life good evening everyone welcome to lecture 417 of the Cataract module in if focus online series for PG students today the topic of the class will be phoric and ftic gloma the management guidelines for the session I would like to introduce to you our moderator Dr Kiran M ma'am completed her mbbs from BJ Medical College in aabad Ms SCH medalist from M&J Institute Civil Hospital aabad M finished her senior residency from De upadhi Hospital Delhi currently she's a senior consultant at Center forite Eye Hospital New Delhi ma'am is a trained and certified PTO cataract surgeon and a refractive surgeon she's also the organizing secretary for prestigious PG training I focus program organizing secretary for irsi fa for I focus RC and various other conferences ma'am has authored multiple book chapters and Publications in various journals National and international welcome ma'am over to you Ma'am yeah thank you very much Gar so today we are very lucky to have with us Rishi sir sir uh his vast wisdom will be helpful to all of us not only we are all students at the end of the day and we'll be we are very very lucky that his wisdom is the one which is going to Enlighten us on such a difficult topic today sir is medical director and chief of uh the MMC Institute a unit of Cent for site New Delhi so has done his mbbs from the prestigious molana aad Medical College in 1982 with gold medal and MD in Opthalmology from RP Center AIMS in 1985 so did his DNB in 1986 and Senior residency again from RP Center in cat and Coria having procured a fellowship with project orus in USA as a staff opthalmologist in 1989 and clinical regist in Prince Charles i unit K7 Hospital UK sir is also having a fellowship of Royal College of Surgeons of Edinburg in 1996 and awarded membership of the Academy of Medical Sciences in 2006 recipient of various academic Awards included uh molana aad Medical College gold medal and certificate of Merit for first position in Delhi University the best resident Award of RP Center AIMS in 1986 sir has been holding various positions in the societies all across the country including member scientific committee iOS 96 to 99 and 2009 to2 secretary Indian Society of Coran Kat refractive surgery 2011 to 2015 Treasurer ibank Association of India 2016 to8 joint secretary ibank Association of India 2013 to5 president of Delhi ofical society 201617 and vice president isus 2016 to karant so we are very very lucky to have Sir with us I would like to introduce now our speaker for today Dr Amit Pand uh Dr Amit has done his mbbs from Surat and postgraduation from Mumbai he's also uh taken up a degree in FICO uh fic I mean he a fellowship has been done in gloma from Shan nalia Chennai currently Dr Pand is a consultant at Cent forite Surat he has been the first surgeon in India and very proudly as a part of Cent for site I feel very happy to say this that he's been the first surgeon in India to implant an ient inject wuse Oculus G and perform life surgery of mix he's also been training all of us with his wisdom in icent and uh we are very very proud of him and his knowledge he's been the first surgeon in Gujarat to have done the Ahmed clath and performed exceptional gomy with kaho's dual blade Glide he has multiple Publications and numerous presentations in prestigious National and international journals and conferences Dr amid before you start may I request a word of guideline from Rishi sir so that the students are also aware as to how to go about learning this difficult topic uh thank you so much Dr Kieran thank you for that introduction and those kind words and welcome to Amit and the entire group uh of residents who are tuning in and listening to this uh talk um so the talk today is going to be on two types of glaucomas which are essentially secondary glaucomas and these have been created by an abnormality in the lens which can either be because of the lens shape or the lens position or there can be a leakage from the lens or a breakdown of the lens in a macro Manner and these nuances and the differences in the approach of these will be taken up very ably by Amit um who is going to be talking about this uh fortunately we don't see as much of these glaucomas now as we used to in eras gone by when there was a fair amount of hyper maturity and inumin that we used to see we're seeing them less and less uh that said it's not that we don't see them we still do see them and so knowing uh um what exactly needs to be done and to be able to identify the reason uh why the pressure has gone up is extremely important very often there is an underlying trauma which gets missed uh very often there is inflammation if there's inflammation which is substantial you need to First lower or quen the inflammation down before you can take up these cases for surgery so there's a lot of intricacies in uh the process of uh uh examining these patients and trying to figure out what the pathom mechanism and then naturally the correct approach to treatment would be naturally the management of the lens in situations like this would be primary to the uh to the control of the IOP but the it cannot be underestimated the value of the medical management so I'm going to hand you over to Dr Amid and I'm sure he'll take us through this journey uh in you know only ways that he can thank you thank you so much sir thank you uh Dr k for the introduction and uh thank you team I focus uh wonderful job uh they're doing in in making this really the of all PG teaching programs uh let me share my screen like sir told I'm talking about theomorphic and the folic glomas and don't have any conflict of interest secondary glomas are basically a group of I diseases which is characterized by increased IOP resulting from an identifiable ocular orbital or a systemic cause and lens induced glomas are uh basically form of secondary glomas where the lens is the primary cause of this increased interocular pressure either by by size by the position or by causing inflammation and it's a very important cause of irreversible blindness secondary to catar cataract basically as we know is a cause of reversible blindness but if it proceeds to a lens induced glaucoma it can lead to a irreversible blindness theomorphic and ftic glaucomas are basically seally to a neglected Advanced Cataract and uh there are various factors which lead to such neglect neglect uh especially the decreased need of vision uh misconceptions that the cataract lens needs to be removed only when it is mature uh lack of awareness about the disease and the fear of surgical procedure also in some cases it's more common in the rural population but it's not very uncommon to see it in the urban setting as well uh mostly elderly patients and females are more commonly involved predominantly this is seen in the developing and the underdeveloped world so uh lens induced glomas there can be fom morphic ftic lens particle induced fotopic and F anaphylactic as well so if we divide the lens induced gloma into we can divide it into an open angle and an angle closure open angle would be the ftic which is caused by soluble lens proteins we'll discuss that in detail now uh lens particle induced can also be there an open angle type of secondary GMA where macroscopic lens particles they clock the tricular measure and uh usually happens if there are some amount of cataract particles that are left behind after cataract surgery or after trauma F anaphylactic is where there is an antigen and antibody reaction happening which causes a lot of information on UTIs angle closure you can see uh in phoric and fotopic phoric is where the lens becomes increased size that is the inent lens basically and fotopic would be a subluxated and a dislocated lens so today we'll be discussing about the ftic and the fomor uh okay so let us start with the ftic gloma uh this is a secondary open angle gloma which is associated with hypermature cataracts uh the mechanism basically is there are microscopic defects that happens in the capsule of the lens and uh of a hypermature lens and this releases the heavy molecular weight lens proteins uh these lens protein directly also causes obstruction of the outflow channels as well as the macras they engulf these proteins and they themselves uh increase the blockage of the trapic mure to increased intraocular pressure the symptoms would be of course vision loss because of the Cataract itself which would be gradual loss of vision over months and years probably lead to a sudden increase and associated with pain which would be accute onet associated with redness watering and photophobia when you look into the slit lamp in these cases definitely you'll see lead edema circum cornic congestion cornal edema AC cells and flares would be there the intraocular pressure will be in the high 30 to 50 mmhg range you'll see a morgagnian or hypermature Cataract and often you might see uh soft white patches on the capsule which are basically Aggregates of macro fases which are trying to seal these sides of leakages and if you're able to do a gonioscopy you'll see an open angle uh theomorphic gloma uh like we uh discussed is a secondary angle closure gloma which is precipitated by a thick lens and inent cataract it is one of the most common causes of secondary angry closure glaucomas especially in India where it has been reported to be as high as 4% uh more common with hyperopic small eyes and predisposed by a rapidly developing uh cataract or a traumatic cataract as well so what happens here in pomor glaucoma is these predisposing factors and the inent lens uh causes anop poster thickening of the lens which increases the arido lenticular contact and also the stretched or the Aging zonules allow the lens to move even more anteriorly increasing the parid lenticular contact so the swollen lens itself pushes the iris and closes the angle as well as causes a pupilary block which causes Iris bomb ultimately leading to a again angle closure the out flow is obstructed and the intraocular pressure Rises symptoms would be similar to what we saw in P litic gloma where you'll have a gradual loss of vision colored Hallows can be there because of the interent lens pain would be again acute onset redness watering photophobia nausea and vomiting as well and signs again would be similar uh other than the fact that there the anary chamber would be shallow both centrally as well as peripherally and you'll see a inent cactus lens and if you are able to do a gonioscopy you'll see closed angles ubm and asoc now that we have these instruments they will also show angle closure and Iris Bombay uh a concept to understand uh which patients might land up with a uh a theomorphic kind of angle closure is lens W lens W is the distance between the the perpendicular distance between the anterior pole of the crystalline lens you see this is an aery image where this is the anterior pole of the the anterior capsule and this is the anterior pole of the lens the distance between uh a line joining the two scarel Spurs and the anterior pole of the lens is called as the lens V so this is supposed to be if it is on the highest side where like in a Chinese study they showed that more than 660 microns if it is there they are more likely to develop angle closures as compared to uh uh eyes with lesser that is 460 less than 460 microns lens V but these were Chinese eyes so it would depend there would be a relative uh relation between the lens W and the size of the eye as well so not all eyes would behave the same so now the concept is of the uh anterior W which is the distance between uh the lens W the addition between the lens W and the entry chamber depth this whole distance is called as the anterior W and the ratio of the lens VA with the anterior VA is called the related ative anterior lens W right the relative lb and this is supposed to be a better predictor of which patients would land up with the uh a lens induced angle closure uh and a fom morphic kind of a setting so let us come on to the main topic now which is the management both ftic and fom morphic glomas are ocular emergencies and they have to be treated like that the principles of management are basically to reduce the intraocular pressure uh decrease the inflammation especially in the ftic cases and remove the cause uh initial treatment of lowering the intraocular pressure would be through manol IV manitol and or alomide also topical beta blockers can be given in fatic glaucomas only topical steroids usually are required because of the inflammation and cyclopic can also be given which have to be really which are really contraindicated in theomorphic cases so you need to identify which patient you need to give Cy cyclopic if that has to be given uh the definitive treatment of course would be the Cataract extraction the treatment of the cause itself uh but some cases would require a combined frabic leomy which are those cases in ftic glaucoma uh when the onset of the ftic glaucoma is more than 7 days or if the pre-operative control of intraocular pressure with maximum medical therapy is also inadequate then you might think of doing a combined F trom or sics tectomy indications in fom morphic glaucoma would be when there are extensive sinal angle closure in three or more quadrants then these cases might require trab leomy along with the cataract surgery what does the trab leomy do is basically prevents the postoperative rise in the IOP and decreases the need for systemic hypertensive medications so coming on to the cataract surgery now of these cases what are the difficulties that you might encounter in in cataract surgery first you need to identify those and then treat accordingly first would be the peripheral rexus extension which is famously called as the Argentinian flag sign uh where uh you put a small lick on the capsule and because of the high intal lric pressure it rips open we'll discuss that in detail the nucleus removal becomes difficult because of multiple reasons one could be a very dense nucleus itself because it's a long-standing case uh second because uh these cases uh the liquified cortex uh is there and once that is removed there there is a lot of space in the uh capsule for the lens to move for the for the nucleus to move around so trenching and chopping becomes very difficult you can have uh hidden pockets of uh white fluffy cortex which is stuck to the capsule away from the uh uh away from our vision so you can have an incomplete cortical removal these long standing cases the zonal are already weak and hence zonular dialysis and capsular tears are much more common in these cases compared to a normal cataract similarly endothelium would be compromised would be damaged because of the inflammation and uh High intraocular pressures to begin with and because of these uh additional uh difficult movements in the uh in the during the surgery uh we can cause more damage to the endothelium ultimately these complications can also result in nucleus of the I drop so the management would begin preoperatively by first counseling the patients properly I would suggest all the surgeons to examine their own patients All Eyes themselves not depend upon anyone else and speak to the patient as well as their relatives that this is not not a normal case this is not a normal cataract surgery this is a complicated cataract surgery and you show them the photographs clinical photographs you can take and that would Aid in the counseling explain that we will be prepared for all possible complications these are the main complications that can happen and we'll be prepared for them and also explain the cost of the extra materials if you're going to use them tell them that we keep them as a backup and if used then this will be the extra cost or at least train your counselors if you have counselors and you don't do the uh you don't talk about the cost we explain the counselors that this is a hypermature cataract and these are the possible things that we going to use during the surgeries to add to the uh main cost then uh you I would suggest at least initially uh in in and very complicated cases perber or rber anesthesia keep micro Rees forceps and scissors handy keep a three piece lens or a pmma lens depending on what patient is opting for and do a correct I power calculation for sucus placement of these lenses according to their a constant uh keep capsu tension ring handy inform your VR surgeon that I'm taking up such a case and I might require your help and in cases of shallow entor Chamber Of course preoperative mantal and don't forget to give an adult diaper to the patient because if you give 200 300 CC of manol to a patient uh and after half an hour or so the patient would definitely want to go to the washroom and if the patient is uh straining that would in fact make the case worse uh being prepared and having the patient on the same uh page would calm the surgeon's nerves as well so talk to the patient pre-operatively keep everything prepared and then go in uh some authors have suggested other means to facilitate the surgery likely laser aodomy or an argon laser peripheral iridoplasty in fom morphic glaucomas ftoc laser assisted capsular exis and lens fragmentation and pass plan V St or sutur small gauge limited pass plan of lomy also to expand and deepen the andr in cases of very shallow AC now let us look into uh the biggest uh problem that we can have at least initially during the surgery is the Argentinian flagen why is it called as an Argentinian flagen because most of these cases the capsule we would stain with tripan blue and uh what happens here because of the incre inreased intralenticular pressure the moment we uh we Nick the an capsule to start our capsu excess uh it rips open the anterior capsule and this uh capsu excess runs posteriorly so we end up with a blue white and blue which is close to what an Argentinian flag looks like and that's why the name so to prevent this preoperative manol is important use high cohesive visco elastic into the entry chamber and make sure that during the capsular exis at no point the entry chamber becomes shallow or else your excess would start running posteriorly a two stage or a double rexis can be done where the first make a small uh 3mm rexus and depressurize the intal lric compartment if it is liquified it would come out on its own but if it is not and which is usually the case then you need to go in either with a uh irrigation aspiration Cela and delicate maners uh to remove uh pockets of fluid filled uh cortex and decompress the posterior part also of the uh lens right and then once you are you have decompressed the lens then you make a small tangential Nick on the capsule and then make a complete 5 mm or 5.5 mm Rees snail track capsular excess also can be done where you the initial capsu excess is kept small and then subsequently enlarged circumferentially like a snail track uh don't do a lot of hydro dissection because already the ular pressure is very high and uh too much of fluid in the in the bag would again lead to an Argentinian fla sign reverse trendal inber positioning as well as uh retro bulbar block with a digital massage are also some effective ways of decreasing the posterior pressure uh Dr deep meor in his YouTube videos have beautifully shown uh uh two types of inent cataracts he has explained that one type of cataract would have multiple fluid Pockets the dull areas that you see here which are Arrow Mark these are the areas which are fluid filled whereas the rest of the cortex uh there are islands of swollen cortex this is one type of interent cataract that you might see which is uh and these lenses are less likely to have capsu excess issues whereas this kind of uh cortex this kind of lens where the entire cortex is swollen uh there the intralenticular pressures are extremely high and can lead to an immediate Argentinian flag sign I would really suggest to visit his YouTube channel and it's got some beautiful videos and which he has explained very well so let us look into a few videos now uh initially definitely for beginners as well as in in even for experts uh in very complicated cases my suggestion is to do a manual small incision cataract surgery uh the point being being a f and reducing the amount of astigmatism doesn't matter in these patients these patients have neglected their cataracts for such a long time that one or 1.5 adapters of astigmatism is not going to matter so I would suggest uh at least initially do a manual small incision CCT surgery let us see a video this is a ptic gloma where you can see how inflamed the eye is INS spite of giving the preoperative steroids and the lens is quite uh you can see the nucleus inside and uh has got fluid filled pockets of Cortex so I make a I've not decided whether I have to do a sorry I've not decided whether I have to do an sics or a f here uh you see I Tred to stain the capsule and under air but the compartment was very uh tight and hence the air bubble just gushed out uh what I do is I first try to do a rexis and if that is not possible then I convert to a sics uh once I've stained you can see these areas of fiberoptic capsule these these areas if I'm not sure whether it is very clear but the capsule was quite fibrotic and stuck to the uh the lens matter posteriorly so I was uh aware that that this is going to uh not going to be a straightforward case but still I first tried doing a rexis here the flap itself was not coming out so then I decided n this is not going to work and I converted to a can opener uh capsulotomy I replenish the visco so that uh the anterior chamber can be pressurized and the combination of rexus and Tommy I could complete the capsu auty and I decided that I would convert to a a small inion cataract surgery rather than a pration uh the nucleus was not looking very Brown very big so usually these nucleus are not very large and then a five or 5.5 mm straight incision would be adequate a nice tunnel is definitely important in these cases you see how much it is bleeding because of the inflammation that the eye had C A entry and side cuts it did not require much of hydro hydro should not be done in such cases the lens itself popped out and with a bit of visco expression I could remove the nucleus see the liquid cortex also came out so not much of Cortex remaining behind the pmma lens was implanted in the back B were hydrated and the in was cized to close up we could do a sutur less surgery in this case also it should be and the patient did well was quite happy with the result but plan on doing a f multiplication in these cases these are a few uh points that you need to consider protect the endothelium that's very very important and asenov soft shell technique is something that I uh follow using the high density visco dispersive which is usually a quiden sulfate and sodium hyon it to Port the endothelium the purple area that you see that's the visco dispersive and followed by a visco cohesive to form the an chamber right and decrease the shock waves of the the energy of the F Pro and uh decrease chances of uh the endothelium cell loss capsule or XIs always stain the capsule under air and trian blue because there is no red glow here and uh there's no support of the EP nucleus and the nucleus also uh so it will be difficult use the side port for the rexis because uh that will maintain the enter chamber if you're going through the main Port the ENT chamber can shallow and the excess can run off uh uh use CTO as well as micro exis forceps if the support is very weak micro exis forceps works better prevention of argentinan flag and we discussed in detail uh don't touch the nucleus or else it it will start rotating uh in the bag itself and make things worse and make a decent size rexes slightly larger than normal because a small Rees would lead to more pressure on the zonules during your nucleus management because and zal are already weak in such cases coming on to the nucleus management the four quadrant technique or the Stop and chop is what I usually do in these complicated cases during trenching low flow rate low vacuum and high power again there's be there will be a lot of space in the back for the nucleus to move around so you uh use a sinsky or a chopper to keep the nucleus in position and then trench uh ensure a complete crack especially through the posterior plate during chopping also first you complete the chopping on all sides before removing the fragment because like I told there will be a lot of space in the bag for the nucleus to move around and if you remove just uh do one chop and then remove half or one quadrant of the nucleus the space would become uh even more and the nucleus would move around even more so chopping of the rest of the fragments would become even more difficult coton removal during coton removal you uh make sure that these hard nuclear fragments they're not flying around in the ENT chamber which can also damage the endothelium and replenish the visco elastic again and again to protect the endothelium let us see a f IM musification this is a topical F in a fom morphic glaucoma uh this patient was very uh apprehensive of uh injection in the eye and uh hence I did it under topical especially looking at the nucleus which is not very Brown so and that's why I tried doing a topical F here the patient is apprehensive moving around stain the nucleus strain the capsule and slowly uh the aim should be to do a smaller uh rexis uh you will end up with a mid sizee or a large rexis if you start and uh aim for a large Reis to begin with then uh your exis might uh again replenish uh visco elastic like I did here to maintain the entry chamber should not shallow at all even uh when I saw that Reus was starting to move away here I put in visco and then brought it back completed a relatively good rexis not absolutely circular but uh not bad minimal or no Hydro if the cortex is completely liquidi very you can see how fluffy the cortex is and I could do a a good Ren and a stop and chop technique because the nucleus was not very uh hard here I'm ensuring with the uh the dialer that the fragments are not flying around in the entry chamber and nucleus was managed EP nucleus also came along with it and a bit of partical matter stuck to the capsule this was not a very complicated case and that's why I could do it under topical anesthesia but I would suggest the young surgeons to do a under Parable balance te this was a single piece l that was implanted in the back the last surgery that I want to show is an unusual case this is a very shallow anterior chamber this case is of a young mid 20s uh guy who had a retinal attachment and after um 2 months of Rd surgery with silicon oil in the back in the eye uh he developed an intractable glaucoma for which uh I did a agv implantation and for a month almost month and a half he did well pressures were under control and the vision also improved to uh 6 uh 9 69 Parts because of the wonderful retina surgery that was done uh but after a month and a half he suddenly came with a absolute shallow or flat anterior chamber and the lens became very very uh interent it's not very cataractous but uh it SW up like anything and the an chamber was completely uh flat uh on asking the history he told he started going to the gym after uh after a month and a half of the surgery and we lifted some heavy weights that that probably led to an over filtration through the AG as well as the lens also started becoming in so what we planned was was more than four months of the retina surgery and we planned a CCT with an S so so because the entry chamber is absolutely flat I first made a very small incision in the with the sideboard so it's just the tip of the sideboard that is going in because anything more would damage the iris as well as the capsule behind and then I form the entry chamber with uh VSS then made the complete size side board this go elastic in the in the eye to form the entry and now I saw that the tube was a little longer than what I usually ped and this would come in between my rexes the first thing that I did was for an inc2 tube shortening this is a microx forceps G countertraction and with a vanana scissor I could cut the tube without removing it out of the and CH then uh proceeded further with my rexit aimed at a smaller AIS and landed up with a good sized AIS here again that was not the case is not very complicated because very soft kind of a fluffy cortex you see uh nucleus was almost non-existent was all the swollen up prodct that was there even with B manual litigation aspiration I could remove place a an advanced monofocal lens this is something that I did for the over filtration of the cube uh this is a piece of 30 aylon and what I planned was to stent the tube so the agv the inner uh diameter of the agv tube is around 32 mm and the thickness of the uh 30 Eon is around 0.15 to2 so that would leave some amount of the Aquas to some amount of space for the Aquas to drain and preventing an over filtration so without removing the tube and ligating it or doing something of that sort uh in C2 I could Sten the tube this manuver has been described and uh we can remove the this thing also if it starts under performing this is something that I wanted to show so to summarize phoric and ftic glaucomas are ocular emergencies and definitive treatment is of course removal of the Cataract with adequate initial management first clearly explain the guarded visual prognosing the chances of complications to the patients and the relatives of course written informed consent is mandatory manual small incision cataract surgery for the initial and complicated cases and prepare for the worst but hope for the best thank you thank you very much Dr Amit it was a very very informative session I have lots of questions to ask but uh I would first request uh Rishi sir to guide us uh and whatever addendums he will give to us today will definitely be the pearls as well that we'll be carrying sir it was thank you Amit fabulous presentation I think you covered all the topics right from telling us about about the kinds of uh the lens induced glaucomas that there can be and also highlighting what needs to be done in each one of them and how some of them can be subtly different from the others uh excellent videos too I quite enjoyed your stenting of the tube um that was a novel and very good idea how did this patient do by the way he doing well it's been a month and a half now after this second surgery third surgery uh pressures without medications are around 18 absolutely fine for his glaucoma and vision also has improved and he's quite happy AC is formed okay so that's that's wonderful good outcomes are always uh Happy Endings um the um the thing that I would highlight which I tend to use a lot in these patients is to use manitol um which I think should become the standard in the pre-operative uh bit the you know that hour before the surgery uh a manitol really helps to decompress the vitus and make a life little easier it allows the AC to fall back um even in patients many patients I don't even mind doing a little bit of a culis so just taking a simple Iris repositor under the presence of a visco elastic and just sweeping the angle because micro CIA Phil form sinia tend to form the moment the inflammation goes up and is there even for a few days you can have a compromise in the angle which is easily treatable on table uh because that opportunity will not come later uh so these are the only two things other than that I think it was a comprehensive uh description of pretty much everything uh Dr Kiran please go ahead with your moderation I just thought I'd share these two you know personal experiences I would just like to add one more thing even in such inumin capsules a fexus also does a very very good job so if you are having an access to a fto cataract and a fto Reus can be performed you can actually avoid the possibility of an Argentinian flag sign though I would still like to warn that the chances do not become zero so so uh when it comes to realtime uh you know discussion with the patient if you're offering the patient of fto cataract there should always be a Clarity that despite the fact that we will be able to decrease the possibility of such an event or a complication the possibility will not become zero or an absolute zero nevertheless but it was an excellent talk Dr Amit I wanted to ask you personally before garv gives us the question which have been asked by students what is your choice of drugs when you are trying to medically manage these patients in the interim period before you take them up for surgery so uh these pressures are very very high 50 more than 50 in fact and usually topical medications will not go into the entry chamber itself so mainly systemic medications uh you start off with the manitol if it is not contraindicated um measure the BP uh monitoring the blood pressure of the patient at least 200 or 300 CC in fact of IB manitol over 30 to 40 minutes uh and uh definitely I give uh now I've shifted to diox er er is extended release which is 500 mg it's a little better on the stomach of the patient so one tablet at least or if I'm if the pressures are not coming down even after m than uh 750 mg that is 250 mg d three times a day and uh topically you can start Bonine with timolol combination uh of course avoid PG analoges and F is a big contraindication uh in in both these cases so that's how we manage and probably take up the case next day or the day after at least uh because again it's an ocular emergency and it has to be managed unless and until we remove the lens it's not going to come down Rish S I have a question for you what would be your way of preventing an Argentinian flat sign what is your uh you know the special trick that you would apply for preventing an urgent flat s so I'm not sure that there a perfect trick to be really honest uh you have to have your fingers crossed um I think the primary thing is to try and see theoretically how you can equalize the pressure on both sides of the anterior capsule so you have intralenticular pressure on the one hand and you have the anterior chamber pressure on the other hand so keeping a tighter anterior chamber uh thereby compressing and reducing the convexity of the uh of the capsule is by far the most important thing and whatever means can be used to accomplish that should be followed so I would prefer to use a very high viscosity uh uh visco elastic um I would try and identify if I can the areas where the fluid Cliffs and the things are and try and see if I can locate my my puncture eccentrically rather than uh in the center um I would almost always treat these patients Amit has already highlighted about acetazolamide being given pre-operatively I in fact started the night before and uh to use uh IV manitol uh in adequate dosage U other than that no special trick I mean there are all sorts of things that have been described from round needles instead of instead of uh uh instead of needles which are having a belled kind of a shape to make the initial entry because if you make a circular opening it doesn't tear as easily as if you make an opening which has a linearity to it so there are all these little tricks but still you got to be a little lucky I guess uh in avoiding these these situations that's my uh take really on it is there anything that you would like to suggest specifically that's it I think uh ni in the center just and and high density Vis lastic sodium hyaluronate 1.4 1.8 is also available now it's quite dense and it uh keeps the capsule under pressure and hope for the best there are some cases that inevitably would land up with the AR PL no matter what you do those will be very very rare uh and uh I think there's one technique described uh forgetting the name uh by moan Rajan sir he goes in with a f probe and punches with the F probe the entr capsule I don't have the gut to do that I yeah has been described and he says that it works very well right so garvita do we have any questions for ramit sir today yes ma'am we have a few questions first question is what to do in cases in which manitol is contraindicated due to any systemic causes you can send it to the physician as well under physician guidance or if you can call a physician to your setup if you have the emergency medications and everything I think 100 cc or 200 cc of mol is not going to cause an immediate problem but yeah if it's a very uh it's absolutely contraindicated because of the heart or or the kidneys uh oral aceros would work and even if that is contraindicated then you have to go in decompress the uh an chamber uh just by a needle first very gradual uh decompression of the entry chamber should be done uh with with probably a 26 gauge needle or a 30 gauge needle first and then slowly uh to prevent corage from happen uh but it would be very very rare that both these medications would be contraindicated 100 cc of manol usually doesn't cause much of a trouble but uh under physician guidance or send to the physician they would be very happy to admit the patient and give manol uh under they will be monitoring all the parameters right sir uh another question is what will be the parameters of machine while doing surgery in fom morphic gloma and whether peristaltic or ventury pump is better whatever suits your hands whatever you are used to is what I would suggest peristaltic or ventury know is doesn't make much sense I I shift from one machine to the other and don't feel much of a difference so whatever suits your hand or which machine you are used to uh uh doing your routine CCT patients I think uh that machine for parameters like I told uh in during trenching uh the parameters have to be uh the flow and vacuum should be very low and your power should be on the higher side uh and what else what should be the parameters in the machine doing pom morphic again would it will depend upon the uh how thick the nucleus is or how what's the grade of the nucleus itself some cases would have very dense Brown nucleus some cases like I showed in my video the nucleus was not very hard in spite of it being an inent ftic gloma move so it would depend upon the nucleus and accordingly we can keep the parameters right uh there's another question about what about the postoperative management in these cases postoperatively they would require a lot of steroids because it's already an inflamed Di and the maners that you do the extra manuvers that you do in the ENT chamber would also lead to a lot of inflammation and coral edema so initially I think 1 hourly uh steroids topical steroids for at least two to three days followed by two hourly and then taper it off as the response the kind of response that you get and uh hypersol hyper sodium chloride solution hypersol would help and if the pressures are on the highest side you might uh give uh more or less arite for a few days at least 3 days or four days and still it remains on the highest side then you might add a combination of Tim ofon if that is not just a second take an opinion from Rishi sir also as to what is the tweaks that he makes to his parameters whenever such a surgery comes to his table um it's a good question I think Amit really nicely answered it I don't think there are any fixed parameters that I would recommend I think it has to be by the case there's a patient with a very shallow chamber um with say a floppy Iris so uh you would you want to go up on the on the bottle height would you want to go down on the bottle height you know these are all things that you have to play on table I would use a lot of visco elastic in between and slow down my surgery and uh do it very very carefully peace whe uh rather than uh you know just try and complete the case you want to be away from the endothelium this endothelium is already inflamed and under tremendous pressure and uh if you're not careful you can easily create endothelial damage you can create decim detachments because it's a swen Cora so uh there are all those issues again uh the fortunate part with my experience with pom morphics is that either the nucleus is very soft or it's very small if it's hard because there's so much liquifaction that uh they come up with this very small nucleus which just spins around very easily you don't have to do much uh if you can just spear it and then stay in the center of the chamber where it's deepest you can very easily emulsify it so that's my experience with uh um with f all right I would just like to add here as Rishi s rightly said that many of the many times these uh uh nuclei are small and they just tend to spin around in the chamber with all the cortical support gone the your nucleus piece is just spinning in the chamber and you do not have any support in your bag and then the bag can have a tendency to collapse and become a part of the or rather come into the P the PC May tend to come into the probe and you may land up having a PC rupture so in such cases one uh if you can use a continuous irrigation to maintain the chamber at all times that also tends to help that's number one and when you're trying to take up the last piece since you do not have any support at the back it is better to shift to lower parameters even if your nucleus density has been higher in till the at the time of the last piece just go very slow there there should be no hurry at all all right and secondly I would also like to ask Rishi sir about his experience which I have observed and Dr Amit you also could just guide us that in such cases where the lens has been very incisent or we have a white cataract if we stain in the capsule very very well so I have uh gone through certain videos and some uh you know articles where the surgeons have recommended that the staining Tripp and blue Dy should itself be used for one minute minimum by the count so that not only tends to stain the capsule well but it also stiffens the capsule the Dy itself and it becomes easier for you to do a rexus and the chances of an Argentinian flax sign also tends to decrease a little though as Rish rightly said we have to keep our fingers crossed so the ones which have to undergo that will definitely do but would you like to comment on that if the die would tend to actually help Amit you want to go first or go ahead no go ahead go ahead I'll I'll sum up there yeah the Dy really helps uh it basically increases the thickness of the an capsule like in in periodic cats also it's recommended even though you get a really good glow uh staining of the capsule really helps in decreasing the uh elasticity as well as thickens the capsule so that it doesn't run off very easily so yeah I would recommend staying all such complicated even if uh the nucleus is not very or you can see the glow I would suggest in these complicated cases stay the stain the capsule always so sir I think I think I agree with that observation completely there is an element of cross linking that happens uh in the collagen when we stain these capsules it's very well documented in pediatric cases again as you rightly mentioned in the adults the impact is not uh as much because these are thicker and harder capsules even otherwise theyve just they're just 40 50 years older um but still I think I totally agree having a better visibility also is a has a role to play these corneas aren't always as clear as one would like and in that situation too you need to know where the edge of that uh of that rexus is so staining has multiple advantages in these patients and I am completely in agreement you should 100% stay in all these capsules yes gar there was another question for Dr amid believe yes sir yes ma'am uh there is uh the question asked is there not a risk of increased IOP postopera with the use of visco dispersive or should they be avoided and endothelial protection should it be prioritized uh if you do a good uh irrigation aspiration at the end of your surgery I don't think so there's an much greater risk than any normal I use visco dispersive in all my uh minimally invasive gloma surgeries also those are normal cases I use 1.8 hyaluronic sodium Hyler on it uh in those cases also and if you uh really uh do a good ensure that you do uh you don't hurry and you don't leave behind anything of course the endothelium production should be prioritized even if there is a postoperative rise in inocular pressure because of a whco elastic that's usually short LIF two days 3 days maximum that gets uh absorbed in the eye and uh and hence endothelium prodection is definitely the priority here because that would be to permanent blindness permanent problems right sir one last question from YouTube Sir in fomor glaucoma if you extract the lens will IOP become normal sir so like I show told in my indications of uh traic leomy if one uh the onset of diseases in especially in ftic glomas if the oner of disease is more than 7 days that has been shown in in a few studies that we should combine a traity because even after removing of the lens the and the I is not going to come down so you combine with a tra in in fomori the chances are a little lesser but uh usually these cases because of the pain involved the patient would turn up uh probably on day one or day three maximum because the pain is so much and uh hence usually uh these cases do well only with cataract extraction but uh tramy would be required if there's extensive pass formation that happens uh in fom morphic so you do a good gonioscopy if you are able to do it after decreasing the inocular pressure by manol and diox decreasing the cona and then you do a good gonioscopy see if there's extensive pass formation and uh and the IOP is not coming down with medications then you plan a combined surgery or but in majority of cases removing of the Cataract would be more than enough right sir thank you sir those are the were all the questions that were available thank you very much garvita I would request to give a concluding comment and I think if there are no further questions I think we can call it a day sir thank you Karan uh and thank you so much Amit and garvita for helping moderate the session and a lovely talk by Amit with some very interesting videos I think you've uh covered the topic uh perfectly giving us the entire range of the theoretical considerations and we had an excellent discussion with some very pertinent questions um so like I said initially fortunately the incidence of these events is actually going down we don't see as much uh going back 10 or 15 or even 20 years ago we used to see a lot of these lens induced glomas uh we are seeing them less and less I think part of the reason is that we taking the cataracts out so much earlier that they don't get a chance to get to the point that they will give us these kind of problems um but still occasionally from the Interiors patients will come uh patients will still undergo traumas and will come with either broken nuclei or subluxated nuclei or even dis located nuclei or lenses which are creating these problems very shallow Chambers High hyperopes uh these are the ones one has to be specifically careful about because they uh come with u uh you know um a compromised angle and a compromised anterior chamber and even a little bit of inumin in these patients can precipitate uh U an angle closure uh so I think that's B basically it and um I'll hand you back to thank you it's an honor to have you as a chairperson thank you Dr Kiran and and thank you team my focus for giving me the opportunity thank you and good night thank you and good night thank you very much