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Thank you for your valuable comments. I just would like to clarify the things with regard of partial Fluid/Air exchange t the end of the surgery. The rule “NO TEAR –NO AIR” was probably more popular before MIVS era. We are ending up the case with partial Fluid / Air exchange for better, self sealing closure of the superior 23/25G sclerotomies. This is not used because of retinal tamponade. As we all know BSS leaks much easier than air because of surface tension. Another advantage of Air is that it makes the optics highly myopic and whatever wide angle viewing devise is used, allows better visualization of far periphery during laser retinopexy. The prophylactic laser is quite debatable up today. In our opinion prophylactic Laser doesn’t harm if doesn’t help, since the small retinal holes can be missed during scleral depression regardless of the illumination systems we use. While indenting the sclera we assess the TOP part of indentation much better than the SLOPE part. That’s why prophylactic laser it still stays up to the surgeon’s preference, like in RD surgery some of us likes to use laser just around the break(s), but some all around the periphery including the break(s). Thanks for the nice technique and discussions. respectfully , Nikoloz

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Dear Dr. Amar These are all nice videos shown here. The question is concerning to safety of these procedures. As we all know the risk of iatrogenic retinal breaks with following Retinal Detachment is quite high, when we are dealing with Dropped IOLs and LCs. As I note here in some cases you use pars plana incisions and core vitrectomy with later delivery of dropped pieces in AC. I guess surgery is ended up without peripheral retinal checkup, because of ocular hypotony due to anterior incisions (limbal or clear corneal or SICS incision or whatever). Isn't it better and safer to left posterior segment complications for posterior surgeons ? and once the nucleous is gone down not to chase to it until is performed complete vitrectomy with meticulous assessment of peripheral breaks and +/- laser or cryo retinopexy? what is your opinion regarding that ? Thanking you once again

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I agree with you Dr. Grigori Indeed the risk of RD is very high in these particular cases. because of nucleous chasing. You provide excessive traction on vitreous base while chasing the nucleous. Once it drops , immediate vitrectomy can be is preferred choise in most cases. Ive seen and have created breaks while doing PPV for luxations. Even I don;t see the breaks at the end of complete vitrectomy/lensectomy I always use prophylactic 360 laser retinopexy and partial fluid air exchange in all such cases. IOL you can implant any time during first procedure or later on. The videos are really amazing. Thanks a lot Dr. Amar

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Dear Grigori and Nikoloz, Good points mentioned by you. In cases in which the nucleus has not gone into the vitreous one can bring the nuclear pieces into the AC do an IOL Scaffold after vitrectomy and then emulsify the nucleus. The IOL can be placed one haptic above the iris or both above the iris or over the capsule depending on the case. In cases in which the nucleus has fallen down one can do a thorough vitrectomy. I prefer to use the FAVIT technique to bring the fragment anteriorly. But one can do any technique one is comfortable with. In all cases one can check and should check the peripheral retina. It is not difficult to do that and there should not be any hypotony intraoperatively for that. One trick which would make your life easier in such cases is to use Chandelier illumination as it gives better illumination. If there is no break seen there is no point of doing 360 degrees cryo or laser. Extensive cryo etc is traumatic to the eye and further blind cryo will not help as one may still miss the break. On the issue of fluid -air exchange , simple way to remember is No tear no air. If I dont find a break I would not do fluid -air exchange unless warranted for some other reason. Finally in cases in which there is no capsule and also iris is deficient example an iris coloboma, one can do the Glued IOL scaffold. In this externalize the haptics of the PC IOL and tuck them. Thus one has created an artificial posterior capsule. Now one can do the emulsification of the nucleus. Then the haptics can be glued. Thus, in such a case one is combining the glued IOL technique with the IOL Scaffold technique. Amar Agarwal

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