to ask him which books were correct and I was trying to tell — impress upon him how much — how hard I was gonna work. When he took his feet down and he said to me, “Where are you from?” And I said, I’m from Massachusetts. And he said, you know what? You need to relax. Relax and we’re gonna teach you what you need to know. And so, one of the first lessons Alan taught me is vitreous loss happens. And if you are going to be a surgeon that does any intraocular surgery, this is a skill-set that you really need to hone. This is not something that when you’re in an airplane and you need to put on your, you know, you need to put on your safety equipment, that you’re going to suddenly start to learn how to do it. We need to know vitrectomy surgery even better than we know cataract surgery. And so, as Alan has said to many people, and to me, is you need to be prepared. This is not a creative process. There is a lot of knowledge and muscle memory that needs to be built into you and in your leadership in your team in order to have a vitrectomy which runs smoothly in your operating room. And this is actually, there’s publication in 2017 by Lockington that really talked about this. That talked about running a vitreous loss fire drill in your ophthalmology OR is a very helpful thing. So, it gives everyone knowledge and it prepares them for the unexpected so they have more confidence. That means you — not your team — needs to know how to set up your vitrectomy. There — it can be a little daunting for your team. And if you have somebody in your team that is on — unexperienced, that it’s very easy for you to take over or even just instruct them in a calm way how to put the instrument together. When you think about, you have your vitrector, then you’re going to separate and take off your phaco tip and separate the tubing into two pieces. Your irrigator is going to be placed for the irrigation, the aspiration will go in the blue port. And then the two other — you have two other gadgets that are going to — that actually are for the vitrector. And that goes into the machine. You should also have a kit, an emergency kit, of everything you’re going to need in that first 10-minute period. And that means the vitrector. That also means ethilon, 10-0 nylon, and some triamcinolone to stain the vitreous. Remember, you’re a team leader. How you treat your support team is going to impact the outcome of your surgery. You need to contain your anxiety, take it down a notch, and really share your confidence with the rest of the team. Let them know that you trust them and you’re working together. Okay. So, the second thing I think that really is important about vitreous is to understand knowledge. And this is something — Alan makes everything look so darn easy. But having spent a lot of time with him, I saw how much he read and how much he taught himself. He constantly was learning. And so, we need to understand that just going in there and doing surgery and just trying to remove the vitreous is not enough. Remember those vitreous attachments. The vitreous has a collagen matrix. And that collagen is stuck on the vitreous. And the collagen has a — a tensile strength that is much stronger than the vitreous. And so, when we pull on the vitreous, we’re actually pulling on where the collagen is attached. And since we don’t have a — and since we don’t have a understanding of the tensile strength, let’s show it here. This is your collagen and your vitreous and you’re pulling on your retina. Just keep this in mind. The tensile strength of your retina is very, very weak. So, when we start our — we identify our vitrectomy. And, whoops. I’m sorry. I’m going to go back one slide. The first thing we’re going to do is we’re going to do our paracentesis. And then we are going to stepwide move to our triamcinolone which we are going to add in our second paracentesis. This time we are no longer going through our main wound. We are going to identify the vitreous. And then we are going to use the cutter to cut vitreous and not pull on the vitreous.
When we do an tear your approach, it’s a very controlled setting. Our pressure should be low. We’re gonna drop the bottle height. We’re going to put our cut rate on as — as high as we can get the cut rate. At least 600. And our movements are going to be very slow. We do not want to grab vitreous and pull it. We want to cut it. So, it’s going to be, as Alan would say to me, it’s like a ballet. Slow movements. Nothing abrupt. And take your time. Now, if you are going to use the posterior approach, what you are going to do is make a incision 3.5 millimeters posterior to the limbus. And as you do that, you want to take down the conjunctiva and use the MVR blade and make sure you can see it in your pupil before you put your vitrector in. And then you’re going to use your second instrument to irrigate and maintain the chamber. Bringing your vitrector. And then we’ll see how the posterior/anterior vitrectomy will pull that vitreous down into the posterior chamber and pull it out of your wound. It will pull it out of the anterior chamber and it’s very slip maneuver to reduce the amount of vitreous that is coming into the anterior chamber and the amount of pull that you are creating on it because it will exit during the maneuver.
The bottom line is, there’s early recognition. You need to set your plans. You need to support your team and maintain your chamber pressure. You can’t quit until you’re done. The lessons I’ve learned from Alan are many. And you need to stay calm. You need to be well-prepared. You need to trust your gut. And remember, it’s not over till it’s over. And the most important thing about vitreous is to take time to do a complete anterior vitrectomy so that you can put your lens in the eye and that the patient has a — a better chance of having a good outcome. The other point he always said to me is you need to make sure that you put a suture in every incision — main incision that you have done a vitrectomy. It’s been my honor to be part of Alan Crandall’s trainers. And it’s an honor to be here today. I think we are all blessed with this man. The other thing I want to say is, the two things I’ve learned from him is really to be kind to everybody. And I’m still working on that.
Dr. Chang: Great. Thank you very much, Susan. That was wonderful. Our next speaker is Bob Cionni. And Bob is a past President of ASCRS and board member. After achieving stardom at the Cincinnati Eye Institute, Bob mid-career moved to Salt Lake City, Utah to back Alan’s partner in practice and join the faculty at the Moran Eye Center and Bob will also be presenting a case involving vitreous loss. Bob.
Dr. Cionni: Great. Thanks, David. And thank you for allowing me to be part of this. As you know, Alan was a very dear friend of mine. And I learned so much from him. I miss him terribly. So, once again, thank you for inviting me. And welcome to all the participants. I’ll begin the case by sharing my screen. And I think you should be seeing it now, correct? For
Dr. Chang: Yes.
Dr. Cionni: Good. All right. We’re going to continue, maybe go a little bit deeper into the vitreous. Thank you, Susan, that was a great beginning to vitrectomy surgery. And since you have shown us how to do it right. I’m gonna start with showing you whatnot to do. Okay?
So, here’s a case where a surgeon obviously had a very accident cataract and complication. The anterior capsule is torn, the posterior capsule is torn, the nucleus, part is in the vitreous. And I’ll pause briefly here. What you want to do at this point is keep calm, as Susan said. You don’t have to rush into anything. But so many people, their first reflex when this happens is to pull everything out of the eye. And when you do that, the chamber collapses and vitreous follows. So, don’t just pull out of the eye. Release the foot pedal so there’s no irrigation, fill the eye with viscoelastic, and then take the phaco tip out slowly.
The next mistake that this surgery makes is going in through the main incision. And Susan mentioned that. Do not go through the main incision. Because fluid will come out through that main incision around the tip. And vitreous follows it. So, more vitreous is coming out. The settings need to be right. This surgeon is in position 2. And there’s no cutting going on. So, he’s simply pulling on the phaco tip. See if we can get that out of the way. And you can see he continues to get occlusion of the phaco tip because vitreous is coming into it. You don’t want to just cut, you want to have your settings set up as cut first and then aspirate. Next, and I’ll see if I can pause it here. Where did my pause button go. Never mind. Don’t go through a tight incision. Open that incision a little bit larger when you’re ready to put the implant in to save yourself some stress and make it easy. And in this case, was planning to suture close to the posterior of the iris. Don’t place it into the sulcus. You’re going to get hung up in the haptics and not be able to manipulate the implant to suture it. Place it into the interior chamber, grasp it with IOL forceps and you can manipulate that implant any way you want. This is a very floppy iris with a broken capsule. And you can see that even though it’s challenging to get that implant in the right place, I’m not in danger of dropping that down into the vitreous and I can maneuver with the haptics to the posterior surface. Here’s some vitrectomies don’t correctly. As we mentioned, if you don’t just pop out of the eye, but instead fill with viscoelastic first, you can present the vitreous from coming forward. And you can remove the forceps even with the — I have no irrigation going and then I come out of the eye. You can then make a small side port incision appropriate for the size of the instrument you’re using. And either with a dual port INA or with a vitrectomy hand piece, you can remove residual vitreous, cortical material. If you’re successful, you can then place the implant into the sulcus, capturing behind the anterior if it’s intact. You want to have myotic available to constrict the pupil. That allows you to be certain there’s no vitreous forward and not a peak pupil called by a vitreous. Here’s a two port vitrectomy through the side port, not the main incision. Notice that the vitrectomy port is posterior to the capsule, pulling posteriorly. You can turn the cutter off if vitreous is gone and use it to strip the cortex. Susan also mentioned use of triinsimolone. You can’t see the vitreous until you put in the triinsimolone. And because he went through the main incision, vitreous comes streaming out of the main incision. The side port incision would have been a much better place to put the triinsimolone in through. Also notice when the vitrector goes through the main incision, this highlights the point of not going through the main incision, although you’re cutting vitreous, more vitreous keeps coming anteriorly and out. Avoid sweeping the incision like this. It pulls the vitreous back into the eye, but also tugging on the retina. It’s better to cut with a vitrectomy cutter. Do not do this, do not pull on the vitreous. You can see it’s just tugging on the retina and more is coming out. And even when you think you have all the vitreous gone, put in more triinsimolone and you’ll see that in this particular case, we haven’t began with the cataract, there’s still a ton of vitreous there. And watch as we come out of the side port incision. Because it’s a fairly large side port incision for that instrument, vitreous will follow it.
Once again, as Susan mentioned, 3.5 millimeters posterior to the limbus. You can make your plate incision, identify your vitrectomy port in the pupil before you begin cutting. And watch how nicely that vitreous is pulled posteriorly. That’s what you want to see. And all that in that case took place before we even started with the cataract. So, the key points. Never let the chamber shallow.Ville it with viscoelastic. Do not go through a large or main incision. Don’t use a weck cell sponge. Use triamcinlone. And pull posteriorly, not an anteriorly. I want to thank Alan for everything he taught me, but mostly for his dear friendship over the years. Thanks.
Dr. Chang: Thanks very much, Bob. Excellent presentation. We’ll bring a couple of our faculty up for the panel. Bob, you know, it was your partner Scott Burke who really brought this technique of triamcinolone and the question is, what’s the source of triamcinolone? And can you use the triamcinlone that you get for injection has a preservative. Can you address how you would use that if you were going to use that for staining?
Dr. Cionni: Yeah. It’s interesting. Scott for many years was trying to see the vitreous better. He started ICG and thought that would work. His wife is a retinal specialist out of Brazil. And they worked together on this, and instead they found it stained the ILM which became a hallmark for ILM peeling. And then work to triamcinolone. And he won awards for that, I’m proud of that accomplishment. We use it diluted, it’s not a big glob. We dilute it at least 1 to 5. That’s a good preservative. I don’t know where we source it from. Maybe somebody else on the panel would be able to answer that.
Dr. Chang: So, I think Triesence is the product from LCON that is specifically safe to use in the eye directly from the bottle. But my tip is you can take the traditional triamcinolone for, you know, sub injection and make sure the bottle is sitting and all the flakes will settle to the bottom and you can pretty much then draw off the diluent which is the wrong Ph. Not meant for in the eye. Draw that off. And then add one or probably 2mls of balanced salt solution, you will have effectively diluted everything so much that it’s safe to use. Let me ask Jeff Pettey.
Jeff, can you just address the foot pedal configuration, the difference between high cut aspirate and eye aspirate cut?
Dr. Pettey: Yeah, depending on the machine that you have, you may have ability to set position 1 as your infusion, and position 2 can take two different configurations. When you’re in position 2, you can either initiate the cutting of the guillotine, of the vitrector. Or begin the aspiration through the similar guillotine. As you go further into position 2, into position 3, you’ll engage the final. For instance, something called IA cut, position 1, infusion, position 2, aspiration, finally the cut engages at the end. When would I want to use that? Where I have my aspiration before the cutting? Perhaps I have residual cortex, and I am moving to the anterior chamber. The alternative is position 1 aspiration. Position 2, the goo owe teen engages. And finally in position 3, the aspiration begins. This is what you want to use for most if not all of the vitrectomy in the eye. It’s the safest to begin the cutting before you pull traction on any of the vitreous fibers.
Dr. Chang: Excellent. Vaishali, another question. Is it necessary to learn how to do this through the pars plana? Or can they just stick with the limbal vitrectomy? Vaishali? Yep. I think we’re having trouble with her Internet connection. Ike, do you want to take that? When should people consider pars plana?
Dr. Ahmed: I think there are very few instances where most cataract surgeons need to work through the pars plana. And unless they are comfortable examining vitreous with that manner, I recommend staying anteriorly. I and others have experience managing complex cases and work through, but members of the panel do that. But those are planned cases with special implementation, posterior entry infusion lines and things like that. So, I think with the arch cataract machine, even myself, if I have a resident case or Bob Cionni’s case to clean up, I typically go through the anterior limbal approach.
Dr. Chang: For Susan, how have you had residents in this situation? Just a quick tip on kind of relaxing. This is an unexpected complication. You’re thinking about, oh, my god. You know, I’m going to be behind schedule for the rest of the day. It’s very easy to get kind of flustered. Any quick tips on just how to relax?
Dr. MacDonald: Absolutely. I think you need to at first stop what you’re doing. This is not an emergency. You don’t do anything for the first 2 minutes. Nothing’s gonna happen. If you have a stable chamber, you just stop. And then you go through it in your head about — you identify the problem. And then you talk yourself through how you are going to do it. And so, you know, Alan used to say to me when I was a resident, what are you doing? And he really meant it. Like, what are you doing? You don’t have a plan. And so, part of that is really is ask yourself that. What are you doing? That will calm you down and you’ll just — just visualize it in your head and then you proceed. And that calmness is great for the entire room. Every — there’s no need to panic. We — this person is not going to lose their sight if you can just wait a few minutes and get the room together.
Dr. Chang: Super. Thank you so much. And just a word to the audience. You know, there is a question and answer function on Zoom and we’ll try to answer your questions either live at the end or by typing in the answers. Our next speaker is David Crandall. Alan’s son. A cataract and glaucoma surgeon on the consult of the Henry Ford Hospital in Detroit, Michigan. A fellowship and very active in residence teaching. David.
Dr. Crandall: Thank you. First I want to thank David and Hunter for organizing this. I’m gonna show a case that will — sort of a case that will illustrate some of the things we’re talking about. And then actually this will tie in a little bit to what Susan and Bob were talking about. And then I’m gonna show a few things that will sort of highlight what can to look for when you rupture a posterior capsule. And so, this just briefly, this is a patient who has a cataract. She has steroid response glaucoma. She was on steroids for a dermatology issue that needed systemic immunosuppression. What I wanted to highlight here is watch the temporal part of the lens where you can suddenly see more of it when we’re filling with viscoelastic. We have issues. And you can see the striae why the capsules. There was nothing clinically that warned me that this would be an issue. That’s why I want to talk about this case. Because you don’t always get to plan these. Sometimes the eye surprises you once you get into surgery. And as we’re proceeding with the capsulorhexis, you’ll see striae leading ahead. This is the quadrants that we have weak zonules. Since we see this everywhere we know that the lens is diffusely loose. We can’t rely just on a focal issue.
And with this, you want to just really take your time. You can use countertraction if you feel you need to. Although I didn’t feel I needed to in this case.
And with — whenever there’s zonular issues, I make very good hydrodissection to make sure the lens is completely free. If you watch the capsule edge, you can see the whole lens moves each time I start to initiate my wavers. I felt I couldn’t free this lens up enough on its own to safely rotate it. Here we’re using capsule hooks. All these through small paracentesis. And once the hooks are in place, you can see we begin to proceed with the case just as normal. We can rotate the lens, being sure to make sure the hooks are staying within the bag. And I’m pausing here to show — so, this patient was very uncomfortable. And very nervous. And she was squeezing enough that she rotated her lid speculum about 45 degrees from its natural position which was making everything more difficult for me and less comfortable for her. And here, this piece of lens is sitting a little bit deeper than I would like. And if you notice her very loose cap bag came up there.
And in a moment, we’ll do exactly what Dr. Cionni said not to do. Which is to come out of the eye.
And at this point, I decided that you could not save this capsule. And so, I’m removing my hooks, proceeding with a vitrectomy, as Dr. Cionni and Dr. MacDonald mentioned through a side port. And here you can see the edge of the posterior capsules flopping freely. I’m going to remove as much of the lens as we can.
And then I’m going also proceed with — using the vitrector to remove the entire capsule which I felt was not going to do me any good. And I’m just gonna pause here. So, one of the things that dad had always stressed was doing whatever’s most important for the patient, whatever is best for the patient, not just whatever is best for you. For our ego, we always like to leave with a lens in the eye. We always want to have the patient doing well from the get-go. I felt that with this patient’s comfort issues, with getting the lid speculum wide enough and knowing that I was planning on doing a goniotomy, I didn’t to want place an tear your chamber lens. We were going to call it a day. We were going to leave the patient aphakic. It’s not the worst. But bad pseudophakia is worse than aphakia. We removed capsule remnants and did a haptic fixation. I won’t go too into the details of that, that’s beyond the scope of this and we can do a whole lecture on that. And then were able to proceed with our goniotomy as planned. And that patient a week later was 20/25 uncorrected. The course was longer than we planned, but ultimately we did what was best for the patient.
And then I’m just going to show a few quick clips of things to look for posterior capsule rupture. This is a patient who developed a dense cataract after his vitrectomy. And after the deflection, you’ll see that the red reflex gets much brighter and we have a much clearer view because the entire lens has fallen to the retina. And here I want you to watch the iris.
If you saw, there was a little pulse of the iris and that quick shrinking is possibly rupture. And this is posterior. This is one I could accommodate. It’s a little bit out of focus. And watch the edge of the pupil. And just in a moment, you’ll see immediately pulse down and then it goes back up. And if you see that, if you even think you saw that, you want to pause and examine things carefully to make sure you have a posterior capsule. Here it’s clear that the surgeon does not have an interact posterior capsule. This one’s also really subtle. You see the — and I’ll show this also in slow motion. You can see, here’s the edge of the capsule dipping in.
And in slow motion, you’ll see that the resident’s reaching out, they’re in foot position 3 instead of 2 when they’re trying to grab this piece of nucleus. And then the phaco passes right through the edge of the lens.
And that’s slow motion. This was in a non-vitrectomized eye. It’s unusual for the patient to fall that quickly what they’re not vitrectomized. Which watch the pupil here, you’ll see the pupil drop very briefly. It’s very easy to watch these in retrospect when you’re looking at when a capsule is ruptured. But it can be really hard in the moment. Just make a moment to make sure everything is still intact.
Dr. Chang: I think we lost the video, David.
Dr. Crandall: Leave that playing. And I’m thankful to Hunter and David for organizing this. I’m happy to be involved.
Dr. Chang: Fantastic talk. I think we’re — we have time for just a couple of comments. Ike, let me — you know, David showed a common problem. Which is, you know, the patient is restless. You know? This was supposed to be a — an easy, brief case. Routine. Any tips if you don’t have a retro bulbar? Any tips on supplemental anesthesia? What do you do if you need to do more extensive things that you planned in terms of supplemental anesthesia?
Dr. Ahmed: It’s a great point. Patients are variable. And as you saw, especially with capsular retractors or hooks, the torquing from the lid can have an impact what happens in the eye. That is really critical to control that. What we typically do is add a little bit of supplemental posterior sub-Tenon’s, us can thing down the intranasal quadrant, and putting 3ccs into the cone. That’s usually enough, but can be done under topical to add to it. A patient that’s a big squeezer, that doesn’t necessarily take care of that. In that situation, we would consider doing a little Van Lint just to block the facial nerve. That’s something we have done in the situations. Fortunately, Alan taught me you can do any case under topical. I’m in the school of Crandall thought, we basically start everything topically and at end of the day, that’s typically what we end up doing.
Dr. Crandall: I will mention, this patient we will general for the secondary procedure.
Dr. Chang: What are your guidelines for — is it okay to leave the nucleus? Or should the surgeon try to remove as much of it as possible once you’ve encountered vitreous?
Dr. Vasavada: Thank you, Dr. Chang, and thank you, everyone, for this opportunity. But I do agree with what David showed there. That if you have a drop, and if you’re not in a position where you either have a retinal colleague or you yourself are proficient enough to perform a three-port pass planner vitrectomy, you’re not trained enough. Just leave it. Remove as much as you can. After doing an anterior vitrectomy, whatever is there in the anterior chamber. And then are the retinal surgeon can deal with that, you have less inflammation. I would not try to fish out the nucleus at any cost.
Dr. Chang: Right. Jeff, last comment. One of the audience members said what if we don’t have a vitrector, the vitrector is broken. You know, you’ve got a Weck cell, you have some scissors, what would you do in that situation?
Dr. Pettey: These are challenging situations. Long Vannas Scissors is everyone should have one. Without using a Weck-Cel to pull, you can place the scissors flush on the eye and cut where you believe that’s going to be. You can take wide swaths within the eye through your large wound. And just take your time. Be very aggressive. The most important thing is to try to modulate that pressure differential. As long as there’s higher pressure in the high and vitreous and aqueous is coming. You can address that and along with the scissors without pulling traction. That’s the best and safest approach.
Dr. Tabin: Can I add a quick comment, David?
Dr. Chang: Sure, Geoff.
Dr. Tabin: Another thing that’s a friend is an air bubble. And you can put an air bubble in the anterior chamber and use the long Vannas and use it as your us cutter right at the pupillary plane and will prevent more vitreous from coming forward as you’re cutting.
Dr. Chang: Excellent point. Those are great points, everybody. We’re going to go ahead and move to our next speaker, Vaishali Vasavada. She’s an ophthalmologist speaking to us from the eye clinic in India. She’s a rising star. She’s part of one of India’s leading ophthalmology families. And completed her cataract and fellowship under Alan Crandall at Utah. Vaishali.
Dr. Vasavada: Thank you so much. Thank you, Dr. Chang. Thank you, Hunter. And I’m really privileged and honored to be talking when we are remembering Dr. Crandall. And in some ways I wish I wasn’t talking in this webinar and that he was talking to us. But that’s how life is. And could I request Lawrence to please play my video? I’m having some connectivity issues. Could you play the video, please?
>> Sure. I can share it now.
Dr. Vasavada: Thank you. So, what I’m basically going to talk about is what I do a lot and what I learned from Dr. Crandall day in and day out. Because like he says, actions speak louder than words. Here is a routine cataract surgery. And I think our whole family has learned. We have a unique family of ophthalmologists who learned from Dr. Crandall. I think two generations of us. And here is a routine cataract. You can see that everything is going okay. And the resident here is performing a bimanual litigation aspiration. I always prefer toot a bimanual here, it’s easier to access the cortex in the 360 degrees around. But as you can see here, if you can see on the screen, the sub incisional area, the bag just got retracted. What do you do and why did this happen? These are the two main questions. What do you do? As Dr. Crandall who was the master of all kinds of problems, rings, hoops, he would have done. I put in a CTA. What I also do is thread in a 10 nylon suture, if it ends up in the sulcus and retracted, it’s easier done. Otherwise it could be a nightmare. Having done this, I now perform irrigation aspiration. Now, can you pause, Lawrence, please. So, what Dr. Alan Crandall taught me and what I really learned from him, one, record all your videos if you have the facility. Two, replay your videos. Whenever something is going wrong, maybe you managed it on table. But then sit down with your juniors, your colleagues or yourself and replay those videos and try and figure out how you could have prevented it when it happens the next time. Could you please play it?
Is so, we went back and you see that the rotation is being performed. Look at the spatula. The nucleus won’t budge, but the resident never looked at the area beneath the phaco tip and continues to rotate. The dialysis already happened and it was not noticed at that time. I think one very important lesson is the physics of rotation. When you rotate with the spatula, you move your wrist. And you don’t push downwards. It’s not a finger movement, it’s your wrists. This is something I learned from Dr. Crandall as well. Your wrists and why elbows are much more important than you think in surgeon. Do not apply pressure, rotate. And now on day one from the surgery. As Dr. Crandall said, you have to think. Think. And this is the anterior segment, almost completed the attachment. Again, I went back to his teaching and reviewed my video. This is the end of the case when the resident here, again, in this case, is doing a very enthusiastic stromal hydration. And you can see how during the hydration a complete wave of separation has happened and again has gone unnoticed. Now, he again doesn’t

— is complete. The surgery. But point is again use imaging in order to decide which quadrant you are going to do it from. So, based on the images, I could see that the superior quadrant a little bit is still attached. And therefore, I make a small paracentesis and inject and fill it up. You can do an air bubble. And this can be repeated if it does not settle with one injection only. Through our good fortune, this worked for us. And you will see in the subsequent imaging again that it cleaned up clinically, but it was almost reattached. So, you can see here that we have a subtotal fill, about three-fourths filled. It’s a gas. It’s an iso gas here. And you can see that the descendant’s membrane is attached. Three things. Number one, always think about what you’re doing. Like Dr. Crandall said. Record your videos. It may not be a 4K recording. See what you can do. A lot of non-medical grade cameras. People like us who don’t have access to the most high end technology, you can use SLR cameras with special adapters and do this simply. And review your videos and you will learn a lot and prevent a lot of complications. Thank you.
Dr. Chang: All right. Excellent. Wonderful teaching pearls there. We’ll bring our next panelist up. And so, let me ask — one of the questions was viscoelastic. When you’re having trouble, how do you know whether to do a cohesive? A dispersive? David?
Dr. Crandall: Ideally the classic teaching is dispersal is what you want. My — in the immediate moment, whatever the nurse can get me. If they give me an adhesive, I will fill with that. Otherwise I’ll get a dispersive. But getting the anterior chamber pressurized and getting out of the eye. Especially when you’re first learning how to deal with this.
Dr. Chang: Great. Susan, you know, Vaishali brought up the case with the decimated attachment. Sometimes you lose visibility from the cornea and so forth. What would you do in that situation? And if the cornea starts to, you know, get — take on too much edema? And let’s say you’re still in the middle of the phaco. Any tips on visibility?
Dr. MacDonald: Well, certainly. The final option is to stop. But prior to that, I — you could very gently remove the epithelium. And then put some glycerin on the surface of the cornea to try to depress it slightly.
Dr. Chang: All right. Perfect. Bob, any, you know, one more comment, Bob. Question is: You’ve now done a vitrectomy. Is it still okay to use an intraocular/intracameral antibiotic? Or do we have to worry about retinal toxicity? Any advice on that?
Dr. Cionni: Yeah. And actually the risk of developing an ophthalmitis increases with an opening. I would use intracameral. My preference is — probably stay away from vancomycin because of the problems with vancomycin. And the other thing to add, when you use triamcinolone to identify the vitreous, you’ll be amazed how the inflammation is much less than that you would expect because you have that steroid on board. So, yeah. I think that pretty much answers that question.
Dr. Chang: Yeah. And do you change your topical regimen of steroid when you’ve had to do a vitrectomy?
Dr. Cionni: If I’ve used triamcinlone, I do not. But if not, yeah. We use more frequent for the first few days until we see that the inflammation is under control.
Dr. Chang: Great. And to your comment, you know, I think some of the best data on PCR and ophthalmitis has come out of Aravan. We had 29,000 consecutive cases, half with, half without. And if you don’t use intraocular, it’s a seven fold increase in ophthalmitis. If you are not doing it routinely, as many are not. We probably all should if there’s a PC rupture. Because then the barrier to microbes reaching the vitreous is no longer there. So, we’re gonna go on to our next speaker. And that will be Jeff Pettey. Jeff was a resident and a fellow under Alan and then later became a fellow faculty member at the Moran at the University of Utah. He’s now the residency program director and the medical director of global outreach at the University of Utah. Jeff.
Dr. Pettey: Thank you so much. And thank you, Hunter and Cybersight for all you door for all of us around the world. You know, it’s interesting. Most of you, I imagine, will never have met Alan Crandall. For those of you that are early residents, fellows, or early in your career, it’s interesting to hear about these giants, right? The Charlie Kelmans of the world, the Alan Crandalls. Why is it that we hold these individuals in such esteem? And I would say this. We only have a set amount of time on this Earth. And if our lives are measured in impact, there’s a few really wonderful ways that Alan showed us how to have impact. Number one was a commitment to his craft. And again, recording your videos with an iPhone, having someone hold it and just watch how quiet the eye is. That’s something you can do to commit to have better results for your patients. Number two is he taught. He taught any time he could. He always had his laptop with him, would sit down and show a video. It brought joy to him. When you think about impacting others beyond your patients. Teaching. Leaving that legacy behind you. And I and others have benefited from that. Without further ado, two cases today. The first case is a case that is a conversion to SICS. I trained as a phaco surgeon in the United States. I saw zero manual delivery of lenses throughout my entire training. And yet Alan was gifted at this, helped teach me this with Geoff Tabin and others. And it’s an important skill-set for you all to have. The second is actually one of Alan’s cases. It’s just a simple, quick case show you the quiet eye in the complex case and how he is able to navigate that. So, without further ado, we’ll go ahead and go to our video. So, this started out as — this started out as a routine phacoemulsification on a white, dense cataract through the paracentesis. We have a microtrauma. We grab the anterior capsule, we actually grab the capsule and we have this resultant tear. So, again, a lot of different things you can do at this point. We use some intraocular scissors. Completed the capsulorhexis around and made the tangential. We’ve sown our wound and now up to our small incision cataract wound in the superior quadrant. For those experienced, you will see this is a little bit of a smaller wound. I didn’t expect this to be a large, large nucleus. I was certainly surprised to see how large it was in the end. One thing to note, you can see the stain of the paracentesis. I’m going through the superior paracentesis. I haven’t had an issue of leakage. But it could appear. The dialing technique I have again learned from colleagues around the world. Using a cystotome to help expose the lateral side of the lens. Putting the viscoelastic. And using the single hand rotation to rotate the lens into the eye. I wasn’t certain whether or not one of those relaxing incisions had run behind the high. Did the removal under Simcoe Cannula irrigation. The posterior capsule was intact as it nearly always is when your capsule incisions are not radial, but tangential. Again, placing a lens under viscoelastic. And the patient did very, very well from here on out. So, moving on to our next video. You know, Alan trained in intra-cap initially. All the way through extracap, all the way through being a phaco master. You can see under the small pupil, he’s able to really kind of sense where that capsulorhexis is being formed. You don’t have to visualize exactly where the tear is occurring. This is a really nice manual technique called pre-chopping. Pre-choppers available. If you’re at meetings, many of the companies have pre-choppers available. For moderately dense lenses, it’s a simple way without phaco energy to divide into quad rants. Some facial cleanup on a sculpt mode. And moving to higher aspiration flow rate to remove this piece. The thing I want you to see here. We do have a small pupil. But if you notice, the phaco tip is always quite quiet. It’s quite. It’s in the center of the pupil. It’s not moving. There’s little to no chance of the iris coming. And this is a hallmark of Alan’s quiet, elegant and beautiful surgery. And quiet hands. This is where, you know, again I can’t stress enough the importance of recording your videos. Because what you’ll see is you’ll see how active your hands are. How much the eye is moving. We can go to this find slide. It’s — Alan is someone who has actually impacted you whether you know it or not. So much of what he did in innovating this beautiful, elegant phaco has been distilled out. He had a commitment to take it to every corner of the world. Whether you know it or not, you’re connected in some way to Alan Crandall and his family tree that you see on the panel. Thank you to Cybersight and Orbis for making this possible.
Dr. Chang: Great. Jeff, thanks very much. We’ll bring our panel back on. So, your first case really brings up some great points which is, you know, how do you make the decision on when you need to convert? So, that would be — and maybe I’ll start with Vaishali. Well, yes. What are some of the signs that you look for or are attuned to that tell you something’s wrong? Because obviously, you want to make that diagnosis early and give yourself a chance to convert. Obviously, when the nucleus dislocates it’s too late already at that point.
Dr. Vasavada: So, thank you. And I would be machine I guard already in a cataract that is very hard and a large, bulky nucleus. So, I would be mentally prepared. Probably maybe give a little sub — or if you’re not very experienced, a little bit of peribulbar anesthesia. If the rhexis runs out, when I try to rotate the nucleus it doesn’t move at all, and doesn’t divide and move the way I want to when I’m doing the actual division, that’s when I will start thinking of conversion. I will — first, I don’t convert. I’ve not converted in the last few years. But if I did have to, these early on would be my signs. I would not wait for the nucleus — if it becomes vertical, then I will not convert also. I will just leave it there. No rotation, not dividing well and things not moving. Not aspirating the way you want. Just convert at that point.
Dr. Chang: Great comments. Susan, do you want to add to that? You’re on mute.
Dr. MacDonald: I think, again, this is going quote Alan. What are you doing? And part of that is do you know how to do an SICS surgery? And if you don’t, you’re really handicapped. And so, you should take the time to really learn this technique. This technique is amazing. And it will make you more confident. And you will stop sooner and convert if you are confident in your skill set.
Dr. Chang: Good. Let me ask Bob Cionni. Bob, if, certainly very few of us in America are, you know, adept at SICS, let alone extra cap. I think a lot of residents training in the last 10, 15 years have very little experience with that. Your tips on converting? Can you — if you don’t know SICS, you’re just going to do a traditional limbal incision?
Dr. Cionni: That’s an awful question for me. I haven’t converted or done an extracap for about 20 years. But we have the good fortune here of having in multiple clinics in Salt Lake City good retinal specialists, right? Generally if I reach a point where I can’t take it any further, then I stop. And I think it was Susan that mentioned this. You don’t have to finish that case right there. You can close the eye and refer and have it removed. It was Vaishali who said that, actually. You can close the eye and send it to a retinal specialist. Doesn’t have to be done that day. It’s not an emergency. And so, that’s what I generally choose to do. I did start off learning extracap. And in fact, had done about 60 extracap and surgeries before I did my first phaco at a VA in Louisville. I was one of the first surgeons to use the units. And I was convinced that the phacoemulsification unit, even though it was meant to eat the cataracts, it liked capsule and vitreous much more than the nucleus. Over the years, we learned how to handle the instruments better and understand them.
Dr. Chang: It was great. I think you all highlighted this. It’s always — you’re on alert when you have a brunescent lens. And for me, as Vaishali said, if it rotates and stops rotating, that’s a bad sign. A zonal dialysis. If the nucleus is tipping and part is migrating under the iris and not rotating back, if it bounces back, these are earlier signs of a capsule rupture. You can find it earlier. If you breed and expand the rip, that’s when everything drops. I think a limbal incision for an extracap is good if you’re not proficient at an SICS. If I’m going cornea, I abandon that and move superiorly and make another incision because the cortical incision is self-sealing. Geoff Tabin, you’re on the screen. Do you want to add anything on converting from phaco to an extra cap? Any tips?
Dr. Tabin: No, what you said is important. You want to have a nice self-sealing wound and control of the anterior chamber. If you have your clear corneal phaco wound, don’t expand into a 7 millimeter corneal wound or try to bring it back to the limbus. I go ahead as you said, move superiorly and move to a new spot and do a really nice self-sealing tunnel wound.
Dr. Chang: Perfect.
Dr. MacDonald: Can I ask you, David, and maybe Jeff. And, you know, what about the decision making before the cataract surgery started? And how about when do you choose to do an SICS? And I really think it is a preferable surgery in many situations.
Dr. Tabin: Absolutely. If I have an extremely elderly patient. 103 years old with a very brunescent, a black cataract, an unsafe endothelium. It’s a safe, gentle surgery. You coat the endothelium with viscoelastic. And the corneas are clear with the great result post-op day one. We did a study with David Chang in Nepal where we were using all — looking at all very mature lenses. And we find that about, you know, in a really very good hands with, you know, doing the surgery, 90% of the patients post-op day one had visual acuity better than 618. And these are with, you know, light perception, hand motion lenses. So, my — if there’s no zonular issues and an extremely dense lens, a brunescent or black lens, this is a nice, fast and safe option that gives a very good result for the patients.
Dr. Chang: Let me ask the same question of Jeff Pettey. Jeff, how do you make that decision? I know you’re very good at extracap as well.
Dr. Pettey: This comes down to you knowing yourself and what your best surgery is. So, you know, in American baseball, there’s the idea of the pitcher throwing a pitch. You know, in cricket, there’s the bowler. And if you have something that looks like a really complex case, you really to want give them your absolute best at that point. And for me, still, phaco is likely my best pitch. However, I will primarily do extracap on a regular basis because I have a level of comfort with that. If I’m not very good at small incision, I’m probably not going to start very many primary small incision cataract surgeries. That’s where expanding your skill-set, finding mentors, learning, will really help your patients in the long run.
Dr. Chang: Yeah, I would agree with all the comments. I think the other thing to add is the comorbidities are what influence me. If I have a super-shallow chamber, well, you got to worry with phaco about endothelial cell loss. If you have zonulopathy and it’s a brunescent lens, that often is not going to end well. Maybe my last question for this section before we move on, Susan, when is it too late, you know, you can do this after the capsulotomy? Can you do this after you’ve fragmented the nucleus into a couple quadrants? Is there a point where it’s too late to convert?
Dr. MacDonald: Well, if you’ve had a significant complication and you’ve lost nucleus, I would say it’s time for you to really clean up, do your anterior vitrectomy and if you can, put in a lens you put in your lens. That would be — you know, the other piece I really want to comment is internationally. The US has a great pressure on us to use phaco. But I will say, I have been so impressed by the SI CS surgeons from around the world. That the quality of their outcomes, not just for difficult cases, but for routine cases, SICS is an amazing technique. And when you look at the advances that are being made. That their refractive SICS is really coming along. I want to make sure that we’re not suggesting that phaco is a superior technology.
Dr. Chang: Excellent comments.
Dr. Tabin: Dave, if I could make another indication, is very poor visibility. When you have scouring of the cornea. A really poor view. You really need to have an excellent view of where you’re working when you’re doing phaco. Whereas with sutures extracap, it’s much more forgiving and you can dial up the nucleus and do a safer surgery with the visibility.
Dr. Chang: Thank you, everyone. One more talk. And I want to remind the audience, please type in using the question and answer function any questions that you have. We’ll do our best to try to answer them following Ike’s talk. And then please stay until the very end when my co-moderator, Geoff Tabin, has a special sort of remembrance to present about Alan. So, Ike was, of course, one of Alan’s fellows. He’s now assistant professor at the University of Toronto where he’s one of the leading teachers and faculty for both residents and his fellowship. He’s one of the world’s leading innovators in both complex cataract surgery and glaucoma surgery. And in fact coined the MIGS term in glaucoma. Take it away.
Dr. Ahmed: Thanks, David, and thanks to Orbis, Cybersight and Hunter for putting this together. It’s a great testimonial to Alan and I’ve enjoyed all the speakers here who shared wonderful thoughts and ideas. I’m gonna hopefully be able to share my screen here. I hope it’s playing. And I’m going to speak about the zonule. This is an area that Alan particularly had interest in and was instrumental in moving the management of these difficult cases forward with modern day phaco. These are my disclosures. And I think we’ve heard a lot about Alan. Alan was the kind of person who would uplift the room just by his mere presence. His positivity and his energy was unparalleled. But most of all, he would basically do this with the humility that we have never seen. There are always egos around the room, Bob Cionni, but he embodied the true human spirit of compassion and sharing. And that was something that was infectious. And we truly miss it. Him being in the room here and mentoring all of us. And as I said before, Alan was really instrumental in managing these difficult cases that had zonule problems. Mild zonular, where a capsule tensioning would be proficient. Or more profound zonulopathy where internal fixation would be required. There were a variety of different devices. And this is one area, where if we’re going to retain the capsular bag, these devices are important to remember. The regular capsular tension ring is for mild cases and non-progressive disease. The modified ring, not bad, is also another alternative for profound zonulopathy. And there’s the segment that can be for more traumatic cases. This is a traumatic zonulopathy. You can see the titration. And the capsulotomy. Those are telltale signs. I put in a CTR early using viscodissection, to avoid capturing the capsular tensioning ring behind the ring, behind cortex, makes it difficult to strip the cortex. The ring provides tension to the posterior capsule, reducing the risk of the capsule trauma with the phaco tip. Prevents vitreous prolapse and cortical fibers posteriorly. Whether there’s presence of existing zonule support. And it goes from stronger to weaker areas. Redistributes equally around the bag to provide support circumferentially and provides the bag in the IOL. This is a fairly routine case after the CTR has been put in. And then we place in this case the one-piece toric lens in the capsular bag and we have that. And helpful for mild, particularly non-progressive zonulopathy. This is where the interocular use of capsular retractors, David Chang’s modification is ideal. Provide the equator, not just at the edge to use an iris hook. If you don’t have it, you can use the iris hooks. And we can use the modified CTR or the CTX. We are using a more durable suture. I like using the Gore-Tex suture. As Bob and others have shown, these can break long-term. We recommend Gore-Tex ideally which is a challenge for a. The benefit is we can do the small incision without the vitrectomy with the excellent refractive outcome. That’s the beauty of taking phaco to do this. And there are other alternatives. Intra cap, extra cap, and lensectomy, and those are more involved. And depending on the resources, one would consider what’s available. These are showing placed through the capsular bag along the rhexis and along the capsular equator, and providing support and collapse of the bag. This allows us to continue along with the phaco in a fairly routine fashion. Removing the cortical material. The bag is evacuated. And we can remove the MST capsular retractors and decide what to do. We can remove the bag if we decide to place an ACI. Or something else. If we didn’t have the resources or the means or the patient indication. Or you can use a fixated lens or a sue cure lens. Using the segment fixated to the sclera, using the suture through the docking approach. Alan Crandall and I published the first approach of the docking approach using the ring in the early 2000s. That’s a testament to Alan’s surgical innovation. I would give him credit for anything I have done. He’s certainly been the inspiration for any work that I may have accomplished. Here is the CTR going in as well to provide circumferential support. And now we have the bag for the IOL to go in. This is a young pediatric patient. We can see with the Marfan syndrome. And it’s through the mesh work. Go back a millimeter and a half, it goes to the zonular plane. And it’s to prevent vitreous prolapse. There should be none if there wasn’t any preoperatively. A bi-manular approach can be used along with the capsular forcep. They don’t need to be perfectly round. They should mimic the contour of the capsular equator. You can see it’s polarized with the lens because of the focal area. These are quite amenable to the placement of the countersegment locally in the dialysis. Certainly more than one can be placed. I typically place a couple of iris retracts I in place, place the CTS in the capsular and then with the hook. It’s like hanging the coat hook. We can remove the lens material, we can place our scleral sutures like described early with the Gore-Tex. Passing through the C TS, and secure with a slip knot. I place a capsular tension ring in. One can go to the one piece design. I like the ability of the C TS to provide verse tilt interoperablely. And we want to avoid capsular contractor. This is using the singular sweeper, removing the LECs under the capsule to reduce risk. They are 3 or 4 years old, they require the cop — and this, again, will be important to prevent secondary PCO. Congenital and pediatric cataract is a significant burden worldwide and I recommend the use of a posterior capsulorhexis like this. The one or three-piece lens with the posterior optic button bolt, capturing through the capsulorhexis. There’s no way for to migrate. There’s no posterior capsule, and it’s sequestered by the IOL. We secure the suture there and we have the nicely-positioned IOL placed with the presence of a CTS. It’s a pleasure being here. We miss Alan tremendously. I miss him every day. My only regret is not spending enough time. We always regret the time we wish we had with people that are important. We will always miss the great Alan Crandall. Thank you very much.
Dr. Chang: Thanks, Ike. That was terrific. I actually want to thank all six of our faculty. Those were outstanding videos. And I think they complemented themselves very nicely. So, we’ll bring everyone, our faculty back on, and we’ll spend the remaining time with some audience questions. So, one of the questions that I saw come up what about the cortex? We haven’t talked about — you’ve done a vitrectomy, you’ve got the nucleus out. How aggressive should we be about the cortex? You know, how much is too much to leave? Let me throw that out first to Vaishali.
Dr. Vasavada: Well, I think once you have done a good vitrectomy and the anterior chamber is free, doing a good cortex cleanup is very, very important. Two reasons. Mainly, if you leave behind cortex, it causes inflammation. And some of it may come out in the anterior chamber and hampers your view of the healing. I’ll do a cortex removal, but bimanual through two side ports. Even if I didn’t make two paracentesis. I would make a new one. I would use a retractor. And you rightly mentioned the two sides. I would go in position 2, I aspirated. And I would do an aspiration in position 3. So, if there’s any vitreous, it also comes out.
Dr. Chang: Excellent. Thank you. Let me ask Bob Cionni. One of the questions is tips for the hyper, the crowded anterior chamber. How do you address first of all trying to deepen the chamber in these eyes?
Dr. Cionni: Yeah. That’s a great question. We didn’t touch on that really in any of the videos today. But certainly if you have a very short eye, you have to worry about that. Classical teaching is doing some sclera windows. But I can tell you I haven’t had to do that in many, many years instead by giving some IV diamox, decompressing the — the hydration of the vitreous. And that softens the eye very, very nicely. In addition, using a more cohesive type of viscoelastic can be very helpful in deepening the interior chamber in these eyes. You need to be on high alert. You really don’t want to be doing a long surgery in a short eye. So, if you have a really dense lens and it’s gonna be a longer phaco, then maybe that is the case where you want to do some sclera windows ahead of time. But simply decompressing the vitreous can be helpful. If dehydrating the vitreous is not enough, you can start with a parse plane and stab. And put a vitrectomy tip in and just remove a little bit of vitreous and you’ll see that chamber deepen quite nicely. And that may save you in some of these cases as well.
Dr. Chang: Yep. And if you’re doing that technique, I would just use the vitrector without infusion. And use your smallest gauge vitrector. But you do, you know, have to go through pars plana. Ike, let me ask you. What about posterior pressure that’s occurring during the surgery? I think that often happens when you’re left with the cortex. And what is your thought process there?
Dr. Ahmed: Yeah, I mean, I think it’s important to sort of understand both external and internal factors that can — positive pressure which can be difficult, look at the external factors. Venus tension, is the patient barrel chested and with the position of the bed. I like to put the bed reverse for that reason. Are they squeezing? Lid pressure? Are there orbital pressures that may be causative as well. We have to be concerned about intraoperative issues, cortical infusions and hemorrhage. And think about interoperative malignant glaucoma. It’s expanding without the frank effusion in the small eye. And think of fluid misdirection syndrome. The key point. A lot of didn’t things to think about. The key point is to identify the cause. The biggest concern is the risk of the supra cortical hemorrhage. Loss of reflex and the shallowing of the chamber. In a small eye, it’s the presence of an effusion or malignant glaucoma situation. In those case with it’s. To look at the fundus, and the tap if needed or the scleral cut down. I would be caution cautious making the incision unless we have ruled out the hemorrhage. That would make it worse and create more problems for us in managing the case.
Dr. Chang: Perfect.
perfect. Let me ask David Crandall. One of the questions was, what if you don’t have triamcinolone. When is it important or not important to use it when doing a vitrectomy?
Dr. Crandall: Certainly not always necessary. And I don’t do it in a posterior capsular rupture. Because you can see secondary signs of vitreous, you can see peaking of the pupil, movement of the bag and lens fragments as you’re doing your vitrectomy. You look for other clues that there’s vitreous there. I typically use it if I’m going into a case knowing I’m going to have to do a vitrectomy from the beginning. If it’s a traumatic cataract and there’s loss in the interior chamber, I use it then. But most of the time, I don’t. When it’s unplanned. I do think it’s good early on until you’ve done a few dozen of them to learn how the vitreous moves and that makes it easier to see the other signs later.
Dr. Chang: Excellent. Jeff Pettey, we had a question about complications of doing the anterior vitrectomy. And I guess this is — when do you feel — should all these patients be seen by a retinal specialist? How do you manage them, and how do you decide what you want to refer someone? Let’s say — there’s no retains nucleus. Maybe there’s a little cortex back there. Let’s just talk about management of that patient and then subsequent referral.
Dr. Pettey: Yeah, you know, in regards to referral. There’s a lot of factors. What is your access? How far does the patient need to travel to the specialist? What is your own skill-set? I’ve got — you know, many of us have vitreoretinal specialists in the building. It’s easy. And I think in most cases, it’s prudent to have someone with that level of training to lay eyes on a patient after you have done anterior vitrectomy. As far as the follow-up, close follow-up is important for a number of reasons. A good dilated exam at each of the follow-up visits is mandatory. Looking pre- dilation for any peaking of the pupil, any pupil is important. And looking at the peripheral retina is important as well. And keep paying attention to the centration of the lens or subtle signs the vitreous may have moved forward.
Dr. Chang: Excellent. Susan, I’m going to have you take this question. Someone’s asking about experience with the MyLoop for a dense lens.
Dr. MacDonald: Delighted to talk about that. The MyLoop is a nitinol fiber which we can use to divide the nucleus in really a one-handed technique. And once you do that, it really is a wonderful technique that you — if you’re a little — if you’re concerned about the — the cornea, or you’re concerned about how much energy you’re going to put in the eye. Because you get beautiful division of your lens without any phaco power. It’s not a hard technique to learn. It takes about a half hour in a wet lab to really get that down. And it is a very save technique.
Dr. Chang: Great. Ike, we have a question about coloboma in cataract. What are you worried about with these patients? Do you do anything differently? How do you prepare for those cases?
Dr. Ahmed: It’s interesting. We have a lot of experience with colobomatis eyes. The bigger issue is positive pressure. They have an — experience. And they aren’t is a major issue with the zonule. There’s often a zonular to be. And should anterior eye are considered. Although they might not have photophobia, the optic exposed by the colobomatis present may be there. It’s p I encourage it’s important to close the defects with a suture that can be done. Bob Cionni in one of his rare accomplishments has published on this as well. I think it’s important to look at that and certainly discuss with the patient. But by and large, these can be managed with modern day approaches, whether it’s phaco or otherwise.
Dr. Chang: Excellent. Bob, you — I have to give you a chance to come back on that one. But specifically, how do you decide when to use a CTR? Not just a coloboma, but in any case, what are your indications?
Dr. Cionni: Well, first off, I would never use an Ahmed segment. That thing is just awful. I don’t know whoever came up with that idea. No, the Ahmed segment is wonderful. And, you know, just as an aside, you know, we all learn from others. We all stand on the shoulders to see further. And Alan has been a great teacher. And taught all of us including Ike how to use these devices. When to use it. There’s so many different variables. If there’s generalized zonular weakness, I would put in a CTR. Not only to get through the case, but post operatively, we if the zonules continue to weaken, you have a ring around which you can put a suture once there’s fibrosis there. Anywhere for 36 degrees. It’s a lot — 36 0 degrees. It’s easier than re-suturing an intraocular lens. You can put the suture aren’t the CTR. The timing is variable and depends on surgeon skill. If you have the loose zonules, sectorial or generalized. May to want put in as soon as you have a completed capsulotomy. Getting rid of the cortex so you don’t trap it under the ring. For those who have done a lot of these, maybe even Ike, you can do the entire case just using viscoelastic and vasco hooks to stabilize the bag. And once you’re done with that portion and all the cortex is gone, you can more easily put in a ring and be certain you’re not trapping cortex.
Dr. Chang: Thank you. Another question. This is for you, Jeff Pettey. Post-op, say there’s a pink pupil and you have a vitreous incarceration, maybe a centesis, do you need to intervene? How soon do you have to? I think we have all seen this situation. What’s the proper management, Jeff?
Dr. Pettey: Yeah. Because this happens so rarely, there can be a little bit of an art to this. I would, you know, perhaps Ike might be the best to answer this. I know this happens a lot to him. But the thing that I would say is as you look at it, if this is something that is clean and simple, you have the YAG laser, this is a simple way to take care of it.
if you don’t have a YAG laser access, it’s not logistically possible for the patient to actually get something where there is a simple YAG laser, then taking them back to the operating room using some soft of, you know, simple technique you have. Either long Vannas scissor, or through new paracentesis. I would stress to address this early to prevent downstream effects. If you don’t have those options, you can observe over a period of time as well.
Dr. Chang: Excellent. Vaishali, we have a lot of — a couple questions on posterior polar cataract. And, of course, your clinic has enormous experience with this. One is your pearls to doing this case to avoid capsule rupture. And the second is sometimes it’s hard preoperatively, you look, is that a PSC or a posterior polar cataract? In say an older patient. It’s not clear-cut. So, if you could tackle those two.
Dr. Vasavada: Thank you. As to how you manage, I have learned this a lot also from Dr. Crandall. Do not allow the chamber to fluctuate during surgery when a clear cut or suspected polar. Every time you bring out your instruments, always inject with viscoelastic. Perform any form of a hydrodelineation. If you have access to the — I would perforate the cataracts. Do the delineation technique. Use lower aspiration forces. And until the end, the posterior capsule drops. I would not be aggressive in the vacuum. Polishing off the capsule is something I would not do too much. How you ensure no PCR or no enlargement PCR. There are patients who have a doubtful case and you don’t know what it is. If you have access to UVM or anterior segment, sometimes they have tell you and differentiate. One step above, if you don’t have access to intraoperative or CP, that would be the best. But I think simple clinical judgment based on the clinical parameters and any doubt, treat it in surgery and before surgery. Council the patient for the possibility of a rupture or a second intervention. Any time you have any doubt and you are not able to meet out. That is my take. Thank you.
Dr. Chang: Thank you very much. Let’s see. Another question is, when do we need to do a — a peripheral iridotomy. You have done a vitrectomy. Let’s say you put in an anterior chamber or a sulcus lens. What are the guidelines for when a PI needs to be done?
Dr. Vasavada: I primarily do not perform a PI as a routine in most cases. Unless — I don’t do the chamber, I was more strict. But if I were to do, yes. That is one indication I would do a PI. But in case I feel there is a need for a PI in a place where I put the sulcus, I would rather not put the lens. Like David Crandall rightly said, you don’t have to put in the lens all the time. If you feel that the iris is very shift and might cause a blockage. Then you can do a PI. With a mechanical retractor. You don’t need a PI. That’s my personal opinion.
Dr. Chang: Excellent. Let’s see. Let’s ask David Crandall, the tips on putting an IOL in the sulcus. It’s ruptured, what are the guidelines and your pearls for that?
Dr. Crandall: So, first thing I do, and Bob mentioned this in his talk, make sure the wound is big enough to insert the lens without any tension on the wound or the distortion. I like to make it large with the cohesive viscoelastic so you have a big target going in. Depending on if you put it in manually or inject it, know how the haptics are going to move. Don’t get the lens upside down, creating iris shaping and a big myopic shift. What I do when in doubt, and I teach my residents this early, is just to put it in the anterior chamber. Get the haptics where you want them, and then with the micro graspers dump the lens into the sulcus. And you have a lot of results doing that and keep the anterior chamber formed and easy to see everything.
Dr. Chang: Great. Let me ask Bob Cionni. A lot of people are not comfortable with suturing or some of the Yamane techniques, intrascleral fixation for PC lenses. Is it okay to put an tear your chamber lens in if that’s what you’re comfortable with after doing a vitrectomy?
Dr. Cionni: Yeah, absolutely. Modern day A CIO Ls are really nice lenses. I wouldn’t hesitate. Just make it’s sized right. And something Bob Osher taught me many, many years ago, make sure you have a positioned properly. That the foot plates of that have not inadvertently grabbed on to some of the peripheral iris and stuck it into the angle. or that they’re not through a peripheral iridotomy or iridectomy. Few if you have positioned it right and haven’t captured the peripheral iris or gone through a PI, they do really well. Don’t be shy for that.
Dr. Chang: Great. The last question I’m going to ask and then we’ll have Geoff Tabin’s presentation. And we haven’t talked about, what do you say to the patient after you’ve had a complication, you’ve had to do a vitrectomy. Maybe you’ve put in an AC IOL. What are the tips for what you would say to the patient? Since I know the men on this call have egos, they’re going to say it’s never happened to them. I’m gonna have to ask Susan to — to tell us what you would do. Oh, you’re on mute, Susan.
Dr. MacDonald: It’s a great question. And I think it’s a really important question. That complete transparency is important here. Because as David mentioned, you really are trying to do what’s best for the patient. And that means explaining to them exactly what happened. And to reassure them that this is a known problem that can present itself and that you’ve managed it properly. I strongly believe as an anterior segment surgeon, if you have access to a retinal specialist, include them in this. Having to send a — send a patient to a retinal specialist after a complication is very different than being proactive. I would also reinforce to the patient that you are going to see them more often. That you expect a good result. If you expect a good result. And let them know that you’re going to use all your resources to take care of them.
Dr. Chang: Great. Thank you. Well, once again, I want to thank all of the faculty for just terrific panel discussion as well as presentations. And we have a special tribute to end with today. I’m gonna introduce Geoff Tabin. Geoff’s on the faculty now at Stanford. But for many years was at Utah with Alan. And they, like several of the other faculty, have spent a lot of time operating in all corners of the world in low to middle income settings doing humanitarian cataract surgery and teaching there. And had a very special relationship. So, Geoff, I’m going to turn it over to you to conclude our symposium today.
Dr. Tabin: Thanks. This is a great honor. It’s been an amazing symposium. Thank you, David, Hunter and all the panelists. I know a lot of people in the developing world live — there’s still about 550 people listening. There was just one comment I would just correct. Which was — was mentioned in a shallow chamber you would use IV diomox to help soften the eye. And I think the speaker probably meant IV mannitol. You use 20% mannitol. IV diomox would not do much for the vitreous. So, I’m gonna share my screen now. And…
And I’m gonna talk for a couple of minutes about — about Alan Crandall as a person.
He, as you heard, was a remarkable surgeon, a remarkable teacher. But he was more just a special person. He was low key. But he had this unique sparkle for life and a twinkle in his eye. There was just a joyous bearing that made everyone feel welcome in his world. Alan’s easy going demeanor, he strived for excellence and maximum from the trainees. His surgical skills were legendary and his teaching and devotion to all the patients and improving world eye care. He was the embodiment of kind, as Susan said. A nice person. Maybe the nicest person in ophthalmology. But I’m going to talk about he was without a doubt one of the craziest. Alan’s love of life was just infectious. Never passed on an opportunity not just to teach and share, but to suck the marrow out of everything in life. He was a great chef. He provided great food and drink for people. And he was famous for his work around the world in Africa, Asia, South America, South Pacific. But it was really his person, his often operated and taught from 7 in the morning until 9 at night with no breaks. But less known is he would then, when we finished, he would help the nurses clean up. There was no task too small that Alan wouldn’t take on. He would help with the garbage. And only when everything was finished, and all the floors were swept. And that was when he would break out the first of several star beers. One year we were in Tanzania and they had this Congolese band in the courtyard of the hotel that played past midnight every night and it was impossible to sleep. Alan was the first out grabbing a cow bell and dancing and jamming after our 14-hour workday. And I would crawl off to sleep, and Alan was jamming with the band and he was the only one who was fresh the next morning. And everywhere he went, he just cared about people. He cared about teaching and making sure that every person he was working with was working up to their potential. But also, Alan just would — anything he thought he might want to do, he never really climbed a mountain. And after this trip to Tanzania, he and his wife Julie joined me and some professional mountaineers to go climb Mount Kilimanjaro. And Alan was able to keep up a pretty reasonable pace all the way to the top of 19,000-foot Kilimanjaro. But then when he started down, he was really slow. He said he was 3 months out from having a total hip replacement surgery. Alan had been a — and this is Alan with his wife Julie in South Sudan. Alan had been a star quarterback on his high school football team. He was a very aggressive skier, living in Utah. And through the years his orthopedic injuries mountained. I never heard him complain. Every year, his gait got a little bit stiffer, but never lost the bounce in his step. And in 2009, we were returning from a week of teaching and doing cataract surgery in Kumasi, Ghana. And we had a phaco machine that we put on top of the — on top of the luggage rack. Unfortunately, right above Alan’s head. We hit particularly big — big rut in a 40-pound phaco machine fell from the luggage rack directly on Alan’s head. And Alan unfortunately, at that time, or fortunately, was very hard to kill. And he seemed like he had a little bit of a concussion, but kind of recovered. He was momentarily dazed. And then we drove to Accra, all night to Amsterdam and then to Salt Lake City. And as usual, Alan had a full schedule of surgery the first day back from Africa. And he completed his last case before uncharacteristically he mentioned that his head and neck hurt a little bit. So, he walked over to the ER for X-rays where he was directly admitted to the ICU with an unstable neck fracture. Had emergency surgery that night to fuse his surgical spine, but he was only out of surgery for two weeks. I had the joy of being in Alan in many places, Nepal, China, Kenya, Tanzania, Ethiopia, south Sudan, as well as at the Moran eye center at the University of Utah. And he really made every person everywhere he went feel special. And when we were in South Sudan, we operated during a heat wave in a tin roof shack that was more like a convection oven. The temperature outside was a little over 100 degrees, 38, 39 degrees. And inside, it was just oppressive. Alan was dripping with sweat and a scrub nurse had to wipe his brow with an alcohol-soaked sponge every 3 minutes to prevent perspiration from falling into the operative field. We struggle requested a generator, glaucoma, dystrophy, hypermature cataracts, pseudo exfoliation. And we had to operate in shorts and scrub tops. We couldn’t wear a gown because of the heat. But there were biting insects in the operating room that were just swarming on fetid and exposed flesh. And bats feasting on the flies. And that night, over rice, beans and ionated waters, Alan said, Geoff. That was the best surgery day of my life. I’ve never seen so many difficult cases or people with needs. Alan never slowed down or lost his enthusiasm for love of his life of family, friends and humanity. This is with Randy Olson, his long-time partner who together they really created the excellence that is the Moran eye Center. But Alan just cared about people. He became a minister online and married the first same-sex couple in Utah as well as several friends, including myself and also Bob Cionni. When the AAO or ASCRS meeting was in Chicago, Alan topped off a full day of teaching and meetings with late night blues, in New Orleans, jazz. At age 69 he took up mountain biking and completed the infamous Tour Des Suds. A long mountain bike race in Utah on a hybrid city bike. And I had the pleasure of accompanying him on the ride. You see there was no one else around. There were about a thousand people in the event. But Alan and I finished an hour and a half after the closest competitor. He went on a father-son rowing trip with his son Jesse through the Grand Canyon and never hesitated in the rapid or launching himself off a 40-foot jump, despite having enough metal in his joints to sink a pirate ship. Alan was a great father, a great husband, a great friend, and a great mentor. This is with his wife, Julie. And when you were with Alan, he had a way of making you feel special. You were the most important person in the world. Alan was present in the moment all the time. And one of my favorite pictures of Alan was this picture here of him in South Sudan holding a small child’s hand. And his too short, but amazing full life, Alan held so many of our hands. He brought joy to our journeys through life and helped us reach where we need to go. And I’m just delighted we could have this conference remembering Alan who was not just a great ophthalmologist, but a great example of what it is to live a great life and a wonderful, loving man. Thanks.
Dr. Chang: Thank you so much, Jeff. That was amazing. And so well-said. I want to, you know, close by, again, thanking our faculty. This has been a really special program today. And obviously, it’s special because we’re all connected to this amazing man. We hope to have this annually. And so, again, thank you to Orbis and to Hunter Cherwek for organizing and hosting this. But I want to also thank the audience. You know, I like to think that everyone tuning in today from every corner of the world is connected in spirit, you know, to Alan. And I think what we all share in some way, shape or form is part of that passion that he had for taking care of patients and being ourselves the best surgeon, the best ophthalmologist we can be. So, kudos to all of you who are tuning in and making the time to be a better ophthalmologist. And have a great rest of the week, everyone. Thank you again. Bye, bye.
>> Bye, bye.
>> Bye.
>> Bye, everybody. Thank you.
>> Great seeing you, Ike! Good seeing you, Bob.
>> You too, Jeff.
>> Bye, Jeff.
>> Bye!
>> Thank you, everyone!
>> Thanks, guys.
>> Thank you.>> David, you couldn’t have done a better job. And I think you and Geoff were the perfect start and beginning. I appreciate the kind words. I got a little choked up. I can’t thank you all enough for such a beautiful delivery. I know some of you all woke up really, really early. So, I just — I just want to say thank you. It meant a lot.
>> What great idea, Hunter. And I’m glad we could pull it off with such a great group.
>> Alan, I was getting blown up on text, people from all over. For the future, we should actually broadcast the speaker chat. And watch the dialogue. There was so much shade going on. I couldn’t believe it. But, you know, it was a special day. And this is something that I don’t know — Lawrence, you’re still on? I wanted to specifically thank you. You spent dozens of hours getting this lined up. And you executed this flawlessly. I can’t wait to see how many countries and live participants we had.
>> Of course, no problem.
>> But David, a specific thanks to you. You were herding the rabid cats and keeping Ike Ahmed under control. That’s almost impossible.
>> That’s great. Well, it was perfect this morning. It was great.
>> Yeah.
>> David and Hunter, I’ll talk to you both sometime soon. David, let’s together now that everybody is vaccinated. We’ll have you guys over to dinner soon. Okay. Thanks.
>> All right. Everyone, take care.
>> David — could you shoot me Jesse’s number? I tried to call Jesse to tell him to tune in. And I got a recording the number is no longer working.
>> Yeah, I’ll find it. He got a new phone a few months ago.
>> Okay. Yeah.
>> For some reason didn’t forward the number to the same one.
>> Well, if you could — if you could email me with his new number.
>> Yeah.
>> All right, everyone. Please enjoy the day and thanks again for all your time. It meant a lot to me and to the organization. So, thank you.
>> Thanks.
>> Bye, bye.
>> Good job, everybody. Bye!