CataractCoach™ 2925: Podcast 163: Dinh Thi Hoang Anh MD and Yury Kalinnikov MD

Added: 2026-05-10

[00:00:00]Cataractcoach.com, podcast series episode number 163 with Dr. Din T. Hoàng Anh and Dr. Yuri Klinikov. Why PDEK is the best way to do lamellar corneal transplantation?

[00:00:12]Welcome back to our Cataractcoach podcast. And today, I've got two very special guests. I have Dr. Din Tai Hoàng Anh from Vietnam, and we have Dr. Yuri Klinikov from Russia. Yes.

[00:00:28]I'm here.

[00:00:28]>> Hello.

[00:00:29]Hello again. Welcome back. Welcome to the podcast. Uh we met recently, actually last year in Chennai, India at Amar Agarwal's meeting, and I was very impressed with a lot of your very advanced anterior segment surgery techniques. So, I'd love to talk about those.

[00:00:44]Uh thank you so much, Dr. Uday, for inviting us. I think it's been almost 1 year after that meet, but we were we were impressed with you.

[00:00:56]Uh thank you very much. Thank you very much for inviting us. It's a great honor to be here.

[00:01:02]Oh, thank you. So, Dr. Yuri, tell me about your practice in ophthalmology, and what do you specialize in?

[00:01:10]Um my practice in Moscow, and I studied in Smolensk and studied in medical Smolensk University located quite far from Moscow. Um one of my closest friends was already student Professor Fyodorov and encouraged me to consider ophthalmology as a career. Professor Fyodorov was a true pioneer, do you know, in the field.

[00:01:43]Yes. He was among the first surgeon to implant intraocular lenses, pioneer of radial keratotomy, designer of phakic IOL, and the developer of non-penetrating deep sclerectomy.

[00:01:57]In those days, things though seem clear.

[00:02:00]I went directly to him, expressed my interest in ophthalmology, and asked if I I could become his student. To my surprise, he agreed.

[00:02:11]Wow. I was honored to work with him until the end of his days.

[00:02:17]They were challenging but exciting times, and the spirit of innovation of ophthalmologist was incredibly strong.

[00:02:28]Can I ask you a question? No. No.

[00:02:31]No. I have many many interest many interest in ophthalmology.

[00:02:37]Uh example, keratoplasty.

[00:02:41]After performing uh thousands keratoplasties, I noticed that even then the graft remained perfectly clear, patients frequently develop significant postoperative astigmatism. In many cases, it's reached five or six diopters and much more, which significantly limited visual outcomes.

[00:03:06]Early techniques attempt to address this problem by placing a ring between the graft and recipient bed. But this technique did not give good results. My idea was to implant the intrastromal corneal ring directly into the corneal graft during keratoplasty.

[00:03:27]This with assistant of femtosecond laser, a canal is created in corneal graft during transplantation, allowing a precise placement of the ring.

[00:03:38]Future details about this technique can be easily found on PubMed.

[00:03:44]Um With our technique, astigmatism in the late postoperative period period typically does not exceed it 1.5 or two diopters, resulting in significantly better visual quality in the patients. It's my interest now.

[00:04:05]Yeah, that's fantastic. That's a great idea, and really very improved to go from six diopters or more of astigmatism to only one or two is fantastic.

[00:04:17]Yes.

[00:04:18]And Dr. Anh, tell me about tell us about your practice Uh in ophthalmology. Yeah. I would add a bit about Dr. Yuri's practice before, because because I think that uh it's a bit difficult for him to speak in English, but so he he's one of the main corneal surgeons in Russia, and corneal cataract refractive would be his main specialty, and so I was his PhD student. So, uh after finishing my PhD, and the subject was on optimized PDEK, which uh you maybe you'd probably remember from the Chennai uh conference last year.

[00:05:00]After finishing that, so we so I came back to Vietnam, and now just with the board of directors, we opened a private eye center. It's called Hong Ngoc Private Eye Center, Hong Ngoc Eye Center, so I'm the head of department there.

[00:05:14]So, the of course the main um surgeries would be cataract and refractive, but now recently we have started with Professor Yuri also doing keratoplasty in Vietnam.

[00:05:27]Yeah. So, I think that it's quite quite big also, and we started and we have recently also done the first PDEK case, first pupilloplasty technique, all you know, pioneered by Professor Amar, but yeah, that's mainly my job for now. Tell us a little bit for the audience who doesn't maybe doesn't know, what's the difference in PDEK versus what we're doing now, let's just say DMEK?

[00:05:59]Explain what that is.

[00:06:01]So, you've also been at Professor Amar's big current lecture on the difference, uh but mainly I would say that you used the Dua's layer, which was not known before 2013, and the graft dislocation rate is much lower thanks to the Dua's layer. But points of our optimized PDEK came to the fact that we tried PDEK first we tried PDEK in Moscow with Professor Yuri, tried to do the same everything like on YouTube videos, like real videos, and we got the first with when we tried doing the big bubble, we got the tissue rupture immediately. So, that was the reason why we decided to optimized PDEK. And there's also big difference, for example, when Professor Amar, he has his own eye bank. Right. He can inflate as much as he wants.

[00:06:59]>> [laughter] >> Right.

[00:07:02]corneas, and here we have limited resource of donor corneas, so we had to be very careful. But that first case was failed PDEK, which later Professor Yuri turned into DMEK, because he could peel the Descemet's membrane from the from the eventful PDEK. But that was the the first that was the first attempt.

[00:07:28]Afterwards, uh we saw the Dua clamp. I don't know if you have seen that.

[00:07:35]So, it was the Professor Dua's invention to to increase the rate of success for PDEK. Right. So, it looks like a chalazion clamp, so it it clamps the donor cornea in the middle, and it does not let the air go into the periphery.

[00:07:53]We also tried that. We understood the idea, but the clamp was, you know, it was not stable on the donor cornea. You know, needle holes here, you know, it was not stable, so we continued to optimize it. And afterwards, we got the whole surgical system with the instruments, and how to do PDEK graft preparation and preservation technique, for which Professor Amar gave us the gold medal. Right.

[00:08:25]Yeah, so that was a high point for us for that. Yeah.

[00:08:29]And yeah?

[00:08:32]But I don't know if you perform PDEK in because it seems to me like you are very versatile surgeon. You perform everything from complex cataract, glaucoma, you comment on keratoplasty, on everything.

[00:08:47]Yeah, I love it I love everything anterior segment. I love it I love it all.

[00:08:52]Yeah.

[00:08:53]Now, let me tell what I really was very impressed with, your method of liquid injection.

[00:09:00]And to avoid problems with like big bubble formation, and explain to us what is your new technique here, which I thought is brilliant.

[00:09:08]Uh so, the technique so, we had four steps. I'll say that first we have four instruments. So, the first would be uh um how to say this?

[00:09:22]A PDEK so, instead of using just injecting the air, we use a spring-loaded plunger, you know? The So, it gives dosage not like you just inject air like this and it rupture, but it gives slow amount of it gives slow amounts of uh air inside the bubble, and afterwards Professor Yuri, he insisted on using the storage medium. After you got that little bubble, you you insist the you put the storage medium, and then it starts to grow bigger, you know, in diameter, like very slowly to avoid the tissue rupture. So, that is only the first part, you know.

[00:10:06]Uh we also have the ring fixator to put on top. Uh also, we have the uh not just ring fixator, but uh a special base to put the donor cornea, you know. So, it's a whole system, yeah.

[00:10:21]Well, I think that's a great idea because when we just do just air alone, sometimes you can't control it enough and you inject air too forcefully and you'll rupture the tissue.

[00:10:32]Yes, we received I think the rupture in the very first cases in PDEK in Moscow.

[00:10:37]Yeah. And it was a big stress for all of us, but Professor Yuri continues It's the research work of Anne. It's beautiful research work.

[00:10:48]Yeah.

[00:10:49]We know that it's brilliant research work. It's fantastic. So, I think yeah, now starting with the spring-loaded plunger, you give a little counter-traction. And once you have that a little bubble, then switching to the storage medium, so you'll have liquid injection to slowly enlarge. Yes. That's really smart. But the Professor Yuri has also thought of an idea how to preserve it. Like normally, you would cut 360°, you know, for the graft to uh So, in order to slow uh to lower the rate of uh lower the rate of uh unsuccessful grafts uh preparation uh he offered to the eye banks to not cut 360°, but you left three place uncut. Mhm. Do you understand? So, So, it's still still a little bit attached, 120° apart. One one one.

[00:11:45]Exactly. Yes. So, the surgeon in the operating room just needs to cut this three pieces and the graft is, you know, he doesn't need to inject it, you know, he doesn't need to form the big bubble. He doesn't need to do anything, just cut the three pieces and he has the PDEK graft. Yeah.

[00:12:03]Wow, that's great.

[00:12:05]I will tell you in Los Angeles, I'm very very fortunate. I can order my tissue, it already comes whatever I want, the diameter, the size. They already stain it. They already put a direction mark.

[00:12:18]It's already in the injector ready to use.

[00:12:22]So, I'm very spoiled. It's just I don't have to any preparation at all.

[00:12:26]We would like to ask you what is the rate of your keratoplasty performing. We heard that in USA, some people even do cataract with preventive keratoplasty, you know, preventive endothelial keratoplasty.

[00:12:39]Yes, there's there's some surgeons who will do combined at the same time, for sure. But we had on our podcast like an an ophthalmologist in the US named Jack Parker who does an unbelievable number of these. He does maybe 25 or 30 in a day in a morning.

[00:12:59]He does it very very very efficiently.

[00:13:02]And so, he's doing maybe a couple thousand of these a year.

[00:13:05]So, patients are referred to him from all over the place and this is he does this one thing just really beautifully.

[00:13:10]Yeah.

[00:13:11]I I I do very little compared to the other people.

[00:13:15]>> [laughter] >> My primary surgery You saved you saved me from one keratoplasty. It's your it's your video on Descemet's detachment.

[00:13:25]I had the exact same situation. So, I did my irrigation aspiration, then wound hydration in the end, and suddenly I see a big Descemet flap, you know.

[00:13:37]>> [laughter] >> Okay, so I'm like, from where should I put the air, you know, like from where?

[00:13:44]And so, I remembered your video. You say, you know, do not put the air from the main incision, put it from the paracentesis opposite. And then, thankfully, I escaped one endothelial keratoplasty thanks to your video. Yeah, it's it's surprisingly in routine cataract surgery, there's more Descemet attachments, maybe even small ones, but sometimes big ones, more than we think.

[00:14:09]Yes.

[00:14:10]So, how do you prevent postoperative astigmatism in keratoplasty in your practice?

[00:14:19]So, luckily for me, I do very little of full-thickness transplants for these.

[00:14:25]So, in in Los Angeles, I tend to just refer those out. It's easier for me to have someone else do it. I like to learn about everything.

[00:14:33]And this is why I keep up with all the glaucoma things, all the cornea things, all the refractive things. My my practice itself is 80% cataract, maybe 20% refractive. Oh.

[00:14:45]Or maybe maybe 80% cataract, 15% refractive, then 5% other, which would be like unusual cases sent in, anterior chamber reconstruction.

[00:14:55]Like like you like the cases you've done. Like I actually liked the Dr. Yuri's uh pupiloplasty gauge for doing pinhole pupiloplasty.

[00:15:03]So, you obviously also do a lot of these very challenging anterior segment reconstruction cases also.

[00:15:10]Yes. Can I speak a bit to Dr. Yuri in Russian? Absolutely, whatever you want.

[00:15:15]Yeah.

[00:15:16]Uh What?

[00:15:21]Oh, it's a very interesting technique, pinhole pupiloplasty.

[00:15:29]In 2 years ago in Chennai, we uh saw this technique and now we used this techniques mhm quickly and often.

[00:15:44]It's very good technique for difficult cases. Difficult case difficult cases.

[00:15:52]And um uh we designed special surgical gauge uh that measure the pinhole size directly in the pupillary plane allowing more precision results. Uh we have performed many optimized pinhole pupiloplasty surgeries in Russia and Vietnam and received good results. We have good um video for last our patient with young young girl 10 10 old.

[00:16:32]Uh she uh have uh scar of cornea in center. And what we must to do?

[00:16:42]Pinhole pupiloplasty or keratoplasty?

[00:16:46]And we uh used pinhole pupiloplasty and uh her visual acuity was 0.05 and after operation 0.7.

[00:17:01]Wow.

[00:17:02]>> It's fantastic.

[00:17:04]Uh we can show our video and uh we will see our work.

[00:17:12]It's good technique. I uh think Dr. Agarwal it's great surgeon great surgeon. This she she she has many technique, but pinhole pupiloplasty is last great technique which Dr. Agarwal made in our practice. Yes. Yeah, I think it's a great idea. So, in a case like this, you have a 10-year-old girl, central corneal scar.

[00:17:43]Are you going to do cornea transplant on this young child? How long will it even last? Will you get the tissue? So, the better idea was just Agarwal's ideas, once these patients are are pseudophakic, to make a pinhole of the pupil, suturing very small, usually about 1 and 1/2, maybe 2 mm. And we can talk about the size of the pupil, but you can also make it somewhat off-center to bypass the scar. So, in like your case, the patient went from 20 out of 400 vision to 20 out of 30 vision, which is just incredible.

[00:18:17]And Dr. Anne in Vietnam uh pinhole pupiloplasty. It's very interesting. She uh have a very interesting uh she um can tell us about this case.

[00:18:33]>> Sure.

[00:18:33]Tell me.

[00:18:35]Uh I'd like to add a bit on about Of course. Yuri's gauge. I don't know if you have heard the idea behind it. Tell me. So, before, uh how do you measure the pupil size?

[00:18:49]You know, how do you know it's 1.5 or 1.0 or whatever the size that you want.

[00:18:56]So, Dr. Amar showed us before that he had an epsilon. I think you also saw Right. epsilon uh triangular something like that. And he has little holes like this, like 1 1.25, maybe 1.5, you know, and up to 3 mm. And so, that thing he put just on the surface of the cornea, you know, like under the microscope, he puts that on the surface of the cornea to see what was the resulting pupil size.

[00:19:25]But then So, Dr. Yuri tried that and he saw that from the cornea, when you measure like it, you know, it doesn't give you the exact pupil size in reality. Mhm.

[00:19:38]It's by AS-OCT.

[00:19:40]So, Dr. Yuri thought of I think he designed and gave it as a gift to Dr. Amar. Uh he called it a gauge, but actually, it's an instrument that you put through paracentesis, you know, like uh almost like a spatula. Okay. With two hemi circle sphere like that. Yes.

[00:20:02]So one is 0.5 0.5 and one is 0.75 0.75 which is half of one and a half of 1.

[00:20:13]uh five. So he made the instrument for both left hand and right hand, you know, so you can see exactly at that plane a pupillary plane so you get the result that you want. I think that's the that's the most interesting part about the optimized pinhole pupilloplasty, yeah.

[00:20:35]Right, because if you're measuring on the cornea Yeah. It's not going to be the exact same in the anterior chamber because you right you have the whatever change in magnification from the cornea.

[00:20:45]So this is a smart idea is just to measure right there on top of the iris.

[00:20:50]So you put it in your paracentesis. And it's it's it's like it looks like a spatula with two half semi circles kind of cut out of it.

[00:20:57]And then one is for for overall diameter 1.0 mm one for 1.5 and then you can judge lay it on top of the iris and see how is your pupil where it is. Now let's talk about this what is the ideal size that I saw some of you worked you like the the ideal size was maybe 1.8 mm you like 1.7? How do you figure this out?

[00:21:19]Kakoy u vas luchshiy razmer? Mhm.

[00:21:23]The best size of pinhole gauge uh 1.

[00:21:29]five. 1.5. It's universal universal.

[00:21:33]It's for many patients. It's the best but epsilon tools for preoperative exam it's >> [groaning] >> good for postoperative results.

[00:21:54]I think that there was already a publication uh of Dr. Priya with Dr. Amar on what size is the best so I don't think that uh we even need to try to find what size is the best.

[00:22:09]But there was a recently a case of also pinhole pupilloplasty we performed.

[00:22:15]Uh so the patient had perforating ocular trauma one year ago.

[00:22:20]And he has corneal scar also central corneal scar. He has big large iris laceration. Mhm. Uh so afterwards the first surgeon at the other hospital took out his lens and took out the vitreous, you know, so like vitrectomy and lens extraction was done.

[00:22:41]So that patient came to us.

[00:22:44]And so we had to perform uh keratoplasty of course but because there was such a big iris laceration that we had to perform pupilloplasty.

[00:22:56]But and also IOL um fixation to the iris.

[00:23:02]But what's interesting is that the iris laceration was so big that me and Professor Yuri we could not do like 1.5.

[00:23:11]Mhm. That would be the perfect but it was 1.8 in vertical you know, horizontal total 2.0 but the patient still see still saw so much better after the Sure, of course.

[00:23:27]Which size which size the best for patient with core aberration?

[00:23:35]If patients have core aberration this size 1.5 is the best pupil.

[00:23:44]Pinhole pupilloplasty for these cases good. Right.

[00:23:51]Yes, we can you can reduce the higher order aberrations that have an effect because with the pinhole you could have some of the very high amount of HOA or higher order aberrations and then with the pinhole the effective one is like 10% of that.

[00:24:05]You've you've addressed or blocked 90% of it which is great.

[00:24:08]Do you do many pinhole pupilloplasty in your practice? In my practice very few.

[00:24:16]Maybe a maybe one or two a year.

[00:24:19]Oh. Not so many trauma I understand, yeah. Yeah, it's you know, Los Angeles is a very big city in where our my clinic is in in Beverly Hills it's a fancy part of the town there's not a lot of trauma.

[00:24:32]Dr. Uday, I think I think they must present you our pinhole gauge and we will perform many pinhole pupilloplasty.

[00:24:44]That's We're sending as a gift, yes, to everyone. That's a great idea. Now when you when you're doing this in suturing it are you doing the Agarwal's fourth row pupilloplasty the suturing? Yes yes yes this good technique.

[00:24:59]And then 10-0 polypropylene?

[00:25:01]Yes 10 or nine maybe 10 or nine.

[00:25:05]Okay. And then we talked about already the pupil size sometimes we can make it off center to avoid the scar.

[00:25:13]But how do you recommend choosing where to center the pupil?

[00:25:18]Um uh then pupil size 1 mm. Uh this pupil maybe not center and and not center.

[00:25:32]Uh visual will be good.

[00:25:37]That's good. Yeah, that's important to know because a lot of these people do have very central corneal scars.

[00:25:43]And so you'll have to shift the pupil you know, off axis just a little bit but if it's a small 1 mm pupil that you created it really is very flexible very forgiving. You can move it around anywhere in the center and they do fine.

[00:25:57]Yes and for example for the center so Professor Yuri said that he'll use the Purkinje image from the uh from the microscope to make it sure Purkinje one. P1.

[00:26:13]P1.

[00:26:14]P1. That That makes a lot of sense. Now how do you take extra care if sometimes after trauma the iris is a little bit atrophied and I found that in the past if I put a suture it we call it cheese wired cuts through the tissue.

[00:26:29]It's problem but we have IOL IOL PPL.

[00:26:37]Uh which only two suture for fixation this IOL on pupil.

[00:26:45]Uh this IOL have size optic 1.5.

[00:26:52]It's our new work in this >> [laughter] >> So you can do a combination of pupilloplasty.

[00:27:00]Yeah, in this case you can do a combination of both. Put your IOL that has a pinhole 1.5 whatever put that in the in the bag in the capsular bag and then suture the iris and even if you don't have complete closure of the iris because of atrophy it's still blocked by the IOL.

[00:27:18]You understood everything.

[00:27:19]>> [laughter] >> But but my question is everyone will ask because I get this question asked also.

[00:27:25]Well how do you examine the retina?

[00:27:28]Uh retina must be showed before operation.

[00:27:36]>> [laughter] >> Before operation but we can YAG laser which help us pinhole pupilloplasty made big pupil.

[00:27:52]Right. Yeah, you can if you need to in your clinic use the YAG laser to break a couple a few sutures and then have a bigger pupil if you need to examine the retina.

[00:28:03]But never tried.

[00:28:04]>> [laughter] >> Yeah.

[00:28:07]No no these cases no no these cases.

[00:28:12]But that's that's obviously the challenge, right? It's just a I think you can sometimes image at least view part of the the retina.

[00:28:20]Um with small pupil but it's hard to see like retina periphery you'll never be able to see through a 1 and a half millimeter pupil.

[00:28:27]When we had also this question when we went to Dr. Amar to see the technique and he just showed us that he has Mirante, you know.

[00:28:36]>> [laughter] >> The Mirante. Mirante is good decision in this [laughter] cases.

[00:28:43]So yeah, that's that's a wide field imaging that can go through the very small pupil.

[00:28:47]Yeah.

[00:28:48]That's for sure now.

[00:28:50]So that's why our clinic also bought Mirante, you know.

[00:28:53]>> [laughter] >> Because because when for example you do keratoplasty and pinhole pupilloplasty I always fear to do YAG laser because you know, you just suture the cornea and then you press the cornea to do the laser will the corneal sutures you know, like be messed up I don't know so I've never tried but in theory I think it's possible.

[00:29:18]Now you sometimes will do very complex cases where you'll do we call the triple. You'll do the cataract surgery put the IOL in the bag and you'll do the pinhole pupilloplasty and you'll do the PDEC.

[00:29:32]Uh Uh so with the we saw many cases like that of Professor Amar, yeah. But we I think that we have done one similar case like that in Russia. One. Yeah.

[00:29:48]>> Okay.

[00:29:49]But in Vietnam, as I we still have not when when it was just PDEK, so the patient had endothelial keratoplasty because he had cataract surgery before. It was uneventful, but so I well was already there.

[00:30:05]The pupil the pupil is normal.

[00:30:08]So, no need for doing that.

[00:30:10]But anyways, yes, it would be extremely complicated surgery.

[00:30:16]Like you say. Right, you can do every everything at once, but you make sure you do it in that order.

[00:30:21]Cataract first with IOL, then pupilplasty, then last step doing PDEK.

[00:30:27]Yes.

[00:30:29]I don't know if you have you tried doing three in one surgery like that?

[00:30:35]I have not. Usually that's that's a lot to do at once.

[00:30:39]And sometimes it's easier to do it stage. Do do a little bit at a time. Do the cataract and pupilplasty, wait a little bit, wait a few months.

[00:30:47]You can always come back and I think it'll be it'll be easier to do the PDEK later then.

[00:30:51]Yes. But is PDEK popular technique in USA or still not very well accepted? I think DMEK is much more popular.

[00:31:02]So, but I think you know all these things it always takes time to change.

[00:31:06]You remember 15 years ago it was only DSEK.

[00:31:11]No one did DMEK.

[00:31:13]Yes. It just slowly with time things change and then people keep advancing.

[00:31:19]Now, I would love to know how did you end up deciding to go from Vietnam to go to Russia to do your PhD? Your extra training there.

[00:31:28]Yeah.

[00:31:29]So, many people also ask that question.

[00:31:33]Uh firstly, there is mutual agreement between Vietnam and Russia for education, you know. I hope that there would be agreement between Vietnam and India or Vietnam and USA, but now most Vietnam and Russia.

[00:31:46]But so I studied medical university already in Russia because my parents and grandparents they also studied in Russia. It was a tradition. Oh, interesting.

[00:31:57]My grandfather was the first to go to Russia to study. So, that's how But then when how did I met Professor Yuri? I actually didn't know him before. I went to ESCRS 2018 and I heard about the PDEK idea, you know. I thought that I must explore it. Like I just must, you know. It was so fascinating, but you cannot find so many people who are willing to try, you know, new ideas because it brings certain risks to the practice.

[00:32:32]You know, and at that time maybe for Professor Amar it was obvious Dua's layer, no Dua's layer, but for other part of the world it was not that obvious, you know.

[00:32:44]So I was searching for professor who was willing to go with me and also for smiley professor, you know, not a grumpy, too strict.

[00:32:55]>> [laughter] >> Yeah, have and enjoy.

[00:33:00]I also like your podcast because you start with a very bright energy, you know, like it makes people already have a better mood, so uh you normally you imagine a Russian person very strict and moody, you know, like like in movies, you know, but Professor Yuri was nothing like that.

[00:33:20]So, I would say it was more that he was so smiley and he was a cornea surgeon, so two in one, you know.

[00:33:28]That's fantastic. Now, you you're practicing in Vietnam. I actually first went to Vietnam 20 years ago.

[00:33:34]2006. I taught there was a meeting called the Imperial City Eye Meeting in Hue.

[00:33:40]Wow. I taught there 20 years ago, 2006.

[00:33:42]I've been there four five times. I'll be back actually coming this July again in Hue.

[00:33:47]I'll be in Vietnam again July 21, 22, 23. We have the Imperial City Eye Meeting again.

[00:33:53]Is it for conference or for For all of the ophthalmologists of Vietnam. Yes, we're we're doing a Yes, so so I but I was always impressed when I was in Vietnam that there's a lot of very advanced cataracts. A lot.

[00:34:10]Like if you were a cataract surgeon in Vietnam, you would do white cataract and brunescent cataract every day.

[00:34:17]I think that is because of the just that old people, you know, in rural areas like in India also they don't have access, so they so, you know.

[00:34:28]Yeah, but Vietnamese doctors are very skilled with hands, but what they lack, I think, is research exposure or like the exposure to Of course, they we all watch your videos, you know, it's all our educational. We talk to each other, you know, what about the last case, why the IOL did not open correctly, you know, what was the reason. But I think that what we of course what we lack here is the educational platform. So, please if you it would be our honor to also invite you to Vietnam and to our clinic. Just clear the schedule and I would ask the clinic >> [laughter] >> to invite you. It would be a huge huge huge event. Yes. Oh, I think that's great. Yeah, the world is changing now.

[00:35:16]Education is the same worldwide and it's on your mobile phone.

[00:35:23]Yes.

[00:35:24]In high definition. So, wherever you are, you can learn from the same videos, the same lectures everywhere worldwide.

[00:35:32]That's the beauty of it. And now with these new apps you can even have it translate.

[00:35:38]Yeah, even in Russia they learn with the blocked internet from you. Yeah, yes.

[00:35:43]You have to you you have to use a a proxy. You have to use a VPN. Yeah.

[00:35:48]Yeah, you but you can certainly get around it. Yeah, I I look at the we have a lot of viewers like you in from China where it's also blocked. You do they they use a you know, VPN or proxy and they get around it.

[00:36:00]But can you tell us how did the idea come to you like to do such kind of videos, you know? How did it start in the beginning? Well, I I've been making videos for a long long time. So, if you look carefully on YouTube, there's videos for me in low definition from almost 20 years ago.

[00:36:18]Wow. Right when YouTube started. Maybe maybe 17, 18 years ago.

[00:36:23]But then about eight years ago in 2018, I thought, well, you know, it'd be nice if I had all my teaching material in one place.

[00:36:32]So, I said, let me decide how do I what do I want to make? I said, I don't want to be cataract professor. I want to be cataract coach cuz coach is like everyone needs a coach.

[00:36:39]When I watch TV and I see the world's best tennis player, Roger Federer, incredible but he still has a coach.

[00:36:48]Because as good as he is, he wants to be better.

[00:36:51]Yes. And so then I thought everyone should have a cataract coach and then I like the way it sounded, cataractcoach.com.

[00:36:57]CCC, cataractcoach.com. So, I decided to make a new video and I said, can I I was going to make one a week.

[00:37:05]Could I do one video a day? Can I do And so the answer is yes, cuz now 2,000 almost 900 days later, I still never miss a day. So, I have a new video every single day. And then I started off with just cataract, but then I want to learn everything anterior segment. So, we cover cataract, glaucoma, cornea, refractive, complex anterior segment surgeries well.

[00:37:26]And then I have a sister channel now called retinarounds.com where the retina it's my colleague, Dr. Pradeep Prasad, who does retina and he does retina videos and retina podcasts.

[00:37:39]So, we got the whole eye covered. Now, what we need is I need to find some young strong ophthalmologist who's going to do orbit, oculoplastics, and strabismus.

[00:37:48]>> [laughter] >> I need those. I don't have those.

[00:37:54]You know, but what we love is that normally, for example, even when Professor Yuri is doing surgery or when I'm studying him, you know, when the surgeon is doing surgery, you are afraid to ask too many questions, you know, like not to be too noisy. And you ask those questions for us.

[00:38:09]>> [laughter] >> And you comment for us. It's like, you know, it's like you are reading our minds.

[00:38:15]>> [laughter] >> But for everyone. Yes. And it's of course there's so much to learn. I learn more than I teach.

[00:38:25]There's so much to learn. Today's video, if you see cataract coach, this video is unbelievable.

[00:38:31]The first time I watched the video, I missed the problem. It's a case where the capsular bag breaks open. Yeah. But it was so subtle that I had to go back and watch the video in slow motion to actually see it.

[00:38:43]And so I put it as a quiz. I said, 99% of ophthalmologists will get this wrong cuz I got it wrong.

[00:38:49]So, do you have many residents now?

[00:38:52]I used to. I don't anymore. So, from for 22 years, from the year 2000 until 2022, I would have residents every week. I would teach we had a big program at UCLA where it was eight residents per year.

[00:39:08]Total of four years, so total of 32 residents.

[00:39:11]Mhm.

[00:39:12]And so a lot of good very smart, very good residents. But a few years ago I had to change gears. I had to do things maybe different direction. Cataract Coach got very busy. I'm traveling a lot more.

[00:39:25]Like I said, I'll be in Vietnam in July, but >> [clears throat] >> just the weekend before I'm in Taiwan lecturing. The weekend after I'll I'll I'll be in Bangalore, India lecturing there.

[00:39:35]Dream life.

[00:39:37]>> [laughter] >> It's That's I know. So, there's obviously a lot of travel there for me to to get around and you know, meet all these ophthalmologists, learn from them, learn together. So what it for me it's a lot of fun.

[00:39:52]But can I ask you who was your coach?

[00:39:54]Like Oh, number my podcast guest number one Dr. Bobby Osher.

[00:40:01]Bobby Osher, yeah. Osher is to me is the Godfather.

[00:40:06]Yes. He's he is his brains, his idea to use video to teach surgeons what long ago almost 30 years ago when I was a resident 1997, 98, 99 I would borrow these VHS video tapes of Osher's video journal of cataract surgery and I would and he made it four times a year every quarter every 3 months there's a new video and I would watch it again and again and again.

[00:40:35]So he was your coach.

[00:40:37]He changed ophthalmology. He taught he showed that yes, you can learn from videos and then he also was very brave in that he innovated a lot of things and he would he made it okay to show your complications.

[00:40:51]Don't just show the beautiful surgery.

[00:40:53]Show the surgery where you had a complication and a problem and how did you solve the problem?

[00:40:58]We remembered, yeah. We remembered last time how funny it was when you were at the judges at the team Chennai.

[00:41:08]>> [laughter] >> You know, and you like a looking at you know, giving comments on the surgery.

[00:41:13]It's like you know, it's like real life cataract coach.

[00:41:17]>> [laughter] >> Reality, yeah.

[00:41:20]But I think that makes everyone a better surgeon. If we all learn from our complications and show the complications. Here's the problem.

[00:41:27]Here's what happened. What should we do now?

[00:41:30]We can learn from that.

[00:41:32]But we learned before that you had also Indian origin. I mean, did you study in India before? No, I'm Indian American.

[00:41:40]Oh. Indian American. My elementary school, my grade school, my high school is 10 km from my clinic.

[00:41:47]Oh. I spent my whole life right here in Los Angeles. Oh, okay. But have you ever come to Russia, you know?

[00:41:55]Long ago.

[00:41:57]Long ago. Long ago. I used to travel a lot for ophthalmology 20 years ago. Like I said, when I was in Vietnam in 2006.

[00:42:04]So in the in the mid to in in 2003 to maybe 2008 or 9, I traveled a lot also back then.

[00:42:12]Oh. A lot [clears throat] of it.

[00:42:14]>> Hue is my town. Oh, really? I'm from Hue, yes. The the perfume river, I love that place.

[00:42:22]It's very calming, you know, and there are many heritage now even more beautiful than I think 10 years ago where you've been, yeah. Yeah, beautiful place. Yeah, certainly if you're listening to this podcast and you would like to come and speak at our meeting in Hue, please contact me, email me.

[00:42:40]>> [laughter] >> Right.

[00:42:42]Happy happy to invite you. It'll be a great time. But no, it's a beautiful place and what I loved was just the enthusiasm to learn. The young surgeons there really want to learn.

[00:42:51]Uh there is a central Hue hospital.

[00:42:54]They're quite they're quite good, yeah.

[00:42:56]Yeah, that's that they're the ones sponsoring our meeting.

[00:43:00]Ah that's that's where you're going. We we probably will probably do it at a hotel meet in a hotel meeting convention, but they're sponsored by Hue Central Hospital.

[00:43:10]Ah please let me book you one day in Hanoi. Okay.

[00:43:17]Well I'll I'll have to come I'll have to come visit you for sure. Yeah, I will bring you bring Professor Yuri to Hanoi when you come. Yes.

[00:43:25]Yes.

[00:43:28]We must to be in Hanoi together. I would love it. Oh in Moscow, too. Yes, my favorite part of Vietnam is probably the world's best seafood.

[00:43:39]Oh.

[00:43:41]Yeah. Cuz you >> yeah. Have you showed me to Hue? You must be in Have you visited Hoi An? Yes, beautiful beautiful. Yeah, Hoi An is very beautiful. Yeah, beautiful country. Had a great time visiting.

[00:43:54]But and then I just realized to cross the street just don't look.

[00:44:01]And then but keep the same speed.

[00:44:03]You walk the same speed and all the motorcycles will just go around you. You don't have to worry. Just just don't look.

[00:44:10]Big traffic jam, yes.

[00:44:12]But you know, for example, in Hue you you feel a lot of history. Yes.

[00:44:21]But also in Hanoi you feel a lot of history. I mean, no matter what happens in the past between the our countries, Vietnamese people are still very welcoming, you know, and and friendly for tourists. I think that especially when you come everyone will be asking where you're from, you know, like that. Like yeah, that would be very nice. It'll be absolutely great. Well, I'm really impressed with all the work that you're doing. I mean, these cases are amazing.

[00:44:51]Um I have a few more important questions to talk about for these are my important questions about the pupiloplasty and the surgical techniques. So let's talk about this one, the learning curve.

[00:45:03]So if you have a surgeon a young surgeon is listening to the podcast and that surgeon says, you know, I have this patient who would benefit from pinhole pupiloplasty.

[00:45:13]How do you start? What's the what are the important ideas or technique of that you have to do? And then what common mistake will they make?

[00:45:24]I translate a bit. Sure.

[00:45:55]He says that for pupiloplasty you have very precise steps like phacoemulsification.

[00:46:16]It starts even before the surgery from the diagnostics.

[00:46:20]Is this patient suitable for pinhole pupiloplasty? And what is the size that that is suitable for that patient?

[00:46:31]Not all people for pinhole pupiloplasty.

[00:46:54]But even I heard that Dr. Amar still do it with glaucoma. But if you have retina problems, so that's not a good indication for pinhole pupiloplasty, yeah.

[00:47:08]Is there a way to know the iris suture?

[00:47:19]He says that the the thanks to the suture the iris the pinhole must go to the center, you know, it must >> [clears throat] >> So you not do not take the iris near the pupil, he says, but you take the iris even from the iris body already, you know.

[00:47:54]Periphery to the center.

[00:48:06]So you use a vitrectomy to make the pinhole exactly at the place where the Purkinje image one is located.

[00:48:18]Those are great great pearls, yeah. I think for for me the mistake I made was not getting a strong enough bite of the iris because they can have some iris atrophy. So you want to make sure that your suture pass through the iris is getting the stroma of the iris so you can really hold it together. And then the idea yes, is you can close the whole pupil completely, then use the vitractor to then create your 1.5 mm pupil in that spot you want.

[00:48:46]I think that's a very nice insight that you just gave us that you can close the whole iris, you know.

[00:48:52]And then just use the vitractor. We need exactly the same like you just said like few few days before, yeah.

[00:49:00]Yeah, then I think the patients can be then really happy.

[00:49:03]The learning curve is not easy. It's not easy at all. So did you pull the iris um you know, that you so much that you know, you get some hyphema or have you ever encountered that? That's a very important thing. So you when you're pulling the iris out of the angle, bring it centrally you have to be very careful to not disinsert the iris root. Cuz otherwise you can pull off the iris root, you can get bleeding from this, hyphema from this.

[00:49:32]So you've got to be very very slow deliberate. The case will take you the surgery will take longer than you think.

[00:49:38]So do a retrobulbar block for the patient. Oh.

[00:49:42]So what I do retrobulbar block with both lidocaine and bupivacaine.

[00:49:48]So it lasts a long time. Uh-huh.

[00:49:50]>> And then just take your time. It's going to take If you think it's going to take you 30 minutes, it will take 1 hour.

[00:49:55]If you think it's going to take you 1 hour, it's going to take 2 hours.

[00:49:58]So put it I I do it my last surgery of the day so I don't have to worry.

[00:50:03]So I do all the easy surgeries first, all the cataract surgery, you know, do 20 30 cataracts, whatever, and then at the end of the day, let's just do this one case. Oh.

[00:50:25]And then finally I mean the last thing with PDEK, I think what you've done there now, you have a huge success. I think it was you said 95% success rate with PDEK, which is amazing.

[00:50:36]And so in the future, do you think we could help to automate this big bubble fluid injection technique [clears throat] for all the eye banks so they can do it for us?

[00:50:46]Uh we actually hoping that it would become the technique that eye banks use.

[00:50:52]And currently it's only in some places, you know, like Russia or Vietnam. It's not being used you know, largely. So in the USA, we know that it's the largest number of eye banks there. So maybe they would start to adopt it. We know that the Alliance Eye Bank has some sort of their own technique for preparing PDEK grafts. I don't know what is the repeatability rate, but in our case, so it was 95% so we were very happy. Yeah.

[00:51:27]That's right. PDEK PDEK better than DMEK.

[00:51:31]Yes. I practice only PDEK. Only PDEK.

[00:51:36]Yeah, I think I'll Dr. Agarwal says the same that PDEK is certainly a better procedure than DMEK and in his in his clinic, it's only PDEK. And I think in the US we'll do the same. We were DSAEK, then we went DMEK, and now we'll go PDEK. There's just an evolution that takes time.

[00:51:54]PDEK better than DSAEK and then DMEK.

[00:51:57]Yes, for sure.

[00:51:59]>> [laughter] >> For sure.

[00:52:00]They will be very happy to hear that.

[00:52:03]If you have a video of this, we're happy to feature the video on Cataract Coach to show this technique or any surgical technique, just send me the video, happy to feature it.

[00:52:13]So we have sent you before the pinhole pupilloplasty.

[00:52:19]I don't know if it's possible that you add add it in this podcast or you'll do it separately, but we'll send you also our optimized PDEK.

[00:52:29]Perfect. Perfect. Yeah, we'll we'll feature it the day after the podcast.

[00:52:33]This My podcast is every Sunday. Yes.

[00:52:36]The the video for the day after the the Monday right after, we'll feature your video.

[00:52:40]Yes.

[00:52:41]Thank you so much, Dr. Uday. It's a great great great honor for us, you know. Before we just saw you on videos and last year we got to see you in real person. You are much much more fun, you know, you're already fun on >> [laughter] >> Thank you very much, Dr. Uday. Thank you very much. It's very interesting for me.

[00:53:03]>> [laughter] >> Thank you. That was a fun discussion. I learned a lot. Thank you again for doing this podcast. I really appreciate it.

[00:53:10]Thank you so much, Professor Uday, and I hope to see you in Hue in July in Hanoi.

[00:53:17]We would talk about that. Yes. And tonight in July. Sounds good, Dr. Yuri.

[00:53:22]I want to remind our listeners and viewers, remember we got a new Cataract Coach podcast every Sunday on Apple, Amazon, Spotify, Google, everywhere you find a podcast, you find the Cataract Coach podcast. And of course, we have a new Cataract Coach video every single day. So until next time, I'll catch you later.