Anterior Vitrectomy Settings for Cortex Removal

Anterior vitrectomy settings for cortex removal depend on your phaco machine.

stellaris.  at our VA we use the stellaris where the cut on and off is controlled by the footswitch. with the stelarris, if you shift the footpedal to the side the cutter goes on or off (footpedal switches are programmable so your machine may be set differently).   as you push farther into the pedal you get more vacuum. the cut rate is fixed by the panel and is not controlled by the pedal. for the vitreous phase we use a vacuum setting of 150 and a max cut rate of 800. for the cortex phase we use the same vacuum but decrease the cut rate to 200.

infinity.  at our university we use the infinity which has 2 modes:  cut IA (used for vitreous removal) and IA cut (used for cortical removal). with the cut IA mode when you push farther into the pedal you get more vacuum but the cutter is on from the start-- thus called cut IA as the cutter comes on first. with the IA cut mode as you initially push into the pedal you get just the aspiration and then by pushing more into the pedal you eventually get the cutter on also -- thus called IA cut as the IA comes on first. for the vitreous phase we use a vacuum setting of 250 and a max cut rate of 800. for the cortex phase we use the same vacuum but decrease the cut rate to 200.

in general.  when removing cortical material you first make sure the vitreous is beaten back to the level of the posterior capsule. then turn the cutter off in the periphery and grab some anterior cortical material bring to the center and turn the cutter on while aspirating the cortical material. you turn the cutter on after bringing the cortical material into the center as you can never be too sure that you might not get some vitreous coming forward during aspiration and dont want to pull on the vitreous without cutting too. presumably you are less likely to encounter vitreous in the periphery when acquiring the cortex. titrate the bottle height so you are just able to maintain the chamber. make sure the cutter and irrigation are separate with a tight fitting wound (eg make a separate paracentsis for the cutter).

A Message From Divine Mother Saturday, September 12, 2015

My Beloved Children,

I come to you with Confidence, and Light. For I AM a Mother of Confidence! And I have every confidence in you, and all your gifts.

We in the Higher Realms have been watching for some time, assisting as a gift, in your own Ascension.

I was 'Assumed' at one time, and I assure you it wasn't scary or frightening.

It wasn't like the art you see, where I am on a cloud surrounded by a host of my angels!

What is correct is that an overwhelming 'Light Beam' of love energy filled my soul to the very limits that my soul could relax to hold this Divine Love.

I and my Son became One.

One Heart, one soul, one Family.

I and Joseph became One, for my dear husband who had passed in the night of the Illusion, was alive and well in the Higher Dimensions.  I too was filled with both joy and delight for setting eyes on the man who was both my partner and friend while I was incarnate, and helped me with Jesus.

At first glance, Joseph and I became One.

One Heart, one soul, one Family.

Divine Father and I always have been One, only this time, while I had been incarnate, I didn't know it, because of the veil which had covered my eyes and my thoughts and my belief about who I am and what is what.

For I ALWAYS have been close in the Heart with Divine Father. I worship Him. I Love Him like a friend and a partner in my Life.

Little did I realize that I am just as One with Him as I am with Jesus my much beloved Son, and Joseph my adored husband and friend...

Once that veil lifts, there is no doubt of anything or anyone in your mind! In your Heart! In the very fabric of your being--for all that is Love is exactly who you are!!

One Heart!

One Being!

One Family!

So even though you are 'cousins' in the flesh, while you are both incarnate, there might be another relationship from which you are hidden--perhaps brothers and sisters from where we are, in the Higher Realms, where all is eternal bliss!

Some of you might talk with us, myself and all my 'compatriots' (she rubs her son's back and he smiles truly enjoying her presence--ed), such as Carla is doing right now for all of humanity...

For those of you who do receive our 'messages of the heart'--I want you to take that feeling of connection, unconditional Love and Acceptance, and magnify it. (She shows a picture of someone turning a volume dial all the way UP--ed)

That is what you shall feel when all of you Ascend...each one at their own time...like a popcorn kernel.  No one knows exactly when an individual popcorn kernel will pop, although there is a very likely probability when there is a heat source and the oil in which the kernel is immersed is sizzling, is there not?

Once you have experienced the feelings of Ascension, you will feel all the gifts of the Spirit: peace, love, joy and fellowship. You will also experience the gifts of the Heart:  intuition that is working and unhindered by the powers that were, the beings who have been once called Those Who Do Not Have Our Best Interest At Heart.

Look at Carla.

Our Little One, for she is my Daughter of the flesh when I was incarnate--in a manner of speaking--for both her and I were close and technically family (she kisses me and smiles--ed), for Carla it is not enough to simply experience the growth Ascension does bring!  For Carla has to Write!

To Write Write Write!  It also opens and relaxes her, it is like a form of meditation which is her 'calling' as you say while you are on Earth.  As you will see when you click here this is the twenty-ninth message for the world and all of humanity, that Carla has been the scribe for me. And there are eleven powerful messages I that have been given to Carla personally, for her own growth, which I have given permission to share with this group.

Carla is most happy and delighted to do this --what you call 'service'--to us, both because of her Love for myself and Divine Father and all of our Family who is 'in the sky' (she smiles--ed), and because of the feeling that is in her heart when she writes it. It is the vastness like the ocean, spreading out so far and Carla from where she is, is just at the very edge, the 'waves' of it lapping at her feet at the 'shore'...for this comforts her and gives her a sense of accomplishment like there is no other...

It is angelic, what Carla does, to serve me, in my heart, in order to get our message out to you.

She does this without pay, without money, and without sleep, or the family time that could go together with it.

Carla gives from her heart, from her soul, in order to make life better for (extends her arms to show a big area--ed) all of us! Both of us up here as well as where you are (it is not 'down' by any stretch of the imagination, for we are One, although of different vibrational frequencies, she adds).

So you are capable of both giving and receiving of Love with your own gift...your own Purpose.

And when you are doing that which you are sent to do, you shall be overwhelmed--in time--with a sense of well-being, and rest.

It shall be a delight!!!

So, from 'all of us' who are your family where I happen to be at the moment, to 'all of you' who are exactly where you  are, at the right time, at the right place, for the right purpose...our blessings and our prayers for your success in your Life Purpose are assured!!!

We shall be sending them to you today, through the portal of our Hearts, which is never ending and ALWAYS open...no matter where you are. <3

That is my gift to you for this Saturday, September 12, 2015

All my love,

The Mother who is of Love and known for it throughout the Galaxy, who also loves YOUR HEART very much, as if it were my own children, which you most definitely are in Spirit, when it comes to me.

Mother Mary of the Heart and of All Time and All There Is.

Aloha and Mahalos,

Namaste,

Peace,

Reiki Doc

P.S. this message is meant to be shared. Please always include all of the message in its entirety, as well as a link to the original page which is this. Thank you.

Uveitis Glaucoma Hyphema Syndrome (UGH)

Introduction

In 1977 Ellingson described a syndrome that included uveitis, glaucoma, and hyphema in patients with a specific anterior chamber (AC) intraocular lens (IOL) [1].   While initially the syndrome was associated with this particular IOL, it became clear that the syndrome was associated with other AC and later with posterior chamber (PC) IOLs.   The syndrome eventually became known as the UGH (pronounced liked “ug” in ugly) syndrome to emphasize the three most important features of the syndrome. An extension of the syndrome, “UGH plus syndrome” refers to patients that have vitreous hemorrhage in addition to uveitis, glaucoma, and hyphema.  

UGH syndrome is related to uveal tissue coming in contact with an IOL (usually the haptics).  The hyphema or vitreous hemorrhage comes from episodic injury to vessels in the iris, ciliary body or angle. The glaucoma is secondary to the uveitis, treatment of the uveitis, pigment dispersion, hemorrhage, or direct injury to angle structures.

When AC IOLs were commonly placed, UGH syndrome was a common indication for IOL exchange.  As PC IOLs began to dominate our practice, UGH syndrome became less common, but still important. PC IOLs in the sulcus seem to be at most risk for UGH syndrome, especially if they are loose or are single piece acrylic (SPA) IOLs with wide square haptics [2].  Even PC IOLs positioned completely in the capsular bag can cause UGH syndrome if the zonules are loose and the resultant pseudophakodonesis irritates the iris.

UGH syndrome

While technically UGH syndrome includes all three entities (uveitis, glaucoma, and hyphema) it is common to use the term “UGH” even when only one or two of the three are present (for example “the patient had UGH syndrome without hyphema”). An irritating IOL is the essential element now to the diagnosis of UGH. As the IOL is the defining feature of UGH syndrome, it would not be consistent to propose UGH syndrome in a phakic or aphakic patient.

The diagnosis of UGH syndrome is not always simple. The differential diagnosis includes many diverse conditions including TASS, endophthalmitis, idiopathic uveitis, retained lens material, neovascularization Angle or the wound (Swan Syndrome).   Slit lamp examination is the most important tool to establish the diagnosis. Identifying areas of iris injury, typically due to a haptic, through direct or trans-illumination lighting techniques can help make the diagnosis of UGH syndrome. Loose IOLs (pseudophacodonesis) can often be seen moving during the slit lamp examination and may be the critical finding to make the diagnosis, particularly with PC IOLs in the bag. Gonioscopy is important to search for residual lens material and to visualize haptic position especially with AC IOLs. High frequency ultrasound of the anterior segment allows imaging of PC IOLs including haptic position and iris contact.   Ultrasound can also be useful to search for residual lens material behind the iris which can mimic UGH syndrome. Optical coherence tomography (OCT) of the anterior segment can be helpful to image IOL malposition and angle structures, but is less useful for locating structures behind the iris than is ultrasound. 

Anterior Chamber IOLS

The classic UGH syndrome is related to an AC IOL. The AC IOL’s association with UGH syndrome and with pseudophakic bullous keratopathy, clouded the reputation of AC IOLs. However, modern AC IOLs are effective.  Wagoner’s classic paper found no difference in overall complications between AC IOL and sutured posterior chamber IOLs [3].  A too large or too small AC IOL can irritate the iris and lead to UGH syndrome.  The most important issue is proper sizing and placement of the AC IOL. The AC IOLs come in several sizes depending on the manufacturer. In general, you should add 1 mm to the “white to white” measurement of the corneal diameter to establish the optimum length for the AC IOL along a particular axis. Typically a caliper is used to measure the distance from one point of the limbus to another point directly across. The point of the limbus where the cornea just turns “white” is the target for the so called “white to white” measurement. When scarring and pannus is present, this can be a difficult measurement. Some of the devices to measure and calculate the IOL power preoperatively will also acquire the “white to white” measurement for you. An AC IOL which is not long enough will tilt and rotate, which can cause UGH syndrome. An AC IOL which is too long can erode into the angle and cause pain and UGH syndrome. 

Treatment of UGH syndrome associated with AC IOLs depends on the severity of the condition.  Mild uveitis alone, associated with an AC IOL, can be treated with chronic anti-inflammatory therapy. When the AC IOL leads to a fuller spectrum of UGH syndrome, the IOL is typically exchanged for either an aphakic contact lens or a posterior chamber IOL.   Occasionally repair of the iris or reposition of the AC IOL will stabilize the IOL and eliminate the UGH.    Glued IOL or Iris Suturing of a posterior IOL can be effective strategies to replace an IOL with no capsular support.  Another strategy which is difficult in the US at present is placement of an iris clipped IOL to avoid angle and iris posterior leaf contact. 

Sulcus IOL

As AC IOL placement becomes less common, it seems that sulcus based IOLs are the most common cause of UGH syndrome in our current practice. An IOL in the sulcus can shift, rotate and/or tilt and irritate uveal tissue to cause UGH syndrome. The risk for UGH syndrome increases, when the haptic length is too small or when the haptics (or even the optic) have a square edge which can irritate the iris. Chang outlined the issues of placing a sulcus IOL and suggested that very few of the existing PC IOLs are well suited for sulcus placement [2].  The perfect sulcus IOL would have long thin angled haptics and a large optic made of a non-silicone material with a smooth rounded anterior edge.

Single Piece Acrylic (SPA) IOLs can cause of UGH if one or both of the haptics are (inadvertently) placed in the sulcus. The large square haptics of the SPA can irritate the posterior leaf of the iris causing inflammation, pigment disruption, and either vitreous or anterior chamber hemorrhage Gonioscopy can be useful in determining if one of the haptics is anterior to the capsule. Transillumination of the iris can be very useful to find areas where the square haptic has dispersed pigment off of the posterior iris.  Here is a case where a patient presented with a convincing story for amaurosis fugax  only to discover the patient had UGH plus syndrome with vitreous hemorrhage from a misplaced SPA haptic that episodically injured iris blood vessels.

The treatment of UGH syndrome associated with sulcus based PC IOL depends on the severity and the amount of residual capsule. If a patient has only mild inflammation, you could consider chronic anti-inflammatory treatment and observation. If the patient has only ocular hypertension from pigment dispersion, you could consider topical aqueous suppression and observation. However, when UGH syndrome is more severe and particularly when it includes vitreous hemorrhage, an IOL exchange or repositioning should be considered.   Rarely the IOL can be repositioned by capsular remnants into a more stable position.  One approach is to replace the posterior IOL with and AC IOL to eliminate any IOL contact with the posterior leaf of the iris.   If the IOL is poorly suited for the sulcus (eg too small or a SPA IOL) then it could be exchanged for another sulcus IOL.  If one of the SPA haptics is out of the bag, then it can be repositioned into the bag or simply amputated. If the anterior segment is so large that no lens is really adequate for the sulcus, you could consider suturing a 3-piece IOL to the iris, suturing to the sclera, or tucking the haptics into glued scleral pockets. Sometimes the best approach is to simply remove the IOL and use aphakic spectacles or contact lenses.

PC IOL in the bag

A more recent cause of UGH syndrome comes when an IOL completely encased in the capsular bag irritates the iris or ciliary body.  The typical cause is weakened zonules (often from pseudoexfoliation) that allows pseudophacodonesis which can irritate uveal tissue.  As our patients are living longer following surgery, subluxed IOL/bag complexes are becoming more common.

The treatment for this condition depends on the severity of UGH syndrome. If the inflammation is mild and the patient older or frail, it might be best to simply treat with anti-inflammatory medicine and observe. However in most cases, if the IOL is loose enough to cause UGH syndrome, it is probably at risk for complete luxation with time.

One important examination technique is to place the patient back into a supine position and see if the IOL, although loose, remains horizontal. If the IOL goes vertical when the patient is lying back, it may make more sense to have a vitreoretinal surgeon remove the IOL as it will most likely be entangled in vitreous. However if the IOL remains horizontal, then an anterior approach is often successful. The typical surgical strategy is to either suture the existing IOL or exchange it for another.

If the IOL is a SPA and not suited for the sulcus, then you have 2 options. One option is to simply remove the IOL/bag complex and replace a sutured PC IOL, glued PC IOL, AC IOL, or aphakic contact lens. The other option is to suture the entire complex to the sclera as we have described [4] also here.  If the IOL is a 3-piece IOL, you may be able to remove the bag (with vitrectomy or other instruments) and use the existing IOL. The existing IOL could be sutured to the iris, sutured to the sclera, or tucked into scleral glued pockets. Often a Soemmering’s ring with residual lens material is present and care must be taken to not allow this material to fall posteriorly. 

Summary

UGH and UGH plus syndrome continues to be an important condition to discover and treat. Even though we have shifted from using AC to PC IOLs, we still see the syndrome. The most common cause now is probably from sulcus placed IOLs (either on purpose or inadvertently) but even IOLs placed completely in the bag can cause UGH if loose. If the symptoms are mild, medical treatment and observation is possible, but typically the IOL is secured or exchanged to eliminate the uveal irritation leading to the syndrome.

References

1. Ellingson FT. Complications with the Choyce Mark VIII Anterior Chamber Lens Implant. Journal - American Intra-Ocular Implant Society. 1977; 3(3-4):199-201

2. Chang DF, Masket S, Miller KM, Braga-Mele R, Little BC, Mamalis N, Oetting TA, Packer M; ASCRS Cataract Clinical Committee. Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture. J Cataract Refract Surg. 2009 Aug;35(8):1445-58. doi: 10.1016/j.jcrs.2009.04.027. PubMed PMID: 19631134

3. Wagoner MD, Cox TA, Ariyasu RG, Jacobs DS, Karp CL; American Academy of Ophthalmology. Intraocular lens implantation in the absence of capsular support: a report by the American Academy of Ophthalmology. Ophthalmology 2003 Apr;110(4):840-59

4. Oetting TA(1), Tsui JY, Szeto AT. Sliding internal knot technique for late in-the-bag intraocular lens decentration. J Cataract Refract Surg. 2011 May;37(5):810-3.

A Message To The Lightworkers From Archangel Metatron and His Twin

Greetings!
It is now the Time to invite you all to the Healing Temple of Zadkiel. It is a beautiful space to meditate, rest, heal, receive guidance, reflect, and even take time to review your Life so far. Ground yourself, allow your focus to be in the Present, and just think, "I would like to visit Zadkiel's Temple of Healing". A lake will appear and Your Guardian Angel will escort you across it. Cleanse yourself with the water as you "Wade" across. You will then reach the entrance of the temple, where St. Germain will shower you with the Violet Flame and lead you into the Foyer. Here, you can choose to take your Guardian Angel with you, or choose to go on alone. (Remember, your Guardian Angel is just one thought away, should you desire their presence again.) To the Right, are a set of stairs that lead to Metatron's (my) "office". It is open for readings, life reviews, and receiving further guidance. To the Left, are a set of stairs leading to healing rooms. You may call upon your Team, Angels, Star Beings, Ascended Masters, Animals, Fae (faeries--ed), and any other Entity that you would wish to assist in your healing for that visit. If you choose to go here, really allow yourself to be released and open to your healing. To the Centre, the area is an open meditation and resting space. Remember to give gratitude to all who assist you in any way, when you are ready to depart. As you walk out, Archangel Zadkiel will be waiting with a gift for you. The Gift can be ANYTHING; a phrase, a message, a song, an attunement, energetic jewelry, a realization. The list is infinite. Sometimes, it takes time to realize the meaning and significance of the Gift bestowed upon you. It took my Twin almost a year to realize the significance of the Key that was gifted to her on her very first visit. I hope that you all will visit often, and use the space well, as you see fit. Love, Light, and Blessings, Archangel Metatron

(This was shared to me with Archangel Lauren, who is the incarnation of Archangel Ariel)

The Disruptive Technology in the Healthcare Industry

The healthcare industry is at a crossroads. Everyone agrees. At conference this week, an expert who is an MD MBA anesthesiologist foretold of a future with bundled payments, and the Perioperative Surgical Home model to bring cost down and quality up. This expands the scope of the anesthesiologist to include patient care outside of the operative suite.

The prospect of physicians and hospitals competing for their compensation 'piece of the pie' is depressing...

And when he brought up a new concept to me of the Disruptive Technology, something inside clicked.

His example was a graph of the camera industry, with growth and technological advanced going up steady as predicted over time.

In the middle was a black line that curved straight up, far surpassing the rest of the old technology, the 'status quo'.

It was the camera on the cell phone technology.

As the quality kept increasing in the cell phone, sales and interest in conventional cameras is down.

Who even buys a conventional camera any more?

Energy Healing is a disruptive technology.

Even in another speaker's talk, about Enhanced Recovery from Surgery (ERAS), where they shave inpatient days off the hospital stay by managing all aspects of patient care, including early bowel recovery of motility to help patients eat...amongst other things--the anesthesiologist speaker brought up ACUPUNCTURE as a way to 'enhance healing' overall.  He showed the acupuncture point for nausea, and spoke about the Chi...

Reiki, Acupuncture, and other methods of working with the life force energy ARE the Disruptive Technology because they can't even be measured by current methods.

Here is a start:  https://youtu.be/wz-vG0HG7yU

The work of Masaru Emoto is another, in measuring very high energy changes in the shape of water crystals, depending on the music or words to which it is exposed.

With his Hado Water, Dr. Emoto, who is not a physician and insisted that his clients continue standard medical care while he treated them--Dr. Emoto found twenty four energy parameters he could measure on the individual at a certain point in time. He would create healing HADO water with the exact opposite spectrum of energy to 'cancel out' the disease and bring a new steady state balance to the energy. As the energy would shift over three weeks or so, he would re-assess the measurement, and give new HADO water. (Treatment would be a cap full of the treated water in a glass of water once or twice a day).

In this manner he healed many, most remarkably a congenital heart disease--cardiomyopathy--in  a one year old girl who was given a poor prognosis to live. She completely recovered and has grown up, and is leading a normal life.

All the way around, Reiki and similar techniques will enhance healing and recovery, using the body's own self-healing methods. It will lower cost. It will shorten hospital stay.

And in some instances, it is possible, that like Hawayo Takata herself, who leaped off the operating table and at the very last second cancelled her gallbladder surgery, only to find Chijuro Hayashi, and Reiki, with after several weeks of treatments, experienced total cure.

In the hands of conventional healers, Reiki, and other forms of working with energy like it--enhance care.

In the hands of healers from all areas of Energy Medicine, patients experience comfort, caring, and balance which is fundamental to healing itself.  Patients are empowered to experience their energy, to heal imbalance (Dis-ease, as some call it), and to work through their blockage.

Ultimately, healing will take place on the energy imbalance long before it manifests itself in the physical plane--the tissues and cells of the human body.

As more and more people discover connection, relief, and healing from their illness through enhanced healthcare--conventional healers who are double-trained such as myself--and through energy healers such as aromatherapy, Qi Gong, hypnosis, biofeedback, acupuncture, herbal medicine, Reiki, light therapy, healing with sound, crystals, Quantum healing, Thetha Healing, and the like...we all win.

It doesn't have to be the dire limited resources doom and gloom that one speaker predicts; with the emergence of advanced healing technology, through energy healing techniques such as Reiki which cannot be seen or measured, but can be felt and experienced by the patient...it is only a short time before it will be like the cameras on the cell phones everybody depends on every day--and we will wonder, how did we ever live without it?


Aloha and Mahalos,
Namste,
Peace,

Reiki Doc