Lecture: My Toughest Glaucoma Surgical Case: Learning From Challenges

DR KAHOOK: Hello, everybody. And welcome to this session on Cybersight. This is probably number ten or eleven for these sessions that we’ve been trying to do. We started just before the pandemic and have worked our way all the way through the past two years. The unique thing about this session is it’s basically seen as friends talking about tough cases, crying together over some of the difficulties that we’ve had. And in some cases, just discussing interesting topics that you have sent in, during previous sessions. And I encourage you to do that. So while we’re going through this session today, if you think of other things you want us to cover, please send in the information, and we’ll make sure to program it into the future. I’m Malik Kahook, from the University of Colorado, and we have three distinguished panelists today. I’m going to do a quick introduction before we move into the talks. Our first speaker is going to be Dr. Erin Sieck, assistant professor of ophthalmology at Wash U at St. Louis. I had the fortune of having her as a resident here during her training. She’s now an attending and an excellent surgeon at Wash U. Subsequent to Erin’s case, we’re gonna have Cosme Lavin give a case. He’s at the Hospital of Madrid, Spain. He has a special case to share with us today. I’m looking forward to that. And finally, last but not least, Dr. Gabriel Lazcano. We’ve known each other for 13 or 14 years now. I met him when he was a fellow at APEC Hospital, but he was functioning as an attending from day one. He has a private practice in Puebla, excellent surgeon, and he’s gonna share a complicated case with us. So without getting into too much of the… What’s gonna happen, I do want to get right into it, and just go into Erin’s case. Erin’s gonna walk us through her case, we’re gonna have a short discussion, and we’re gonna move on, subsequent to that, to Cosme’s case. Erin, do you want to take it away here?

DR SIECK: Sounds great. I always like to be invited to the glaucoma specialist therapy sessions. You have to be tough skinned to be a glaucoma specialist. A lot of things are out of our hands. Even if you do a perfect surgery, things don’t always go how you want. So I’ll start on my case. This is a 67-year-old male, presented with acute angle closure glaucoma on one side. With medical management, they were able to get his pressure down to 15 in the emergency room. He came into my clinic the next day. His pressure at that time — he had a patent LPI, pressure was back up to 32, on exam he had significant lens rise, and when I did gonioscopy, he had a slit. We could not see any angle structures on the right side. The left eye was open to anterior trabecular meshwork. So in this case, we planned for an urgent phaco, since his pressure continued to be elevated despite an LPI. We’re gonna get started. As you see, I’ve already placed iris hooks. This patient was a poor dilator, which is not too uncommon in these cases. We’re gonna start with capsulorrhexis. I went in with the cystotome. You may have noticed that initially you can see the capsule dimples. When patients don’t have any zonules — once we got the iris hooks in, we had high suspicion that he had poor zonules. He denied trauma when I talked to him the day before, but his family member says he’s a rowdy patient. Maybe he had trauma back in his college days, but nothing recent. We had a high suspicion he didn’t have good zonules. So when you’re doing a rhexis on a patient with no zonules, you’re not gonna have the same tautness of the anterior capsule, since the zonules 360 are not pulling that anterior capsule tight. So you have to push a lot harder than you would expect and sometimes it will make you uncomfortable how much you have to push, so I’ll always use a cystotome. I’m going in with Viscoat. Some people may talk about using Healon 5 or something heavier. I don’t want to push the lens more posterior so I just do Viscoat to do my capsulorrhexes on all my patients. As we’re pulling around, trying to do a normal capsulorrhexis, you can see the entire lens move and not too uncommon, it ends early. We don’t have the same forces we’re used to working with. So oftentimes the capsulorrhexis is the hardest part of this case. Because you want to get big enough rhexis to be able to remove the lens. But oftentimes it’s hard to get the centrifugal force of pulling it all the way around. So when I have a rhexis that ends early, I take whatever section is left and cut it in half. I’ll do my cystotome right across what’s left. So you can see that I went right across there, what’s left, and that gives me a flap to pull up and then a flap to pull down. Because we want this to be as continuous and curvilinear as possible, because if you have areas of not continuous, then you can have an anterior rent, when you do a hydrodissection. So you can see I’ve finished those last two flaps. And we have a pretty decent rhexis there. So I go in and do a normal — sorry. We’ll get to hydrodissection in a second. That was a little bit of Viscoat being placed between the anterior lens capsule and the lens itself. And then we’ll be placing the capsule hooks. Now, I wanted to pause here. Because I want you to pay attention to how my paracentesis blade is directed. When I’m placing iris hooks, I go posterior to the surgical limbus, and I go parallel to the iris. Because we want to pull the iris out. We don’t want to tent it up into the cornea, as opposed to when I’m placing capsule hooks, I actually go much more at an angle of where I’m pushing towards the anterior capsule, and I’m going more clear cornea, because we do actually want to lift up this lens, as opposed to the iris we just want to dilate. So that’s the difference I do when I’m making my paracentesis between an iris hook versus a capsule hook. Here I’m placing three. You may be asking yourself why I did not place a fourth. When we get later in the case, I also ask myself that question. So if you’re concerned that we have 360 degrees of no zonules, I highly recommend placing four. That is much safer in the long term. But how we place these is… And this is another — a good thing to bring up. Some people will talk about using iris hooks on the capsule as well. I think that’s very common, because then you can use maybe one pack and get away with not having to open two different packs. The reason I like capsule hooks versus iris hooks is just the shape. If you can see while I’m inserting this one, it has a wide flange that’s plastic. And so that actually can hook that anterior capsule, and doesn’t have the ability to puncture it. As opposed to iris hooks. They’re smaller. You can’t get as good of a grip on that anterior capsule lip. And then they are a little bit sharper. So they can potentially puncture. I’ve used them before. So you can use either one that you have. But I do prefer capsule hooks, if you have them. And then a normal hydrodissection. Now we’re gonna get into our phacoemulsification. There’s a lot of comments, and we could talk a whole hour about just phaco techniques. Dealing with patients with loose zonules. I personally just don’t want to spin the lens. That’s the one thing I’m trying to avoid. And so I’ll do a primary groove and then take each hemi, and then avoid spinning the lens as much as you can. Again, we don’t have the zonules keeping that capsule taut. So if you try to spin this, the capsule is gonna want to rotate with the nucleus as well. And so you’ll see I make this initial groove, and then everything we do is to try not to rotate the lens as much. The other hard part is you just can’t push down, like what you’re used to. You don’t have anything keeping this capsule up, other than these plastic hooks, so you really have to focus on pushing away from yourself, not pushing down. That’s the biggest thing. A lot of studies have come out that phaco chop might be a little bit safer on zonules. Less phaco energy into the eye. So I do recommend that if you can. I personally just like the central groove and taking out the hemi flip, but if you’re proficient in chop, I think that’s extremely safe if you have loose zonules. So we’re slowly trying to limit rotation as much as we can, getting our hemis out. The hard part here is when you start to get a bite on your nucleus, the bag wants to come behind it as well. So sometimes you have to keep grabbing and try to find a safe place to grab that nucleus. So that the bag doesn’t come back. So we’ve got our entire nucleus out there, it got a little scary for a second, when we thought we ate the bag, but as we can see, the bag still looks intact. So this is also an extremely good teaching point. That if you do break capsule, even in an eye that doesn’t have loose zonules, you always have to refill the eye with a viscoelastic, before you take out your phaco tip. Because you want to prevent as much vitreous prolapse as possible. So I’m coming in with Viscoat to tamponade the vitreous posteriorly, taking out my phaco tip, and here we go in with the retractor to get the last bits of cortex. Here I’m doing an A cut with the vitrectomy settings, which allows me to suck the piece in and eat it up, as opposed to the constant chopping which would kick away the cortex pieces. You want good suction. So that’s an easy setting you can change on your phaco machine. There wasn’t any vitreous prolapse. I was surprised by that. So I’m going back, filling the bag with a little more viscoelastic. And we’re taking out our capsule hooks to see what we have left. And it looks like we have an intact anterior hyaloid with no vitreous prolapse. We got the entire cataract nucleus and cortex all. We’re taking out our capsule hooks and we have a bag that is free-floating in the posterior chamber. So I’ll pause here and stop my share, so I can ask my panelists: How would you guys address where we are now?

DR KAHOOK: Yeah. Maybe we can go to Gabo. I think one of the things that I want to say first is, Erin, you touched on a lot of the teaching points. A lot of the questions I was gonna ask you, you actually answered along the way. Which is really good. I do have a couple of questions for you. But Gabo, I know you do a lot of difficult phacos. I’ve had experience in the operating room with you, when you were doing difficult cases. But what would you have done in your experience? Especially with the equipment that you have available to you? Would you have done things a little bit differently?

DR LAZCANO GOMEZ: Yeah. Well, first of all, my first step… Could be just to pray with all my heart. On my side at that time. No, just a couple of points. We usually use Trypan blue on regular cataracts. So for these cases, I would recommend especially for residents and fellows to use Trypan blue. So you can have a better view of the capsule. Capsular hooks — we don’t have them very available here. So use iris hooks for the capsule. But you’re right. Sometimes you can tear the capsular bag. And it’s really bad. So I would say in my private setting that we’re kind of limited. Probably I will clean the anterior segment, and if there’s not a retina specialist available at that moment, I will clean the most I can in the anterior segment. And go on the second time for a scleral fixated IOL.

DR KAHOOK: Yeah. We just had this discussion last week about using Trypan on phacos or not. Do you use Trypan on these cases? Any other observations with these cases, Cosme?

DR LAVIN DAPENA: I always say to my residents: If you have any doubt, use it. There’s no point not to use the blue. It’s so much easier. You see perfectly the capsule. So it doesn’t make any sense… It’s not expensive. So I really recommend if you have any doubt to use it. And then… How much was the zonule away? 180? I’m really not sure how much was it. Because I don’t see… The whole thing down or up or… You think it was 180? 90?

DR SIECK: You could see at the end there was definitely at least visible 270 degrees of zonule loss. We did tug on that last little section, because you could see the rhexis was a little bit tugged nasally. And there was maybe a few clock hours of intact zonules there. Not a lot, though. That kind of limits our options for what we could do next.

DR LAVIN DAPENA: Did you know about it when you were beginning?

DR SIECK: That was something I was gonna ask you guys. It was not in the forefront of my mind, but looking back, since he had unilateral narrow angles, his other eye was open to grade four, so it was a unilateral angle closure, so that should have been higher in my mind, that this is a patient who could have weak zonules. Since he had such significant lens rise. It wasn’t on my forefront. That’s why it was signed up with a resident until I had to take over.

DR LAVIN DAPENA: To my resident I usually say that… Any glaucoma cataract, be prepared for anything. I think it’s just… Regular small angle with a little laser… No. It’s not going to be that easy. They usually are used to go to other anterior segment and they say… Well, that’s just a cataract. In glaucoma… That’s always… Be prepared.

DR SIECK: I definitely agree.

DR LAZCANO GOMEZ: Erin, just one quick question. Did you use mannitol before the surgery?

DR SIECK: I was just about to ask that. If there’s anything you do if you have a narrow anterior chamber in the case. In this case the axial length was normal length. And his other eye had a normal ACD. I did not give mannitol, just because when I was able to place the iris hooks, he deepened extremely well. So I wasn’t concerned about posterior pressure or intraoperative malignant glaucoma. So I did not pretreat with mannitol. But if I have shorter eyes or extremely small and symmetrically narrow or shallow anterior chambers, I will pretreat with mannitol for my eyes when they get closer to the 20 millimeter axial length.

DR KAHOOK: Just a couple things to add before going on to the continuation of the case. So if you’re in a setting where you have femtosecond laser available to you, this might be a good case to take advantage of it, and do less manipulation. Cosme does not like that. I can tell from the reaction on his face. But we have some cases that are compromised before you even go in. So with a closed eye, if you can get the rhexis done, if you can help with segmentation of the lens, it’s not always perfect in the alignment with some of these lenses with weak zonules. It makes it tougher and almost impossible on some, a minority of those cases, depending on the location of the lens. There are some devices that are approved in some markets but not available everywhere. Like doing Zepto capsulotomy. I would not do Zepto in this case with the compromised zonules. I think that would be really tough. CAPSULaser, which is approved in some markets in Europe but not in the US, uses a laser, basically, after coating Trypan blue over the capsule. It’s a diode laser. So for the absorption to create the rhexis. Anything you can do to minimize manipulation might help. But with Cosme’s wincing, that’s appropriate. You have to be careful with everything that you might do. One last piece, for any of the trainees that are listening on the examination, any of these cases, you should check for phacodonesis. And it’s not always done. Sometimes you’re surprised when you go into the operating room, 180 degrees of zonules are missing, lens is dancing around, and it wasn’t seen on examination, but that can prep you. A lot of times when we’re prepped for the worst, nothing happens, and when we’re not, everything happens. So Erin handled that really well. The question is: What do you do with the empty capsule? How do you treat the aphakia? I’ll let you take it from here.

DR SIECK: Another point is a lot of times we don’t dilate these eyes, because they have shallow chambers. So great points. One more thing I want to say before I forgot — when you are using Trypan in an eye that you’re concerned about loose zonules, make sure you don’t fill too much. You can send Trypan blue, posterior chamber, and it can fill the space between the anterior hyaloid and the bag and you use your red reflex which as surgeons we know is very useful in cataract surgery. So I do use it, but do a very soft fill, or you can fill with Viscoat and paint on that anterior capsule so you can control how much Trypan is going in the eye. Great points, guys.

DR KAHOOK: Great points from you. Keep it going. Show us what you did or what you could do.

DR SIECK: In this patient, we actually left him aphakic. Because we didn’t know what his visual potential was. Since his pressure was so high. And he was relatively unreliable. So we left him aphakic just to make sure that he had a good iris. But we did vitrectomize the bag. I’m gonna present other options. These are other patients I took care of, options that we could use. If we wanted to save the bag in this patient, Cosme asked how many clock hours of zonules we still had. He only had probably three or four. It’s pretty tough to suture a partial segment. You could consider a Cionni ring, which is a 360 degree CTR that has a little islet that you can suture in place. But again, that’s only one point of fixation. So if you have a significant amount of zonule loss, doing one point of fixation for a lens in the bag is not helpful. However, this patient was a Marfans case. So Marfans patients have the supratemporal dislocation. So the rest of his zonules were extremely healthy. But he had 6 clock hours of no zonules. So in this case, we did a partial tension segment ring. So you can see we have the capsule hooks in from when we took out the lens. And the device is actually made of PMMA. So you cannot fold it. And it extends about six clock hours and has two distal islets which I don’t suture. But you can if you want to. And then it has that anterior — or the islet that’s in the middle that sits slightly higher than those two posterior ones. So you’ll put the ring actually in the bag, and then that top islet is what will be anterior to the anterior capsule, and that’s what through here I have strung Gore-Tex suture. So I use 8-0 Gore-Tex if I’m fixating anything to the sclera because it has good strength and longevity. So here we make a small localized peritomy, three clock hours, clear off Tenon’s, and use a little bit of cautery to make sure we’re not gonna have significant bleeding into the eye when we start making our scleral passes. Now, the measurements for this — you’ll see next we go with a caliper. We’ll measure about 3 to 3.5 millimeters posterior to the limbus. Once you have that point, I’ll go 3 millimeters on either side, so we’re making two scleral passes 6 millimeters apart. And the blade you can use here — this is one of my fellows who liked to score his. I typically don’t do that. But he thought it would be nice for the Gore-Tex to sit in that small path. Here you can see we’re using an MVR blade. I’ve tried probably several different sizes, from an 18 up to a 23 MVR blade. The smaller that you go, the harder it is to grab the sutures. The larger that you go, the more likely you are to have hypotony afterwards. But we do a slight beveling. If you’re inserting retina trocars, you bevel a little bit so there’s a small scleral tunnel to try to prevent post-op hypotony. Most patients within a day or two of the pressure being on the low side, it bounces back up after that scleral tunnel scars. So we’ll externalize the suture, going in with some microforceps. The thing is to be gentle. We have 6 hours of zonules and you want to keep those intact for the rest of the case. And we’re grabbing our other suture there to externalize it. I’ll tie this on a slipknot so we can titrate how much tension we want on this. So as I said, this is PMMA, but the next case I’ll show we’re suturing against a lens that it could potentially tear the islet. So once we’ve got it in good tension, then we can place a lens. Now our bag is nice and centered, our rhexis is nice and centered, and we’re inserting our one piece acrylic lens. Now, here I’m using an MX60 lens. There’s a lot of different materials that you can use. I prefer an MX60, because they are stored in BSS, as opposed to stored dry. Such as the Tecnis or the AcrySof. So those lenses take a lot longer to unfold, they’re a lot more rigid, so they’re harder to position in eyes that have loose zonules. So the MX60 is extremely flimsy. You can even tear it in half. I’ve done that when I’m trying to remove these. You can tear a haptic off by just pulling. That’s how flimsy these lenses are, but it makes it easier to manipulate if you’ve got a small bag that you’re trying to get a lens through. So now we have our lens in the bag. And we’re just closing up our conj here. So that was a great case. This patient — he was 20/80 with his lens decentered. Everyone told him don’t get cataract surgery. Because it’s gonna be extremely complicated. But the longer you wait in Marfans patients, the more dense the lens is gonna be. So in this case, we were able to prolapse the soft lens into the AC, use I/A, no phaco energy, to get it out, so it’s a lot safer to take the Marfans patients when they’re younger, as opposed to waiting until they have a visually significant cataract. But post-op, he had a great outcome. So that’s if we’re gonna save the bag. Let’s say we got rid of our bag and we’re gonna scleral fixate a lens. There’s a ton of different ways you can scleral fixate a lens. You can talk about Yamane technique, which is where you externalize the haptics of a three piece and you can use cautery to make little bulbs that will go in your scleral tunnel. I like that technique, but the lenses that you use… The original Yamane paper used two different Japanese lenses and the Alcon and the Tecnis ZA9003. And they had no haptic breakage. I think maybe one case had haptic breakage, which I think is pretty surprising. When I used those haptics before, they’re a lot flimsier, as opposed to a Zeiss CT Lucia. So if I do a Yamane, I prefer a Zeiss CT Lucia. The haptics are thicker and less likely to break. They’ve been on back order for a long period of time. Finally back to where we can order them and get them within a few weeks. So I’ve mostly been doing scleral fixated MX60s and suturing through the islets that that lens has. But you can also glue haptics. Dr. Agarwal has so many videos on that. You can use an Akreos Lens, a CZ70 lens, which is unfortunately PMMA, so you have to make a huge 7 millimeter corneal wound or scleral tunnel. But there are a lot of lenses you can fixate. I like to use the MX60 just because that’s what we have on consignment here, and it has two islets. You’ll see this is an extremely similar technique to what we just did with the tension segment. However, now we have to be a perfect 180 degrees away. So I’ll actually use a toric marker to mark that. But again, it’s 3 millimeters posterior to the limbus and 3 millimeters on each side for each of my scleral passes. Now, I do cut off the haptics. That went a little fast there. Just because the more material you have in the eye and if there is any tilt, you can get some iris chafe. So I cut off the haptics to make sure you have the least amount of potential iris chafe. And then you can see now we’re doing the same thing of grabbing the Gore-Tex, of going outside in with our micrograspers. To grab our sutures. I always leave the last one just because if the lens flips on itself, you might have to unravel suture inside the eye. So if you leave one out before you center the lens, then it makes it a little bit easier. And then these are foldable lenses. You can fold it and insert it through a 3 millimeter wound. And same thing. When we’re doing tension here, you don’t want to overly tie these down. People always want to tie really tight, but the MX60 material is extremely soft, extremely pliable, so if you tie too tight, you could rip through the islet and cause intraoperative or even long-term dislocations. So closing conj there. But I think the biggest thing here was the only change from the last case — so this one is that we’re doing two sets of fixation and making sure they’re 180 degrees away. Nice and centered in the end. And lastly we’ll talk about AC IOLs. They get a bad rap. People talking about endothelial cell loss and if you’re a good anterior segment surgeon, you should be able to scleral fixate a lens. But I love AC IOLs. If you don’t have the skills to place a scleral fixated lens and you place an AC IOL, people have fantastic outcomes. Recovery is really quick on these patients. So don’t shy away from AC IOLs. I think they’re great options for the anterior segment surgeon to be comfortable placing. So what we’ll do here is… You can do either a scleral tunnel — a lot of people do scleral tunnels to place their AC IOL. I do a clear corneal. And you’ll see my stitch at the end that keeps it pretty tight. But a 6 millimeter incision, since this is a PMMA lens, cannot fold. And to make the PI, there’s a lot of different ways you can make the PI. This was a patient who was left aphakic by an outside surgeon, so they had already had a vitrectomy. So I wasn’t opening a vitrector. If I was doing the vitrectomy, that’s my favorite way to make a PI, is to turn the vitrector down towards the iris, get your cut rate low to like 400 so it takes one or two bites of the iris, makes a beautiful PI that’s really peripheral. But here I’m using microscissors to open, spread, to make the PI, or you can do a Sinskey on top, a Sinskey on bottom and have them meet and spread it apart. Tons of ways you can make a PI. Placing the AC IOL, a lot of people do Sheets glide. I don’t. I think using a McPherson and grabbing over the haptic gives me good manipulation to know where my inserted haptics are going to make sure I’m not hitting vitreous or iris. So I don’t use a Sheets glide. So I’ll close my corneal wound to make sure we’re not prolapsing our viscoelastic, and I’ll do a double X suture here. So we go all the way to one side of your wound, all the way to the other and then tie it to itself. And then we can rotate the knot in. This is pretty water tight. Even if your corneal wound isn’t fantastic. I’ve had really good success with those being water tight and taking the sutures out at 8 weeks post-op. You can see we’re marching out the haptics to make sure it’s not catching iris or bunching up into the angle. Make sure that it’s free of the iris and sitting comfortably. And then we’re rotating our knot there and that’s the AC IOL. So those are just a few options. But obviously multiple ways that you can put a secondary lens in.

DR KAHOOK: It is a mini- mini-fellowship basically in 30 minutes with all the other things. Maybe we can get Cosme to load up his talk as we’re going through a couple of things. The CT Lucia lens has different haptic material. That’s important to note, so it can bend and go back to its own form. It’s made out of PVDF. So that’s why a lot of people end up using that when they’re doing scleral fixation. But all of these techniques work and your skill set will determine which one you choose. There’s no shame in using AC IOLs. That’s an important point that you gave. So for the sake of time, let’s just get into Cosme’s case. Cosme, go ahead and narrate your case. It’s definitely different than what Erin was presenting and it will introduce a lot of other questions. So I’ll let you take it from here, if you want to go into slide view and just go ahead and play it when you’re ready.

DR LAVIN DAPENA: Can you see it?

DR KAHOOK: Yep. We can see it. Bottom right hand corner. If you can go into slide view, it might make it a little bit bigger.

DR LAVIN DAPENA: Sorry.

DR KAHOOK: Just presentation mode, basically. There you go.

DR LAVIN DAPENA: Well, this is a unique case, I think.

DR KAHOOK: If it’s not going into slide mode, you can go ahead and just play it and narrate as you wish, just for the sake of time.

DR LAVIN DAPENA: Okay. This is the overripe eye. Can you see it?

DR KAHOOK: We see the video with the globe, basically. We’re looking at South America. That’s what I’m looking at.

DR LAVIN DAPENA: No, okay, then something has gone wrong.

DR KAHOOK: There we go. Now it’s playing. Yep.

DR LAVIN DAPENA: What about now?

DR KAHOOK: Then it stopped. I don’t know. Maybe Lawrence if you have access to his video, can you put that up?

>> Give me one second.

DR KAHOOK: Why don’t we have Lawrence pull it up and then you don’t have to worry about… You can just tell him when to stop it. This is what happens when you’re doing a session from three different continents. Luckily Lawrence is a great team member behind the scenes. There we go. So Cosme, just let Lawrence know when to stop it. But it’s playing for us right now.

DR LAVIN DAPENA: Perfect. Okay. Can you stop here? This eye was brought to the ER. And can you stop?

DR KAHOOK: Just pause it there, Lawrence. There you go.

DR LAVIN DAPENA: So this was the eye that the resident sent me the photo. He told me: Well, you have two options. You can come now, or you have to do it tomorrow. So there was no match to do it. It’s a 52-year-old man with three trabs. 20 years ago. He arrived to the ER because of pain, basically. And there was not much anterior chamber left. You can play. We’re examining the operating room. And just trying to see what was going on. We put some liquid and we will see that there was an opening. There was some scleral melting. Conjunctival melting. We saw some vitreous. We tried to do less pain if possible. The other eye is pretty much similar. So we didn’t know which one was a better eye. So we tried to save it. And we filled with viscoelastic. We did some more procedures to fill it also — the anterior chamber with viscoelastic. You cannot see really well. But it’s a phakic eye. It still has the lens on it. And we begin to try to see what we could do with that conjunctiva. Initially I was thinking… Well, maybe gel with the conjunctiva, I can close the hole and go back home. That’s why I’m putting it over the hole to see if that would be enough. But of course it wasn’t enough. So we continue to try to dissect these conjunctiva with… I guess MMC in the old way. Maybe 5 minutes. I don’t know. We are a big hospital. We have sclera always. We have to prepare the sclera before putting it. Pick out all tissue you don’t think you like. Maybe… We could do it thinner. Can you stop it here? Okay. So one of the interesting things about this case is I didn’t see how to be able to put some stitch in that sclera. I was like… How am I going to fix this? So my resident said: What about superglue? They have it in the ER for some injuries. I thought it was a really good idea. So that’s what we did. We used the cyanoacrylate glue instead of stitches, because I thought I couldn’t touch the sclera. You can play it. So it’s quite easy. You just have to put a few drops. The medical one is really easy to use. It’s for small injuries. Try not to touch too much so it doesn’t get glue everywhere. It fixates really well. Now we have to put the conjunctiva over it. This is 10 velocity right now. So we were really patient. Trying to put the conjunctiva over it. As you can see, the sclera doesn’t move at all. The glue was good enough to fix it. We just tried to close the conjunctiva. Pretty much that’s the end of the case. We can see… That’s the whole case.

DR KAHOOK: A little bit of a different flavor from what we saw from Erin just a little bit ago. But a lot of teaching points. Because you’re going in and you’re expecting the worst. But vitreous coming through was a little bit surprising to me.

DR LAVIN DAPENA: And to me!

DR KAHOOK: Yeah. And I think you handled it really well. The use of cyanoacrylate glue — like you said, we can use it for small cuts. When you go to the emergency room, basically the Dermabond type where they reapproximate — we use it as a temporizing measure for corneal wounds. If there’s a corneal ulcer, if it’s perforated or about to perforate. One of the biggest things with cyanoacrylate is if water touches it, it crystallizes it immediately. So you have to be really careful with that part, which Cosme, you were. You were being very careful with all of the steps. We have Tisseel available to us, fibrin-based glue, which is a lot friendlier in terms of positioning because you can slide it once you put it in, but it’s expensive and it doesn’t itself hold very well.

DR LAVIN DAPENA: I also have fibrin, to use it. But I don’t think it would be enough for the sclera with sclera. We use it for pterygiums. We use it a lot for maybe… Conjunctiva. But that hole… I was also worried that… You know that you have the two parts of the fibrin that you have to put it… So I wasn’t really sure it was going to work enough to glue it.

DR KAHOOK: Right, yeah. The tensile strength of fibrin glue is not very much. We tend to use it on patch grafts when we’re doing a tube but we’re not worrying about the forces on the Tutoplast or pericardial tissue. But you did really well. It obviously wasn’t moving after putting it on. You mentioned something, though, that this was 20 years ago that the primary surgeries were done?

DR LAVIN DAPENA: Yeah. It’s like… I didn’t even know the patient. It was a patient from the hospital. I had never seen him. Actually, he had three trabs. I guess he had some issue with all the MMC, or maybe he has a sclera…

DR KAHOOK: A primary process. So pathology from the sclera itself.

DR LAVIN DAPENA: I guess so. Because the other eye is not that bad. But he also has some kind of scleral melting. So maybe he has some component that was too weak for the MMC. And also… It’s 20 years ago trab. So they used to do it a long time MMC, also they used to do it more concentrated than right now. So probably… It’s just time. That’s why right now, I’m really worried with the easy use of MMC, when they tell you… No, use some more! Well, maybe wait and see. What’s going on.

DR KAHOOK: In my training — and we can switch over to Gabo’s video, as we’re finishing up this part. But in my training, one of the attendings who trained me in fellowship always said that glaucoma specialists should move every five to seven years. So you don’t see these complications that come up. I think that’s really good advice. So… Cosme, it’s gonna be time for you to move pretty soon. So come to the States and hang out with us a little bit. I do want to ask one question, as we’re switching over to Gabo. You can go ahead and share your screen for your talk. Erin, do you inject mitomycin? Or do you use sponges for your cases?

DR SIECK: So I inject mitomycin at the end of the case once I have good closure. I try to avoid sponges just because I think even as you’re being as careful as you can, you’re still potentially touching the edge that you’re gonna bring up to the limbus to close. And so you see those very thin avascular, really anterior blebs — I think some of that is secondary to sponges. Just causing some toxicity to that conjunctival edge that you want to heal as tough as you can. Back to the limbus. So that’s why I inject, once I have watertight closure. I make sure that we’re Seidel negative and I inject pretty far posterior, probably 6 millimeters posterior to the limbus and I’ll milk it up closer to where my scleral flap is, but I won’t inject right on top of my scleral flap. Because I want the mito to mostly be in the Tenon’s that’s posterior to my bleb so we form a nice posterior bleb.

DR KAHOOK: That’s great. And Cosme touched on a lot of the questions that were coming in prior to the session. So thanks to the faculty for answering these questions that were coming in. For the sake of time, let’s move into Gabo’s case. Gabo, please take away.

DR LAZCANO GOMEZ: Thank you. Thank you, Cybersight. Thank you, Malik, for the invitation. It’s nice to be with you guys. Hope you’re doing good. So this is my toughest glaucoma case. It happened ten years ago, when I was a glaucoma fellow. So my experience was not the same as today. This is the case. This American lady. She’s still my patient, so far. So she was 59 years old at that time. She had a diagnosis of primary open-angle glaucoma with high myopia. 7 diopters in the left eye. Visual acuity was count fingers right eye. Because of macular atrophy, because of the high myopia. Left side, 20/100. Intraocular pressure was 19 on the right and 21 on the left on four medications. So for this patient, we aimed for a target intraocular pressure below 12, because of the severe glaucoma damage. As we can see in the visual field here. And also because this patient has very thin central corneal thickness. So that’s the reason for IOPs below 12. So the story with this patient was… At that time, trabectome, the NeoMedix company, was coming into Mexico and they had a very experienced and skilled surgeon to train different doctors in glaucoma on trabectome. So I told this lady: You can have the surgery by the best surgeon on trabectome. What do you think? And the patient told me… Okay. Let’s do it. I feel very safe with this doctor. This was the first time I was helping on a MIGS procedure. The quality of the video is not very good. It’s old. But you can see how with trabectome, it’s moving — she got stuck there. Moving backwards and forward at that point. I was not sure what was happening at that time. Because it was my first time on a MIGS procedure. But can see here — there’s a brownish area going here from this side to that side. That’s a cyclodialysis bleb. The truth is that the doctor didn’t tell me about this. So I didn’t mention it. So things happen. Day one, the patient was really happy because she had visual acuity of 20/40. She was looking really good. And IOP was 9. I told this doctor: The patient is doing really good. IOP of 9. Good visual acuity. I saw cyclodialysis bleb from 7 to 11 clock hours as you can see in this image on the red line. But the patient was happy. So the first month we started on Pred Forte and antibiotics. Doing good. But by the first month, she came to the clinic. And said to me: You know, Doctor, my visual acuity went really bad. 20/160, and IOP was 16 millimeters of mercury. So I decided to check for the posterior pole. There were macular folds, as you can see here on the OCT. And also I saw some peripheral choroidal detachment. So we decided to go for a UVM, as you can see here. And we saw what we expected. Communication between anterior chamber and suprachoroidal space. So by that time, what to do next? Step one, as I told in Erin’s case, I started praying with all my heart for the cleft to disappear, but it didn’t happen. So Cosme… I don’t know. What…

DR KAHOOK: After prayer, Cosme?

DR LAZCANO GOMEZ: After praying…

DR KAHOOK: How would you address this case that has a cleft with low pressure, decreasing vision? What would your first step be?

DR LAVIN DAPENA: One of the things — it’s not a really big cleft, I think.

DR LAZCANO GOMEZ: It’s 100, 120 extension.

DR LAVIN DAPENA: It’s okay. It’s not a big trauma. But… I would try probably… I would go for some kind of repair of the place. I’m not sure it’s the best thing. But it’s what I enjoy more.

DR LAZCANO GOMEZ: For sure. What we did — we reduced the steroids. And we started with atropine. Three times a day. For one or two weeks. IOP was going down. Also visual acuity. So Dr. Erin, help me.

DR SIECK: It is pretty large to try to do argon laser. If it was a smaller one… So maybe less than 90 degrees, you could try argon laser to try to scar that. So what I’ll do is I’ll fill the anterior chamber with some Healon in clinic and do the argon laser so you have a good view. The hard part is when you have to do laser on eyes that have a pressure of 6, the cornea is gonna dimple. So I fill it with Healon and you can burp it out at the end of the laser. So it’s something you can try. But this is pretty large. So it’s probably gonna require surgical correction. Something interesting I was talking about with one of the meetings is — where was this located? Superior?

DR LAZCANO GOMEZ: Nasal. From 7 to 11.

DR SIECK: Down at Baylor, they’re injecting gas for some of these patients to create a tamponade. Depending on the patient positioning, if they could position in a decent way, you could consider gas tamponade. They’re treating it almost like retinal detachments.

DR LAZCANO GOMEZ: Thank you. Nobody told me this. So we went for an argon laser photocoagulation. Here what you do is just… Do some shots or spots of laser at the extension of the cleft. We did it. Didn’t work. So we decided to go for a surgery. Direct cyclopexy. At this moment, visual acuity was 20/400, IOP was 2. I developed diabetes, high blood pressure, depression, I wanted to kill myself, so we decided to go for the surgery.

DR KAHOOK: Gabo, before you go on to hurting yourself, I think… One thing that we don’t talk about a lot in any of our meetings are some of these sort of bread and butter… The second point was photocoagulation. Most centers now don’t even have an argon laser. Right? The anterior segment places have SLTs. And we’re not doing as much suture lysis, at least in the States. So we don’t talk about the settings as much. And also the technique. So if you’re treating a cleft and it’s a fairly deep cleft, or you can see a couple of millimeters down, even, it’s good to start your laser from the bottom up. Because you’re gonna stir up pigment. And you’re not gonna be able to treat further, if you start from the top to the bottom. The settings, if you’re trying to laser sclera, versus the choroidal side of things, is gonna be about a third less for the choroidal side of things, because of the pigment. So about 1 Watt for sclera, 0.3 for choroid. 200 micron spots should be good enough, and you really have to be pretty aggressive at doing the laser in order for it to stir up… And that’s why you mentioned stopping the steroids as well. Because you’re trying to get that inflammation. Let’s go through your cyclopexy and talk about alternative techniques as well.

DR LAZCANO GOMEZ: True. So first of all… Well, this is a description of the case. Cyclodialysis, left eye from 7 to 11, the gonioscopy, the UVM image. So we went for a direct cyclopexy. So first of all, I want to tell you that in these cases, I always recommend a traction suture. In this case, 7-0 vicryl so you can move freely the eye and do a peritomy so you expose all the damaged area. After that, we do a paracentesis. We prevent going through the supraciliary space and allow the ciliary body to attach to the sclera. So what we’re going to do here — full thickness incisions, 1.5 millimeters posterior to the limbus, in parallel to the surgical limbus. So we can — these incisions may allow you to see directly the ciliary body. So all these incisions were around 2 millimeters long. And you have to leave scleral space between each incision. Because we’re going to anchor the suture there. So once you have the incisions through all the extension, using a 10-0 nylon suture, what you’re going to do is a full thickness suture. So I’m gonna pause here. Can you see the arrow on the screen?

DR KAHOOK: Yes, we can see it.

DR LAZCANO GOMEZ: So we’re aiming for going here to the other side of the incision. That’s one suture. The next suture is just from here, from this side of the incision to the other side of the incision. And so on. So in this fashion, you will have like an interrupted running suture. So this allows to you… Like you can see here. You can anchor on the sides of each incision. Through all extensions, 100 and 120 degrees in this case. And the final image is like… Let me go forward here. Like this. So we have a running interrupted suture with one going from here to here. The other going from here to this side of the incision. The other going from here to this side, and the last one from this side of the incision to the other side. So with this technique, we cover the 100 degrees extension. And then we just close the conj like in a regular fashion with the same 10-0 nylon suture you can see here. Don’t forget to use BSS to the cornea or viscoelastic to prevent it to become dry. So this is the paper published for this technique. You can check it out later on if you want. So just take a look to the image on the bottom on the right. What we did was a technique with separate nylon full thickness suture. Just to cover the extension of the whole area. Pre-op UVM. You can see — I showed this before — the communication between the anterior chamber and the supraciliary. By the first week, during the whole month, visual acuity was 20/40. IOP was 11, and with no communication at all. My diabetes went away. Blood pressure went normal. I didn’t want to kill myself anymore. And this is gonioscopy picture on the left. This is five years ago. You can see where the red arrows are. Used to be the cleft. We cannot see a cleft anymore. On the right — so I told you this patient is so far my patient. I’m very sure this technique worked very well. Because she needed an Ahmed valve to control IOP five years after. You can see the iridotomy — I placed the tube posterior to the iris, I got iris strut on the tube, so I used the jack to release and open the tube. On the bottom you can see the red lines where the original sutures are. They are still there, no problems at all. Patient happy, doctor happy. Thank you very much.

DR KAHOOK: That’s good. Really important for the doctor to be happy in this case. So you mentioned something about a pressure going up and needing an Ahmed valve. I think that’s one of the big things we worry about when we close these clefts. In my experience, unless the cleft is a clock hour or left, medications don’t typically work, and you wonder… Would it close on its own without using the atropine? When it gets more than a clock hour, surgical maneuvers are necessary. They’re wide, as Cosme was pointing out. And Cosme was saying… Unless the cleft is 6 hours, it’s nothing. I’m used to big trauma cases. But for us, when it gets beyond a clock hour, we think… Do we use an external or internal technique and what does that do to pressure? I’m gonna use a slide to talk about some of the other techniques, but I want to thoughts about: How do you handle the pressure spike? What do you expect from the pressure spike? Cosme, maybe you can start. You closed the cleft. You’re seeing the patient postoperatively. What do you worry about? What do you do?

DR LAVIN DAPENA: In my experience, I don’t know why they always go high. The IOP is not sooner — it’s later. Two years later. It’s a patient that always has high IOP. And you have to do some other surgery. That time it didn’t work. The rest of the body got stronger, produced more aqueous humor. And I think… We have to assume that later on, we’re going to have to address high IOPs. Lately, I’ve seen more traumatic ones and surgical ones. But I don’t know why.

DR KAHOOK: They tend to come in clusters. Sometimes we don’t see them for a couple of years and then sometimes we get three in one week. Right? So from a hypotony standpoint, and then the spikes that can occur after fixing these clefts, about half of these are gonna spike significantly. And that’s something that we always have to keep our eyes on. And keep our mind tuned to that possibility. The longer the hypotony and the lower the pressure, the more likely it is to see those significant spikes as well. That’s just kind of a soft rule to use when you’re following. But you should worry about all of these patients. Can you guys see my screen here? I just put up a slide. I was gonna play a video. But for the sake of time, I’m just gonna show that there are alternative techniques that can be done. For the smaller clefts, if it’s a couple of clock hours, an ab interno or combined ab interno/ab externo technique can work well. If you go to the website, and the book is also on Cybersight, but if you go to the website, you’ll see some videos associated with this. Where a 27-gauge needle can come through and then accept a 10-0 prolene suture, and you’re basically going through and threading and then tying it externally. The good thing about that is you can locate it specifically at the cleft, and you’re observing the cleft as you’re demarcating on the sclera to put the dots. Again, the video on this website can show you exactly what that technique is. If the cleft is further away from the scleral wall, I like to go in from the internal side and push the needle out through the wall rather than come in with a 27-gauge and introduce it into the anterior chamber, because you’re just really kind of pushing away and kind of blindly trying to figure out where that needle is going. But you can do both sides. You can either use a 27-gauge to pull your 10-0 prolene or you can use a cannula for some of these maneuvers as well to kind of move the needle around atraumatically. Just something to think about. Look at the videos and consider the different techniques that can be done. I do want to try and show one last case. This is a case that was done by my partner, Leo Seibold, along with Cara Capitena, who Erin knows well. She was a fellow at the time. It is Cara’s birthday. So she might be watching. I wanted to play one of her favorite cases. Let’s see if I can advance this. Here we go. I’ll narrate this. Because I don’t think the audio is gonna come through. I can hear the audio, but I believe you guys can’t. Is that right? Any audio on your end? I just hear Leo Seibold’s voice in my ears. So this was a non-valved plate placed on the sclera. But look at the cut when trying to bevel, bevel down. So you can kind of see what’s coming here, right? This is a very, very good surgeon. I want to emphasize that. If I need cataract surgery tomorrow, she’s doing my surgery. She’s very, very good. But when you’re going through and doing glaucoma surgery, things like this happen. So the tube is lifted up and you can see the edge of the scissors are anterior or closer to the plate. And then the cut happens here. So it looks like a really good bevel. But then when taking a Westcott and going over the tube, this of course is the scleral tract. Look what happens to the tube here. So essentially what happened — and you’ll see a replay of this — is as the tube was cutting the bevel, it also cut more proximal towards the plate and it caused a double cut, essentially. So now you have a tube that has no chance of getting into the anterior chamber. And the question I have for the three of you is: Erin, what do you do? Besides Gabo’s technique of diabetes, heart attack, and depression? What would you do in this case?

DR SIECK: There’s a couple options. Some more cost effective than others. You could be tempted to just say I want another tube. I work in a university setting. I don’t get bonuses. So might as well just charge the hospital for another tube. So you could ask for another tube. But that’s definitely not reasonable for most patients. A lot of people talk about the tube extender that I think New World Medical makes. It’s a large profile that I’ve seen actually a patient once ripped it out of their eyes at Denver Health. Exactly. This is… That’s the tube extender. So you can see that large plastic thing that’s gonna attach your old tube to this new tube. Is really, really high profile. And that’s gonna be very close to your limbus with a high risk of erosion. Even if you have a plate that’s appropriately sutured, 8 millimeters back, this just doesn’t leave a lot of room for error. So I don’t love the tube extender. So I think what you demonstrate later in here… Using an angiocath is something that I typically do when I’m not trying to charge the hospital extra money.

DR KAHOOK: Gabo, what would you do in this case?

DR LAZCANO GOMEZ: I’m not sure if the extender of New World Medical is still available.

DR KAHOOK: Not globally, I believe. But you can still get access to it, with the limitations that Erin mentioned, of course.

DR LAZCANO GOMEZ: You know, APEC, a colleague, Dr. Mariso Durati, he has a paper. And he used this needle protector for it, just to cannulate the tube and use it like an extender. So that could be a good option. I see the tube is very short. So you can not advance the implant. And the other option, as Erin said… You know, go for another device. That’s it. But that technique of using an extender is a good option.

DR KAHOOK: Yeah. Cosme, anything to add to that technique-wise? For a short tube?

DR LAVIN DAPENA: What you’re going to show is pretty much what we do.

DR KAHOOK: The angiocath is what you do? So let me play this and show. So basically what Dr. Seibold was saying on the voice-over here is exactly what Erin said. You put it in place. There isn’t a lot of space for this to go more posterior, and this is relatively high. So if you have it close to the limbus it’s gonna cause erosions. I don’t use the tube extender. It’s not my favorite thing to use. But there are a couple of different techniques. One of which is using a 22-gauge angiocath. And I’ll try to forward to that over here. So here. Basically trimming… You can ask the anesthesiologist for the angiocath. They almost always have a 22-gauge sitting in there. You trim it to a couple of millimeters. You put it into the proximal tube. You want to make sure that you’re saving… This is another lesson. No matter what, when you trim your tube, save it. Don’t ask the nurse to throw it away until the end of the case. You suture it in place, connecting it to the tube. And now you can use the tube extender for the remaining tube. So I’m gonna stop here and just make another point. One of the points that isn’t employed frequently and is maybe hard to do, but if you’re in a resource challenged area, you can take that tube that was cut off and hand it over to the nurse and introduce forceps inside the lumen of that tube and stretch it and put the proximal end into that tube. That sounds really easy. It’s not. Stretching the inside of that tube — it’s a 300 micron hole on the inside of a standard Baerveldt or Ahmed or ClearPath tube. But if you have an assistant, you can stretch it and put the proximal tube into the distal tube and thread it in. The easiest thing to do is using this 22-gauge angiocath. And you can see it looks really good. Right? So I was able to extend the tube quite well. He didn’t waste the tube extender. Because he trimmed the tube from that. This time he trimmed the tube bevel down and then introduced it into the sulcus. And this patient ended up doing really well. I think one of the lessons from this case is: When these things happen, take a deep breath. And I always try and teach the easy button. You know, we have a commercial here in the US about pushing an easy button when you need something done. You should always have those things in your mind when mistakes happen. Right? So if a tube is cut too short, if you’re in the middle of surgery and you have a bag that is loose, similar to what Erin showed. If you’re going in and you’re doing a standard surgery and you notice that you may have created a cleft. Right? Which is the case that Gabo showed. With trabectome. And I think it’s really important to say: We have seen clefts created with every single type of angle surgery. This isn’t a fault of trabectome. I’ve seen it happen with multiple different goniotomy devices. I’ve caused clefts putting in iStents. So it’s not exclusive to one device or another. You should always have a list of the top two or three things that you would do when something like that happens. And the way I was taught is: Sit back, take a deep breath. One of our teachers that taught me and Erin, his name is Rich Davidson. He taught me to do cataract surgery. A couple times when we had a complication, he would sit back, put his hands like this, take a deep breath and say… Okay. Well, that wasn’t planned. And reengage and go through those easy button one two three… What do I do? Something as simple as I/A cut instead of cut I/A on the vitrector. You should have that in your mind that I need to tell the scrub nurse or change the setting. That’s gonna make my life easier. What type of suture do I use? Do I know my anesthesiologist has a 22-gauge angiocath sitting? Not somewhere they have to scramble for it. So these are things I hope when we do sessions like this, anybody who is a trainee or has been practicing for 20, 30 years, you can write these things down and remember them before you do these cases. I was able to go through and answer a lot of the Q and A questions that came through. So hopefully the audience was able to do that. The questions that came in when people were signing up for the most part we’ve answered a lot of those questions. You guys did a great job answering the questions as they were asked. And I asked a couple of them and you were able to address. We always try to keep these sessions to just over an hour because I know people are busy. We’re just hitting that 65 minute mark. So I think instead of going to a couple more cases we have, I think it would be good to sort of sum up and say thank you to the three of you. And I have been able to work with all three of you in different capacities. Cosme, I’ve been able to do your meeting a couple times with virtual as well as recorded talks. I appreciate the invites and the work you’re doing in Spain to educate everybody on modern glaucoma surgery. You’re definitely at the forefront of doing a lot of these cases. Gabo, I was just with you last week and I’ll probably be with you again soon enough. So it’s always good to hang out with you. And learn from you. And Erin, just to watch you blossom from the resident that you were an excellent resident — we were trying to keep you here. Weren’t able to do that. Wash U is lucky to have you. So I want to thank all three of you and thank you, Lawrence, for being behind the scenes. And thank you to the entire audience. This will be recorded and put on the Cybersight website. So if you want to go back and review, you’ll have this available to you. And please come back in about three months when we do our next session, which we’ll put out and advertise pretty soon. Thanks to the three of you. Really appreciate it. Have a good one. Bye-bye!