CataractCoach 2997: is low IOP phaco really that important?

[00:00:01]Cataractcoach.com is low IOP phaco really that important?

[00:00:06]A low pressure 20 mm mercury causes a challenge when the capsule breaks. Let me show you this interesting case here.

[00:00:11]So, we've got an experienced surgeon here doing a routine cataract surgery.

[00:00:15]And again, this is using a low power, low flow, low pressure phaco. Now, we've heard a lot of stuff recently from some of the companies about, "Well, you want to have phaco done at physiologic IOPs.

[00:00:29]Don't get the IOP up so high. Operate with a lower intraocular pressure."

[00:00:34]Okay, that's interesting. Now, remember in the old days, you know, even just 10 years ago or depending where you are, maybe your current phaco machine, you can't set the IOP. All you set is the bottle height.

[00:00:44]And that determines the infusion pressure. And it's usually gravity based. So, the higher the bottle is from the ground, the more the gravity infusion pressure is. So, you're setting infusion pressure.

[00:00:55]And then doing that is a proxy with bottle height. Now, there are some machines that had an, you know, forced infusion. So, you could actually set an infusion pressure. Great. And now we've got machines where we can actually dial in the exact IOP that you want. And there are sensors that detect that.

[00:01:09]I'm trying not to look at those eyelashes. I know I know it's a good surgery and we're going to watch that, but the eyelashes are making me crazy.

[00:01:16]But, let let I digress.

[00:01:18]Now, here it goes. It does not spin, you will not win. If it does spin, you're going to win. Fantastic. So, look at the beautiful result here. Little bit of a groove there. Split the nucleus in half.

[00:01:26]There are two halves. Probably going to do a stop and chop. Bring that piece up.

[00:01:28]Again, not a very dense cataract. Now, look at the AC. Is there any bounce in the AC?

[00:01:33]So, the bounce in the AC where the iris flops back and forth and with capsule moves a little bit is when your infusion versus your um outflow fluid is not the same. It's not balanced well. And there is bounce here.

[00:01:44]Look.

[00:01:45]There's bounce. Look at the iris. It's bouncing. Yes, 100%. And that means the capsule is bouncing, too. So, this needs higher intraocular pressure. This is not good right here. To me, there's way too much bounce in the eye and I would not want to operate this so much of a pressure. Like if it's my eye and I don't have like advanced glaucoma, I have healthy eyes. I don't want to have such low pressure during my fake out. That's the truth. Because what's the advantage of having a little bit higher pressure? Better stability.

[00:02:14]Again, you get that ratio of the inflow fluid to the outflow. And you want to use outflow where you're efficient surgeons, you want to use 40 50 60 cc's a minute of outflow. That's a lot of outflow, right? Well, you have to have the inflow to match it. When you have a very low infusion pressure, that's kind of not good, right? In certain terms.

[00:02:33]Now, I get it. You have a patient with a very cupped out 0.99999 optic nerve. Okay.

[00:02:40]But watch in this case. So, it looks pretty good, right? Getting the lens in the bag. Routine case. Here's what's going to happen, though.

[00:02:46]Get the lens in the bag. There it is.

[00:02:48]Open up the haptics. And now you can go behind and remove. Now, to remove the viscoelastic, I want to actually a little bit higher pressure. I want a high flow.

[00:02:56]Right? To wash out the viscoelastic, the OVD.

[00:03:00]So, watch this. Going behind the optic and look carefully. Look watch watch watch. Here it comes. I'm telling you right there. Right Look carefully.

[00:03:07]Aspirate and oh, do you see that? Look right there. There's a hole right there.

[00:03:11]There's a hole right there.

[00:03:14]Yeah, put the optic over again.

[00:03:16]And I I'd come out of the eye here. You got the That's the hole for sure. I think you may not have vitreous prolapse. Maybe there's a little bit. So, I'd come out infusion on. Come out keep the AC deep.

[00:03:26]Inject BSS with the other hand. Yeah, yeah, yeah. And come out of the eye now.

[00:03:29]Oh, infusion bottle's empty. Dang. Bad luck. Okay, there's the triamcinolone.

[00:03:34]Come out of the eye. The infusion bottle's empty.

[00:03:37]So, remember this, too. If you have a break in the posterior capsule, what's the vitreous pressure?

[00:03:42]Well, if it's higher than 20 and your anterior chamber anterior segment pressure is only 20 on the machine, guess what's going to happen to the vitreous? It's coming forward.

[00:03:53]See that? Now, what if you had a pressure of 40 mm of mercury, your infusion pressure? And then you break the capsule. Well, the pressure of the vitreous cavity is not 40, so you won't get prolapse. But here, you know what?

[00:04:05]You're almost certainly going to have a little bit of prolapse. I know you don't think so.

[00:04:09]That See, there you go. Single vitreous strand. Did you see it? Right there.

[00:04:12]Right there.

[00:04:14]I bet you you would have not had any vitreous prolapse at all if you had an infusion pressure of at least 40 mm of mercury. So, please stop with the No, we must lose use a much lower infusion pressure. No, I don't think I think you're wrong. I think I disagree with you. For the vast majority cases, for more than 99% of the cases in your clinic, I am telling you you are much better off with a intraocular pressure of 40 than you are of 20. Oh, look how much bigger the hole got.

[00:04:42]Why did that posterior capsule hole get so much bigger?

[00:04:45]Cuz you brought vitreous forwards.

[00:04:46]Vitreous prolapse forwards.

[00:04:49]Now, more times than one, I think all the issues in this case, all of them stemmed from using the low IOP.

[00:04:56]So, listen.

[00:04:57]Call me out if you want. Put a comment below. Tell me how wrong I am. I'm willing to learn. I'm willing Teach me.

[00:05:03]Teach me something.

[00:05:04]But I'm telling you right now, if you're doing my phaco, do not use an intraocular pressure of 20 because it's more physiologic. I don't want it. I think there are so many benefits of having a pressure that's a little bit higher, and I promise you my nerve, my eye can withstand a pressure of 40 mm of mercury for the duration of this beautiful surgery. Oh, the capsule tear is even bigger now. Look at that.

[00:05:25]What do you think? Comment below.