And she had the Manzo Ladies Club. So there was a raid at the bakery one day right there, the Rio, the Miigra King. And Contreras got all the Villanas out of the church. They surrounded all the Border Patrol vans. They couldn't drive them away. And like, that was the spirit of Manzo. And then these two kids came. Sobel Garcia and Margarita Bernal. And they're like in law school. Like, we're just rocking the world having fun. And these sisters come and they're going to avoid you. They want to volunteer. Well, of course, we couldn't. Now it would happen. It was a really, really special moment. I think it was in this historian thing, too. It was a special moment in history. And it was a really special moment that brought together just all sorts of people with all sorts of gifts that came together with me. Ricardo, Raquel all came and had a wife. You did that. I used to have the greatest fight with John. They were great. It was a spot for magic. I was just curious about maybe even just taking the first part in terms of this play we just saw. What kind of lessons did you learn? Oh, what kind of lessons did you learn? The question was, what kind of lessons did you learn as you were thrust into this work? Well, I think the most important thing that we learned, we called it civil initiative, to distinguish it from civil disobedience. All of us thought we were doing civil, this lasting sense of Dr. King. And I quoted King and Gandhi and the Bible to establish the principle of civil disobedience under these certain states. And then I get a call in my office. And this guy says, my name's Ira Gullivan. I'm a human rights attorney from New York. And you've got to stop talking about civil disobedience. You're not doing civil disobedience. And I said, yeah, right. I'm just waiting for the indictments to come down because they told us that's what refugees back to El Salvador and Guatemala. So he said, stop talking about civil disobedience. And I said, well, I think I understand. But what do we call it? And he said, I don't know. Make it up. And so of course I went to Corbett and told him about the phone call. And Jim took it from there. He developed the whole concept of civil initiative to distinguish it from civil disobedience. And that was the ground we walked on for the rest of the sanctuary movement. Would anyone else like to chime in on that? We weren't just left just like we bonded out people who were in the death squad. We represented the national chest, everybody, everybody. Because we understood that we didn't live their life experience, that we could never comprehend. Part of this, I don't recall that it was written out, but was that charge you let out to the Corralon 115 degrees in El Centro that King put in the motel. OK, so Father Ricardo's wanting me to tell stories. I won't tell too many, but I will tell one little story. In those days, there were five detention facilities in the whole United States. It's hard to believe, five. And so the one that took care of our area was in El Centro, California. And they had huge, I don't know, 25 foot chain link fences. They had cots outside. In the summertime it would get to be your feet would stick in the asphalt. It was just horrific. So when John was doing his best work raising bond money, we'd bond out like 75 or 100 people at a time. And so then we'd throw a picket line around the facility with the same guys that just bonded out. Yeah. And that's how we kept everybody's anymore, everybody's spirits up, because we said, we're coming for you. This week we got these guys, and next week we're coming for you. And what was really, really beautiful was that we took those people to a Catholic church, a black Catholic church in Watts. And their families came and met them there and reunited with them there and then went off across America. So all the little pieces of our mosaic that are so powerful contributed to that magic. So these nuns, I will tell you one little story. Because this one's too good to pass up. So they didn't have internet, and they couldn't communicate and all that, INS, in those days. And so we kept bonding out with people all over the place, and they would have call-ups. So they'd say, you have to be in the Manhattan Federal Courthouse in two weeks from when you were out of El Centro. So there's this church in Brooklyn called the Church of the Transfiguration Catholic Church. And in those days, the nuns did their whole thing. They had their whole, their uniforms, right? And so I told them, you've got to find these 18 boys, because I'm coming. See, one thing we did is I held all the notices of appearance for everybody who was in detention so they couldn't have multiple hearings so I could control the calendar. And that kind of backfired after a while, because when they got bonded out, then there'd be hearings in states all over the place so I had to run around for a while. So I told these nuns, gather up these guys, and I'll fly in, and we'll go down, and we'll present them, and then I'm going to have to go somewhere else. They couldn't find them. So they brought 18 other guys. And you know, these women are like, you're not going to say that they're running a game. I mean, you're just not going to say it. And they didn't have fingerprints. They didn't have photographs. They didn't have the internet. They didn't have anything, file by file. Pose so-and-so, presente, you know. Juan so-and-so, presente, you know. And these nuns are just real serious. They did stuff like that, you know. And it worked. And then came the amnesty of 1986, and everybody legalized, and it was a gift. And you know this guy, we have a clinic at Pueblo High School. In case anybody wants to volunteer, Thursday nights at 5.30, keep Tucson together. And so this guy comes in, and he says, no te recuerlas en mí? You know, you don't remember me? No. He said, you got me out of El Centro, and guess what? What? My daughter's a lawyer, and she works for the Florence Project. And over the years, we've heard all sorts of stuff like that that comes back. And I just share that, because when we do this kind of stuff, you know, maybe we get somebody out of detention. Maybe we get some green cards. But we really, really don't know what we do. The stuff that we do is incredibly powerful. I just wanted to mention something about these first-person stories, that are three-story telling, is essential. I did want to ask John's play ends when the church, this first play in the sequence, and it's a discussion in the play about how we're going to get this word of us a little history of your interactions with newspapers, or TV, or things, how fast did that happen? I don't think you can manage that. But a couple of significant things did happen. One was, I had this, he's been alluded to earlier. I had this seminary intern who was on my staff, who was supposed to assist me in the ministry of the church. And so we had to sit down and write a job description for the seminary about what he was supposed to accomplish while he was here for that year. And at the end, I said to him, Tim, this is his name, Tim Nott. And I just happened off the top of my head, say, Tim, one thing that you might just add to that job description, if you have any time, we have been doing all of this crazy stuff and making it up as we go along. And we've never had a time to sit down and really think about what it is we're doing and why we're doing it and what we need to do in the play Vizel is going to do the keynotes with media and of sanctuary. I get a call in my office from 60 Minutes, who say to us, we think it's an interesting story about priests and nuns smuggling refugees across the border out there in the wilds of Arizona.  Can we do that? And so we all sat down. And it was a long conversation because how do you take the care for a refugee family for that additional risk of taking 60 minutes? And so what happened was we did the crossing down in Douglas. Then there wasn't a wall. There was just a raggedy old fence. And the cemetery in Douglas was right next to the fence. And so we'd dress up people as mortars with flowers and cross them through the pop them through. And they'd spend some time in this. And 60 Minutes filmed it. And when they showed a couple of episodes of Jim and Pat which were very powerful, then a movement started. And we had never imagined that we were doing anything but self-defense before we got indicted. That was everything up to that moment. And then when 60 Minutes really did those couple of episodes of Jim and Pat and the crossing, I get calls from all over the country, what's this sanctuary idea and how do we do it and that's where the whole rest of it. I've got a question for Pat. Sanctuary really started when Corbett came to me and said, my wife says she's gonna divorce me if we don't get 17 refugees out of our trailer. And can we bring them to the church and keep them there? And that was really the beginning of sanctuary and I don't know, Pat, was that a true story or was Jim just? Well, it was funny some as I recall. And the other thing, no, I didn't threaten to divorce him but I did threaten other other things which I won't mention here. But I just thought, well, there's some more but it was like at their house asking. If anybody comes up, I do have a question. There's a microphone right here by where Mark is. If somebody has a question, please come up, please. Great. Actually, because I belong to a religious order and they kind of leave us alone. At that time our order had a Western province. Among the men's Catholic religious orders there were the Mary Knolls in New York, headquartered in New York and our Oakland province that publicly said we do sanctuary. The problem with the hierarchy with the bishops is that two bishops at that time, national names, one of them was also still a licensed civil lawyer and they sent out this letter all over. Don't get into this. The ones that did across the country beautifully were the most. Steve, that's a really important question because I was fortunate to, I had just finished up eight years on the National Policy Council of the Presbyterian Church. So I had personal relationships with the leadership of the denomination. So when we started this, well, even before we started this, Margo would come to the office as you could see and say I need $30,000 more for the action in El Centro or we need, yeah, tomorrow or it's on my credit card. It was yesterday or whatever it was. And so I was able to just make those contacts easily. Because of those personal relationships. And then the denomination was great in terms of support. Many of our volunteers later on after, in the next version, the next iteration. The guy who was the head of the office of young adult volunteers for the Presbyterian Church, I mean, literally gave me a blank check. He said, you tell me how many young adults you need to come volunteer on the border and we'll make it happen. And there was a whole community of folks that grew out of that blank check. So I was very lucky, but most other denominations struggled with the idea of sanctuary for some time. But eventually there was pretty broad unanimity among all of the denominations. If it wasn't sanctioned by the bishops, there were convents and monasteries and churches and parishes and bishops and archbishops that said to hell with the national conference, we need to do this. And so it really was a grassroots rising and movement that eventually the denominations and the hierarchies had to recognize, I guess. I have a question about, because it sounds like when you, and just from what you've shared with me when I interviewed you all, that churches, there was a network of churches throughout the country that were doing this kind of work. And can you talk about how that network has moved through the years and if it's still happening right now and how that functions? Well, as you all know, this idea of sanctuary is currently a much broader and a much deeper movement than we ever envisioned or experienced in the 1980s. The big difference now is that it's primarily a secular movement by cities and states and counties and colleges and universities to protect the community of whatever that secular institution is. But there are also thousands of churches and synagogues and mosques that have declared that they will be a sanctuary. In the 1980s, the leadership was by faith communities that were declaring sanctuary and formed the network that was faith-based. And cities and the state of New Mexico as secular institutions did so in support of those faith communities. But the leadership was clearly from the refugees and the faith communities that were a part of the sanctuary movement in the 80s. Now it's the opposite side of that coin. It's cities and states and colleges and universities that are primarily the leadership in the sanctuary movement now. And I keep telling them secular humanists that they stole our idea. But it's fine, we're delighted they stole it. But as you know, sessions is already in the Justice Department attacking those secular institutions. And colleges and universities are every bit as vulnerable as cities and counties and states. So we'll have to, so far the courts have upheld their right to do that. But if that fails in the courts, then faith communities are gonna be the strategy of next resort. And we're gonna have to be there and we're gonna have to step up in ways we never imagined in the 80s. So it's a different context that we're dealing with now but it's a much broader and much deeper movement than we ever envisioned in the 1980s. I think what John said, and it's, there's a different kind of sanctuary in some churches. It's not, some cities around the country do public sanctuary. I believe that's very, very dangerous. I think especially in Tucson, that's where the birthplace sanctuary. I feel like that's putting a target on a church in this political moment. But what we see is we see many churches willing to say that I wanna take you, your family, into our family of faith. And our embracing people and our protecting people. And we see that, we see that in many, many, many different kinds of configurations. And so it's interesting that we see the secular institutions being very challenging but we see the faith-based community also very engaged but not feeling a need to get into that public kind of fight. So it's a real interesting policy shift, I think. But the bottom line is a whole lot of folks are being helped and protected. I think we also have to understand the different conditions that we're living in. The militarization that we all predicted was coming before us that we first experienced is on us. Okay, and so what we have is now a police state. You know, and so that was different from that time. We could cross people over, we could take people up to Los Angeles, whatever, because literally like John was saying, the fence was just a rickety wire line. It's different today. It's different in the courts. It's different in the detention camps. It's different on the line. I mean, when you consider that the border patrol is now up to 20,000 agents and ICE is rolling around everywhere, so the pressure on those even doing political asylum going into the courts is horrific. We are living in different conditions. That's something to that. Those of you who don't know the fence in those days, you could go into the, right into Narada Sonora, downtown, sit in a restaurant called El Vida and watch just as the sun went down, men, women and children, they would come and go, but they would cross the street in the restaurant, go down a tiny gully from here to the bench and then up a little hill and they're there for sanctuary, one of the ways of moving people, they would stay at a church in Narada, I said, a parish. And then they'd move toward the east hill. The cook in one of the parishes helped on this. Sunday morning, because of large holes in the cyclone type fence, they would carry a Bible or a missile, a prayer book, go through there and you can see Sacred Heart Church on this side of the tower and walk as if they're going to church. And there the next day, you know, they'd be the arrangement to move, check out the roads, roadblock, move from there. They're going through that fence and they would sometimes seal it with new wire. And the next day, chop, chop, somebody in sanctuary, I've really forgotten who it is now actually. Nobody had the big clippers like this with the nose on it, you know, we're not brought to Newark. I have a rebuttal to John, which is kind of my job. But a point of clarification, I think when we look at sanctuary today, I think the real leadership isn't necessarily coming from colleges and universities, but from communities organizing directly effective communities who are using this idea of expanding sanctuary because like Lupe said, it's different conditions. And so they're saying to their cities, they're saying to people like Rahm Emanuel, you can't say we're a sanctuary city and then hire all these more police officers that just become part of a criminalizing community of color, which ended up being this pipeline to the tension. So I think we're seeing a lot of leadership from directly effective people who are helping us deepen and expand sanctuary. And but I still think that there is a strong faith role in all of it. There's 50 people publicly in sanctuary across the nation and they're having successes in their cases amazingly because every case is so different and the situation is just a different situation. But I still think we're seeing a strong faith. Yes, if I can say so myself. So I think that I have one last question for the panelists, unless there's a burning question out there in the audience because I think it's time that we wrap up a little bit. So my last question is, would any of you like to talk about the work that you're doing now, how you built on the roots of the 1980s and then continue the work? We'll just pass it down. Okay, all right. Well, the work that grew out of the sanctuary movement in the 80s is really the work of Samaritans and no more deaths in humane borders out in the desert. And the practice of civil initiative, asserting our right to provide humanitarian aid and lifesaving aid out there in the desert and document the human rights abuses of the border patrol out there in the desert and in the detention systems here and then lawyers suing them to stop the abuses. And I'm talking about physical abuse and verbal abuse and withholding food and water and medical care from desperately poor and wounded people from the desert. So that work is directly related to the sanctuary movement and I think it's the really important, one of the really important aspects of what we learned in the 19 years. And I'm just amazed because I sort of continue to do today what I was doing then and you know, that's very, very sad. It's very sad. I always thought it would just be, it would be different but okay, so it's not, so we have to keep doing it. We have a clinic, it's sponsored by No More Deaths and my office, the Pima County Public Defender and it meets at Pueblo High School every Thursday at 5.30 and it meets in this church the first and third Saturday from two to five. We have Peter, Pat, all sorts of people are volunteer. We file asylums for people. We file cancellations for people. We do bond work. We reunite families and get them out of custody as soon as we can. We have volunteer lawyers in court every day in three cities. I mean, we're on it, you know, and it's horrific and we lose every single one and we don't care because all we care about is getting them out. Peter cares, he does asylum. He has this, he does mushrooms or something. He has this dream, you know, that we're gonna win an asylum case and you know, we didn't win him during the Central American Wars but then everybody got legalization so in the end, hey, we won. And it's the same deal, you know. Whenever you do this kind of legal stuff in a little box you have to put it into the context of the political moment. And so I really don't care if we win. What I care about is no families get separated. That's the only thing I care about because this will pass. This moment can't be sustained, no. It can't be sustained just like the 80s couldn't be sustained and when it passes we wanna have as many families together as humanly possible and that's really what we're doing in. You know, we need a lot of help. I mean, so, and it doesn't matter what you can give an hour or whatever you can give. Let me tell you, we have a job for you. I've been concentrating for 15 years about with healthcare but I don't wanna take time to go into that because before this group breaks up there's something else I wanna add. As century evolves, so many people starting with Jim Corbett that were at the heart of it have died. Rabbi Weisenbaum, for example. Gary McCoy and sisters that, I can't, I could sit here, I think I'd shoot out a lot of names but in my life, because of studies and all I've been exposed to a lot of, I think, great minds but honestly, and I've felt this for decades, the greatest mind I've known in my life is Jim Corbett that's what I believe and his writings, you know, we have the presence of things going on, drama, studies, presentations and all but those writings of Jim, I think, his writing is so important urgently that that remains available. To me he was really the soul of the movement. Somebody else who believes that. Ricardo, I'll tell you though, there's an expression that might be worse and even more. One of the things also out of the sanctuary is like to get back to what has emerged from the Monzo experience and that it went through a transformation and from there we went to organizing under La Mesía, organizing projects and after that Pueblo por la Paz, working with the Chiapas, uprising fighting against NAFTA, Derechos Humanos, Alianza Indígenas y Fronteras so that the work, the political work and advocacy and education of community continues in face of this horrendous movement from many different directions and that as Jim taught us that the basis of all of this is hope, that is in the love that we have. There is one final ending of a Jim's story. He and I would travel to California often taking refugees and one night he said to me, I'm tired. He said, so we're gonna stop, tell people we're gonna stop for a couple of hours. I said fine, he just drives into the desert. The next thing I see is he walks down and he clears a little path among these cactus and he just falls asleep on the desert floor. That was Jim, that was Jim, I mean, you know, and but anyway, let's remember that we have to be hopeful and we have to maintain our passion. I think that's a great note to end on. So thank you very much, HowlRound folks for tuning in and all of you for coming out so we can all take a photo.


Hello everyone, good morning, how are you? Happy new year, happy holidays. I can't believe that I'm picking up a camera and talking to you again. It's been like three weeks I think of much needed rest. I am back, I am so happy to be here with you. Today I just really wanna do like a reset vlog and just really get back into my routine, sort of ease back into my work month, year, et cetera.  This portion of the video is sponsored by Neutrogena, so let's go ahead in there and we'll continue to chat.  The face wash that I have been using and really, really loving lately is the Neutrogena Hydro Boost Gel Cleanser. I have the fragrance free version and this is phenomenal if you have acne prone skin, sensitive skin. I have always sort of had like problematic skin and this is great because it's gentle but it's effective. Like it makes your face feel like it's clean but it doesn't feel super stripped down and dry. 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So thanks to New Jersey Uniform for sponsoring that portion of my video. Now let's jump back into the vlog, my regular content. I'm gonna do my skincare and then we're gonna sit down and chat and we're gonna catch up all the life updates, all the things. Okay, apologies if this is a little wobbly. We moved some things around in my office. I'll show you like updates and stuff in the next video but I've got my coffee nice and hot. I just heated it up and I put my makeup out here and we're just gonna get ready and chat. Also, you're probably gonna hear rain sounds outside. I actually have a couple of buckets or like little bowls and things out there because I'm collecting rain water to water my plants here in a little bit because it has been raining so much in LA and I could not be happier about it. I love the rain. I'm an Arizona girl so like it never really rained and I mean, I did live in Tennessee for like 17 years of my life and it rained a lot but I've been back in Arizona for the last like six or seven years or something like that. And so it just like never rains and I'm so happy every time it does. But yeah, hi. Wow, it's really, it's been a minute hasn't it? It's been a few weeks since we caught up. I'm trying to think of like what even I've been up to. Like, I don't know. I guess where we left off was that I was leaving like the next day. I think the last vlogmas that I filmed, like the following day, which was the 23rd, we were leaving for Arizona and we went back to Arizona for Christmas. It was really lovely. We actually ended up renting a van so that Layla would be more comfortable. We found a pet sitter to come take care of Moo but Layla just requires like a little bit more, just a little bit more. She's our special girl, we love her. I think it was like accidental one time that we rented a car and they gave us a van and it worked out so well for Layla because it's really low to the ground. So she doesn't have to like jump up or anything like that. And also you can like fold the seats down and she can just spread out. So we ended up putting her bed in the back of the van and like loading up all of our presents and heading back to Arizona. It was really nice. Spent Christmas Eve and Christmas day with our families. It was great. It was just so nice to have time staying at my mom's again and seeing Drew's family. We also ended up staying for my birthday, which was December 27th. So we had a day where we spent time with our best friends in Arizona. They're literally like our family at this point. We've all been friends for well over a decade and it's just amazing. Love them to death. That was wonderful. And they like decorated and Drew had set the whole thing up so that like when I got to their house like the decorations were already set up for my birthday and it was really cute. Like he sent the decorations to their house and then they set them up. And it was just, I felt so special and so loved. He ordered a cake. We had pizza. It was great. It was like a really wholesome day. And then the following day, which was my actual birthday we spent the day with Drew's family, his nieces. We took them thrifting. Like it was a great time. So loved that. And then a couple of days later we drove back to LA, returned the rental car and then just kind of like hibernated. Honestly, we didn't do anything for New Year's like anything for New Year's. We literally like went to bed before midnight. I don't think I've ever done that before. I literally fell asleep before midnight. So I was just like, I think that happens maybe when you get older. And we were like, should we be going out and should we be doing something? And like one of my friends was like, do you want to come over? We were just like, no, not really. Like honestly just really wanted to go to bed. And so we did. And I'm just trying to put less of like a emphasis on New Year stuff. Cause I think we just put a lot of pressure on ourselves and it ends up just becoming like kind of stressful. So yeah, just went to bed at 1130, felt great about it. Couldn't be happier. And that's pretty much it. That's what I've been up to. It's been great. So today pretty much what's on the agenda is catching up. Like I said, sort of easing back into work. I'm going to film stuff for my main channel. I'm going to, I've been like answering emails, doing tax prep stuff. We have some laundry to put away. We have some dishes to put away.  I'm going to finish my coffee, maybe make some breakfast. It's about that time. I'm getting kind of hungry. It's around 930 now. And then film up my main channel video and then we'll continue this day. But cheers, welcome back. I'm so happy you're here. Got myself all ready. I actually did, I've been doing like a little bit more of a soft eyeliner lately. And I've been doing eyeshadow. I don't know, it's like kind of hard to tell in this lighting, but I've been doing like eyeshadow instead of like my liquid liner. And I decided to do, I don't know, I've been seeing a lot of people do this sort of like hair front pieces tucked in the front. That made no sense. But you know what I'm trying to say. So I'm attempting that. Anyways, we're going to film a main channel video for the first time since literally, I honestly don't know. Maybe late November of 2020, like very first week of December. So it's been like a full month since I've filmed a main channel video. And I'm actually really excited about it. We are going to tackle this bad boy today. By the time this video goes up, that main channel video will probably already be up. But yeah, let's clean, clean out the closet. Time to film. Okay, it's many hours later. It like literally looks like it's seven PM outside. It's three 28 and it's getting dark, like dark outside. I think it's also just the rain in combination with winter time. So that's depressing. I'm literally wearing a jacket. I had to put a jacket on over my shirt because I took Leila outside hour and a half ago probably for her like midday post lunch walk and poor thing. I was wearing a raincoat so that I could have like the hood all pulled up. So literally all that was like was showing was my face. And then I was holding an umbrella over her and like she went to the bathroom, everything was fine.  I want to take a bath so bad, so I might. But first what I'm going to do is I am going to take some of the rain water that I got from this rain today and water our plants with it. I feel like that's such a, you know, you're getting old when thing to do. But I don't know, like plants, they want fresh water too. So that's what we're gonna do. Okay, we're gonna move a few of these to the bathroom. I don't have that much.  So I'll collect more of that water tomorrow. Cause it's supposed to rain all day tomorrow but in the meantime, we'll just use what we have. All right, and here it is. This is literally full of rain water. I think there's like a little bit of dirt at the bottom but that's all right. And she is full. Let me tell ya. So we'll see how far we can get with this. Oh my God. It's so heavy. Look at that. I got to sound like my dad. Drink up babies. Aw, they get rain too. I'm gonna give them a little, a little shower. How cute. Why is this so sweet to me? There you go. Hope you enjoy. Okay, you can probably hear the rain hitting. I did end up going out there and I put the watering can back outside so it could refill and then emptied the bowl into another bowl. And now you can probably hear the water filling up the bowl again. But I'm trying to save all that rain water I can. So basically I filmed my main channel video. I ended up sending what in the heck? I don't know what that is, tape. I ended up sending the footage that I just filmed over to an editor that I used from time to time and really need to start utilizing more this year because that's sort of like one of the things I wanted to talk about is just like doing a reset for 2023 and sort of like what I'm looking for, what I wanna do, boundaries I wanna implement, et cetera. And I think it's good for everyone to do this in their life in general, not just like if you do social media for a living but just like at all. I really, really need to start accepting help this year. I am not good at that. That's like number one on my list is to start kind of reaching out if I need help. Both mentally and also just like work-wise, I run two YouTube channels by myself, literally by myself. And I have tried various techniques of like hiring editors or hiring people and I'm always like, I can just do it myself. And sure I could, but at my own expense, you know, and I end up being extremely stressed and it's just like not worth it in the end. So that is definitely something that I would like to work on for this year is being more intentional about having free time. I would like to have more of a work-life balance. Actually, I already put it up so I can't grab it but my friend Laura came over last week and we made vision boards. We spent the night making vision boards and it was so much fun I have decided that my word of 2023 is balance. That is the word that I want to guide me through this year and just really be the thing where I close the chapter on 2023 and be like, yeah, that was the year I finally accomplished that. I think I'm like getting better year by year but this needs to be the year where something gives because I can't take on that workload alone anymore. And in just a lot of ways, like I want to find balance with like how I eat, how I move my body. There's just, I could say so many things but I just feel like I'm an extremely all or nothing person in a lot of areas of my life and touching on the body thing for a second. I feel like when it comes to trying to put nourishing foods into my body and try to implement an exercise routine, I can be very all or nothing. I can fall into like diet culture or into extremes and I'm really trying to strike that balance this year and just be like, yes, I wanna move my body because it feels good physically and because it's good for my health overall but also because it's good for my mental health and because I want to and because it gives me endorphins and you know, all these different things. So that's kind of one of the big things that I really want to work on is balance and then yeah, just like work-life balance, making sure I'm really good at unplugging in the evenings and the weekends. I mean, occasionally I'll vlog on the weekend or if I have a deadline or something but I'm pretty good about that but I just need to have like a separation. Like I need to have much more of a separation going on and more of a balance, like I said. I would be so curious to know if you all have, you don't have to have a word for the year by the way. I just noticed some people doing it and I thought about it and that was kind of what I came up with. So be really curious to hear if you have a word of the year and sort of what that is for you and your thought process behind it and all that stuff, because I find it so fascinating. I really do feel like with my vlog channel, particularly with this channel, I have struggled because on my main channel, I really kind of keep that focused on like fashion, secondhand fashion, body image, sort of confidence, body neutrality, all that kind of stuff. And so when someone leaves a comment that's maybe negative on that channel, it kind of rolls off my back.  Doesn't bother me.  So my life is my content. So sometimes when I get unsavory comments from people, it can tend to feel like a personal attack and it happens to everyone who makes videos on this platform, but I'm just gonna be a lot more strict in blocking people and possibly even look into someone who can like monitor my comments for me to like help my mental health so that I'm able to continue doing these videos because I really, really enjoy it.   And I love that I can go look back and watch, you know, when Drew and I went to Japan in 2018 or see both of my trips to England or, you know, just like, I love it. It brings me great, great joy, but I need to find balance with that as well because especially towards the end of the year, last year, it started weighing on me mentally and just letting other people's opinions, you know, get into my head and whatnot. And I have to say that 99% of comments are so wonderful and amazing and I'm so appreciative. Like I'm just so thankful that I get to do this for my job and that these are my things that I want to change in 2023, you know? But yeah, as far as like some boundaries, we're gonna do a little boundary town hall. I'm not gonna like useless criticism that's like very nitpicky and like kind of rancid in energy, if you will. That's just gonna get blocked. Like I don't care to see that. No one does, honestly. And it really is a reflection, like I fully realize that. It's not necessarily as much about me as it is about the person who's leaving the comment. But yeah, just a reminder to like be nice to people on the internet in everyday life. And yeah, I don't know about that, that's boring stuff. But yeah, will be, you know, protecting my peace this year, very, very much so. Also, I talked about this in my vlogmas Q&A where someone said like what was one thing that you did this year that you were really proud of? And I said, like I'm learning to advocate for myself, say no, et cetera. I wanna get better at that. Just because I'm doing that doesn't mean it's easy. I did finally text our upstairs neighbor, Drew and I text our upstairs neighbor and we're just like, hey, sorry, don't know if you know that we can hear, but like, would you mind? Like we were really, really nice about it. It was just like, we would like to kindly ask if you could just take notice of like, you know, laundry at three in the morning and blah, blah, blah. And his response, like literally I built it up for weeks. I was like, no, I can't say anything. I can't say anything. Like I don't wanna be a difficult neighbor. What if this, what if that? And like wasn't advocating for myself or speaking up. And then finally we decided that we were gonna do it. And he wrote back and was so nice. And he was just like, I'm so sorry. I had no idea that you guys could hear that. Like I will absolutely do that. Happy New Year, have a great night. Like literally the nicest guy ever. And so it's just like a lot of times things like that work out in your favor. And you kind of like, I don't know, I was scared to speak up and take up space and scared to like say something. And I was in that situation before with, you know, previous neighbors. So things are great now, no complaints. And yeah, I just wanna be better about that and not have it be such an anxiety inducing thing to be like, hey, this is what I need or hey, can you please do this or that or whatever. So yeah, and I have, I've actually, do we wanna talk about this? I have actually started being honest when I reply to people in text messages when I can't or don't wanna hang out. So like before I used to, I don't wanna say lie but I would give this like long explanation instead of just being like, nah, I'm not feeling it tonight or whatever because I am such a deep people pleaser that like even just the thought of saying no to something could make me unlikable or something. So anyways, I've started just being like, nah, I'm in bed for the night or I'm on the couch in my pajamas or like I need a couple more days to hibernate or I'm not feeling so hot or whatever. It's been really great and it's a good sort of practice for me because it's not like I'm trying to hide the reason that I don't wanna go or I can't make it or whatever. It's because I don't wanna like disappoint the person or make them think I don't wanna hang out with them or whatever. And so I've just been trying to get better about that instead of doing the like, oh yeah, I'm busy this week but check in with me next week. I'm just like, no, I'm not gonna be able to make it. You know that type of thing. So I want to continue to get better at that and just get more comfortable saying no and advocating for myself. So yeah. Anyways, that's gonna do it for the rest of this vlog. I just kind of wanted to ease back into the year and let you know where I'm at mentally. I'm really, really excited to hang out with you this year and take you along on the, you know, small parts of my life that I share on the internet. It certainly means a lot to me that you're here. So thank you so much. I'm gonna go sit on the couch in my comfy blanket and enjoy this rainy evening and I will see you very soon in the next vlog. Bye.


If you think Descartes standard is a good standard, well, let's use it, right? Let's use the standard of knowledge So right now you think you are sitting in your room or or library Copasha, whatever, right?  So the matrix some of you Probably a good number of you since the movies darn your 20 years old at this point You know the matrix is this you know hypothetical scenario is the setting for a movie, right? And in the matrix every last human being Is plugged into a computer, right?   And so your consciousness is living out Is living out life in a computer simulation? And the computer solution it since it's feeding the sensory information. That's what you think exists is You know that's what you think is is going on, right? You think you're sitting in the in the world in a physical world watching a computer But if you're in the matrix, right you're plugged in and just in a scenario just in a simulation. You're not actually in this world There are other of these what they're called Skeptical hypotheses, right and what a skeptical hypothesis is constructing some scenario that's You know would mean that your beliefs are radically false, but are but it's indiscernible from what's actually happening So here's another one inception, right? This is another good one inception You think you're watching me on a video, but really it's the inception team that's going in and planting an idea in your head You're dreaming all of this And you know you can't tell the difference between the dream and what's a really heavy and this is what happens in dreams But you don't or at least it's highly rare usually without training You know that just sit there. Oh, yeah, this is a dream.  You'd believe it You'd believe it The Truman show is another fun one another these a lot of these side fun Fun scenarios where you're not actually you're massively deluded and not actually living on the road So the Truman show of a baby assault to a TV network and raised on a TV studio Which looks like a neighborhood and this guy just lives out his life and people in cameras always point out I mean he never knows right? He thinks he's living in a neighborhood.  But really they're working for the TV studio and they're paid to act this way around you So you think that you are Living out in this real well nobody here nobody watching the video thinks that they're actually watching actually in the matrix or in the Truman show Whatever so you have some reason for that you have some reason to believe that you're not in one of these skeptical hypotheses What's that reason? Yeah, what's that reason? Go right it down


Well, good afternoon and thank you so much for coming and I apologize. There was a small Misunderstanding about this lecture this morning, but I'm so happy that this could be organized for noon and thank you again for coming So Lisa I said does not really require an introduction, but I'll do it in any way So she's a very well-known Interior segment surgeon and she's now retired from her private practice But she's still very active in research and giving ideas And we are very happy that she's an adjunct faculty here at the moron So she's going to present something that's very interesting and important for us because she came This weekend to work with us in the lab this afternoon in a related subject So this is going to be a perfect background for that. Thank you very much Thank you so much. It's really a pleasure to be here Thank you so much to Elaine and others for making this come to fruition today It's been such a pleasure to be associated with you the last Important labs that Liliana and I did together became the nightest of my talks on complication management and avoidance and I'm looking forward to talking to you about a new subject here very which I think is very very important and to me Will be the future of medicine. I have disclosures. I am a consultant to menosis, which will be Important to this talk. The smart vision lab is irrelevant to the talk I'm going to try to convince you to abandon the bag I'll introduce my new surgical technique of scleral bicop capsuleotomy capture that I'm calling SBCC and To my knowledge, no one has ever recommended this as any routine procedure And I'll explain how I came to it and why I'm working to see if this is the right way to go Keep in mind being a great surgeon isn't just acquiring skills and having good hands But it's also having good judgment to know when not to jump on a bandwagon and neither to eat its dust now as you know when we operate there's a breakdown of the blood aqueous barrier and Healing response that involves the lens epithelial cells with proliferation Which is what we're mainly concerned with because we just take for granted the transformation proliferation of course leads to elchonics pearls and the typical PCO that we use Yag laser spore And then there can be fibroblasts and myoblasts that occur that actually lead to the Opacities and rigidities and then wrinkles and contraction that we see that we have often thought there's not much to do about And we're used to seeing these things over time and of course This is the phymosis that often leads to bag lens subluxation and needs early treatment and By and large it's thought that this is a normal perfect eye This eye is 2020 and although maybe they could have blown away that flight floater for them Whenever we do a Yag laser for secondary cataract, which as you know would be a hundred percent in children if we didn't do enter a vitrectomy and vitrector rexis But good 20 to 30 percent arguably probably more if people live long enough and as we do earlier surgery We'll find this out so many people undergo PCO and need a Yag laser Which is thought to be kind of very benign because it's quick and easy and painless But on the other hand we do always or virtually always break the anterior hyloid Which is actually our protection between the posterior segment and the anterior segment Which protects the macula and the retina Now I'm going to try to convince you regardless of whether you're interested in these future concepts to master the posterior capsular rexis and There are various reasons to do that in order to reduce PCO obviously But to convert an unstable accidental tear into a continuous tear that allows us to continue to bag and plant It's a very important skill Because a tear well that isn't finishing outside of where it began with any force can tear out To allow the immediate visual rehabilitation in unpolishable plaques You know we have we usually wait till the blood retinal barrier is restored It's six weeks to three months usually patients have to wait three months since that's the global period for payment before going ahead with the Yag laser and and they have to suffer a decreased vision in the interim and When general anesthesia is required for people who can't sit for a Yag mentally handicapped people or physically Distorted bodies that won't fit into the Yag laser and then I think it's an important technique Which people don't keep in mind nearly enough for optic capture for subluxated lenses We have a membrane or posterior capsule or an anterior capsule that can be converted in some way to a large enough continuous opening to be able to Optic capture then we don't need to suture to the iris which usually Leads to some low-grade chronic inflammation, and we don't have to do a major vitrectomy in order to scleral fixate Now here's an example of a patient a case where And I turn them all down. So sorry about that. I'll just have to do it again I saved it and everything but at any rate I'm happy to give this To you these videos. I can also substitute with the voiceover or if you'd like them later And it's a routine case I always support the anterior chamber when removing the INA and I saw a clear area here And I'm exploring it by putting OVD through that apparent hole Which obviously is a hole because you can see the viscote just fall down into the vitreous if you had 3d You know through the microscope it'd be very obvious. So I'm quickly Putting more OVD into the sulcus and I'm taking a little edge. Sometimes you need to use a Avanus to make an edge although that's rare And I'm going to convert this small tear as round as it looks it will not hold up to forces to a true continuous curvilinear capsular exis and We can do that nicely If there's already vitreous prolapse through there Then we have to deal with that vitreous first preferably with irrigation Anterior and a pars planar approach to bring the vitreous home and not enlarge the opening and there are many videos on that It's a course that I teach at many many of the meetings and actually abe viscavita has one of the nicest Videos through a SCRS showing how important it is to consider learning to do a proper pars planar approach At any rate here. We are it's not really rocket science though You see that the forces have to be more centripetal Because the anterior capsule is about 14 to 16 microns thick and the posterior capsule is in the range of five microns of Thickness and of course behind that is the anterior hyloid like the yolk of a like the membrane on a yolk from egg Very fragile and there is a space delimited by Weigert's ligament The posterior zonials all around called burger space between the anterior hyloid and the posterior capsule And so you can see we were able to save the day and place our one-piece Toric lens in the bag and rotate it properly And then you just have to be sure that you don't allow the chamber to collapse and that you keep it Down as a nice barrier to keep the hyloid from breaking when you finish Which is why I use the acetyl choline that you might have seen bring the people down now here's an example of obviously very mature cataract and Using tri-pan we've made a nice anterior capsular rexus have another whole lecture. I'd love to talk to you sometime for an hour about my Circumferential cross-action shop disassembly technique for very brunessant lenses such as this is that that tan Gooey bruness and variety, but they get black as well and sometimes the tan ones are even more leathery and more difficult And we won't concentrate on that But what you'll see here is that once I've completed the Faco and of course there's even a calcific Rim at the periphery and once we've completed that nicely I'm using my terry squeegee and you can see that this plaque Absolutely will not polish off and I feel that it's the bag is very It was very extended extensible So I've added a CTR to make it a little more taut in order to make it practical to be able to do the posterior capsular rexus and I'm putting OVD into the sulcus just to flatten the anterior and posterior Leaves I left this bubble in because you don't want to bubble in your you know in your Syringe when you do this ideally and the idea is to take a 30 gauge Bevel up needle not a cystatome which could poke down enough in order to break the hyaloid But rather lift it off make a little tear and then put the OVD through to define burger space And in this case because of the fibrosis we go two directions And I decide not to opt to capture which I'll talk about later in this case because of the fibrosis and not being absolutely certain of the perfect Continuousness of this particular rexus in this case But a patient like this instead of seeing 2050 or 2060 for three months will be 2020 on day one and So we've saved them the early YAG laser capsulotomy and all of the potential consequences of that Which as you know include particularly in my hopes the increased risk of retinal terror detachment and possibly CME and in diabetic Retinopathy we allow all of our compounds to move forward and back and in glaucoma There's some good evidence that it's the vitriol elements that Are toxic to the Trabeculum that increases the pressure sometimes not just as a pressure spike, but actually a long term after YAG laser and glaucoma patients So we've managed to complete this and then we're going to blow up the spare tire Basically, which is the bag because now we have a posterior rexus in an anterior rexus blow up the Spare tire the sulcus with OVD so that we can implant a lens and we could opt to capture a one-piece into burger space That's posterior optic capture, but three pieces are better when we intend to optic capture And certainly critical if we're going to put it in the sulcus and optic capture through the anterior capsule Since we never want a one-piece lens in the sulcus And you can see that this ends up very lovely. We've supported the chamber and this patient can be 2020 the next day Now there's lots of literature about posterior optic capture and It goes back to probably 1996 when gimbal first described this Certainly passing on a menopachy or two of the biggest proponents of posterior capsular rexus with what he calls Manipachi calls posterior button-holing and Perhaps we would add what would you say to Groot and noi hand perhaps to this list, but these are the big relevant articles and Basically the question is why should we do that? What if we just do a posterior capsular rexus? Will it always avoid visual axis obscuration? Absolutely not in children. We still have a very high percentage because of the vitreous being Pretty solid and the anterior high-loid gives a scaffolding for it to grow over and adults it even maybe two to seven percent of PCO despite posterior capsule capsular rexus itself This is a very nice picture that actually shows Burger space between the anterior high-loid and the posterior capsule. It's menopachy's picture and We have an earlier history a different way of doing this but Dr. Stegman in South Africa who mainly does a lot of pediatric trauma has just done slit capsulatomies and then optic captured But that means you've got to be really careful not to place any forces on that that might cause it to wrap around And we don't really consider that sufficiently stable though He has quite a bit of literature showing that five to twelve years out It's both stable and has a clear visual axis still I think we should strive for continuous rexus if we're looking to have all surgeons of all capacities and abilities to do a technique Now here is a case that I've done and You'll suffer through for four minutes Pediatric case always I don't like to use a tri-pan blue for the anterior capsule in pediatric cases Although it does make it less elastic and a little easier to deal with it does make a permanent molecular change And who knows that what that'll mean 50 60 years from now So I think it's quite possible to do a decent capsular rexus anterior capsular rexus without and I'll take time to measure Because anytime I'm going to deal with the posterior capsule It's really important that you have a well-sized and reasonably centered anterior capsulatomy since that's our backdoor option Should we have a complication in doing our posterior capsule or exis we can always Sulk us implant an anterior optic capture and So that's why I wouldn't attempt a posterior rexus in most cases if I don't have an appropriate Anterior capsule rexus the posterior capsule rexus can be quite forgiving in terms of its size and its And its Centration because when you place a lens in the bag or the sulcus for that matter an optic capture posteriorly into burger space It's not the capsular rexus that's centering the lens It's the haptics that are sitting in the bag or the sulcus that are centering that lens And so it can be fairly forgiving, but you can't make it too small or it's possible to break it So here and I'm a little slow dr. Menopachi feels that it's a hundred and fifty case learning curve to be really Facilate doing a posterior capsular rexus. I made it up to 80 I did all of our pediatric cataracts, which weren't that many my husband's pediatric Ophthalmologist and we thought we were the ideal team where I worked as his technician He actually you know followed the patient decided when and if they needed surgery and then followed them immediately afterwards and Even the newer pediatric ophthalmologist who joined our group Asked me to do anyone that needed an implant because these eyes are so quiet as opposed to Doing an anterior of a track to me or leaving them a faking, you know the recent infant a fakia study involve posterior vitreorexus and an anterior of a track to me capsule rexus and and anterior of a track to me and with or without an implant and They found that they had similar ultimate visual outcomes But more interventions with the ones within plants at early ages because of fibrosis and sublexation and inflammation and problems But all pediatric cataracts Have something like or congenital cataracts have something like a 15 to 20 percent risk of consecutive open-angle glaucoma Which is the truly once we get over amblyopia the truly vision-threatening problem and Stegman at least believes as do I that it's because we do something routinely in children That's considered a complication in adults and that is an anterior vitrectomy and that allowing those vitreal elements Access to the immature trabeculum makes for that high rate of glaucoma now some of these eyes may have just immature trabeculum I'm not including Anterior segment dysmorphic angles. I'm talking about normal-looking eyes with just congenital cataracts. So Posture optic capture and here what you're seeing is that I'm pushing the the poles of the optic having completed the capsule Arexus filling burger space through the small opening and I'm pushing on the poles 90 degrees apart 90 degrees away from the optic haptic junction in order to capture the optic into burger space below the posterior capsule And you'll see in a moment. I I'm doing lots of irrigation so that when I come out it won't collapse and just any by the way any OVD visco elastic that's left behind the implant with an open posterior capsule will not cause Capsular distention syndrome nor will it cause a pressure rise because it doesn't have access if you're hermetically Sealing it into the posterior segment. It doesn't have access to the trabeculum So of course you're still going to remove any OVD and I wanted to stop it here So you could really see just a little bit different than that So you can really see the capture and you can see here the cat eye appearance of the posterior capsulotomy from haptic optic junction to optic junction and then the intact capsule arexus which is undisturbed and Round here that you can just barely see and that's what we're looking for for posterior optic buttonhole And when we do this we find that the eyes are exceedingly quiet that the visual axis remains clear throughout life actually Now here is a beautiful Video from Maria Jose Tassiana in Brussels and it's intraoperative OCT so you're going to watch as she Violates the posterior capsule here. Here's the anterior hyloid and you'll watch as she goes and makes that that stab opening and pulls it around to make a little a little curvilinear tag and then takes the OVD and Puts it through the opening to push back and you see how burgers came I mean how anterior hyloid came forward But now she's got this little this little cannula and you see how she's pushing it backwards out of the way So that you end up with a fairly and you can barely see the hyloid here But you end up pushing the hyloid back with your OVD making a nice bubble of OVD and you have a fairly Convex posterior capsule and now she's going to grab the capsule and she's going to make this continuous circular curvilinear posterior capsular rexus and You can watch that happen on OCT and She is probably one of the world's masters at this Especially in pediatric cases and her goal is to make the anterior and the posterior Capsular rexus both perfectly centered perfectly sized and symmetric because she has a lens called the bag in the in the lens Which is not FDA approved and something that I found very fascinating that we'll see a little bit later in this presentation as well so here is a menopachies picture of a button-hold Lens in an adult and you can see there's just a little bit of opacity of the anterior capsule, but no real fibrosis He is extremely meticulous in scraping and polishing lens epithelial cells off the anterior capsule flap as well as doing the posterior capsule OREXUS and you can see how clear and beautiful that looks well Is it safe to do this menopachies added to the literature immeasurably and I actually went to study with him in order to learn this technique some years ago and he has Paradise studies of with and without capsular rexus with and without optic capture and so on and in fact There's no increase in CME. There's no increase in intraocular pressure and no increase in RD In fact, I'm thinking that when we get to enough numbers, we're going to see a much lower rate of eye of retinal detachment because we're Stabilizing the vitreous base and preserving the hyaloid for life Hmm now here's an example of one that went awry in one of my early series and I was hoping Sorry, I was hoping to To use the same lens that he uses which was a Hoya lens and I was told that that would be the case And perhaps I was just a little chicken on the size of my posterior capsular rexus at any rate It turned out to be rather a stiff lens He chooses a lens that has a very 90-degree optic haptic junction because that's the only place that our material our lens material is going to touch lens epithelial cells Which is what creates the transformation of these cells to fibroblasts and and myoblasts and so here I'm trying to optic capture and I realize at some point that as I'm trying to get the Proximal pole captured that I have broken the posterior capsule here And so I no longer have a continuous capsule you'll see after a bit here And so thinking quickly all I had to do was forward capture forward of the anterior capsular rexus Because I don't have a stable lens if it's in the bag But I don't have an intact and reliable posterior capsule and there's always the chance of subluxation later And so here I'm sort of digging underneath cantilevering over the edge of the anterior rexus in order to bring that Pull up out of the bag and then bringing the other pole up out of the bag into onto the Surface of the anterior capsule rexus so that the haptics are still in the bag But now the optic is reverse captured forward of the anterior capsule rexus And this is a technique by the way They can be used if say you put in a one-piece lens in the bag and then suddenly on removing OVD or something you break the capsule You can reverse optic capture rather than have to exchange a lens in the middle of things And I've added tree essence just to be sure that no vitreous prolapse And that's always a good idea whenever you're at risk for that and there was none in this patient did just as Beautifully as far as I could tell as if I had actually managed the procedure of putting it posterior So we have two back door outs in case of complication, and that's one of the beauties of this technique now Pediatric buttonhole avoids vitrectomy and I have six years experience as I said with small numbers But I got abevisavita who sees tons of pediatric cataracts to please please try the buttonhole technique because he had been involved in the a fakia pediatric a fakia study and And finally because of his particularly because he had ephemto laser and I'll show you that he decided to do a series and when I saw Him last as a personal communication in the last askers He had done 50 and he said they were the best eyes that he had seen in all the series that he had done Now let's get to that bag in the lens And so the typical thing of course is that we put our lens in the bag right with an anterior capsule or exosin and intact Posterior capsule but really testing you on designed a lens that doesn't actually have haptics the haptic is simply a collar button So there's two like parts of your haptic is kind of a base for the optic with a collar button around so that the two edges of the Capsula rex's the anterior and posterior fit right into that collar button So that's why she calls it the bag in the bag in the lens rather than the lens in the bag And she has some startlingly wonderful outcomes The only thing is it must be perfectly centered because centration depends entirely not on the zonules or on the bag itself But on the centration of the two capsula rex's and it must be perfectly centered and they're not FDA approved But look at her data between 1999 and 2006 and this hasn't caught on like wildfire. I think mainly because it's so technically difficult to do She did 300 eyes and they included babies and children and uveitis and diabetes and all the worst cases and her PCC closure rate 0% not only that but on pathology you can see the Cells these are the lens epithelial cells on the capsule with a regular lens in the bag and look at what the capsule looks like For the bag in the lens. It's devoid of these transformed fibrotic cells And look at these post-op results now Lilliana has seen some of these eyes postoperatively and seen that they do often have a summering's ring that remains questured out in the equator and really kind of shocked Maria Jose because she wasn't seeing them when you dilate the pupil and But the point is that they're sequestered And don't have that and that antigenic material which normally leaches out of our normal in the bag technique You know to cause inflammation. It doesn't happen because it's sequestered and it's That was another piece of my thought about SBCC, which we'll get to in a moment Now remember we think it's normal and great when people see 2020 and they've got you know There's white Fibrotic thing and then this little hole that we've made for you know with the Yag laser and they can see out 2020 but that's not physiologic. This is physiologic. Okay, this is what what our eyes are meant to look like and The sooner we recognize that I think the better. Well in my opinion neither the bag in the lens nor the posterioptic buttonhole takes care of every problem and I bet anyone here who's clinically involved has seen bad lens Subluxations which is becoming more and more of an epidemic and we know one thing is in common of all bad lens Subluxations although most have pseudo exfoliation some have either surgical trauma or true trauma Non-iatrogenic they all have one thing in common then that is an intact anterior Capsula rexus and theoretically some degree of Phymosis And before of course the Capsula rexus, which was one of the best things in sliced bread for making Faco practical We had tons of lens Subluxations and not very many people who have pseudo exfoliation and don't have cataract surgery come in with spontaneous Subluxations of their cataracts. That's rare as hands teeth right but bad lens subluxation isn't and so I came to our realization about eight years ago that There was a better way to do this and rather than put the lens in the bag and I guess I was a little ahead of myself here, of course We don't really know if something's going to work for eight to ten years Which is the average time from surgery to bad lens subluxation? I don't have great data though. I did large numbers of cases I was strictly a clinic clinician and didn't have good data and no randomized trials But my experience told me that the right thing to do is to put it in the sulcus So let me show you this video. Are you seeing them all enough with the light the way it is everything? Okay with that okay, so you can see the pincushion effect of this very Loose bag trying to make the hole in the anterior capsule to initiate the capsular rexis And we finally get that done you can use crossed blades if necessary in order to get it done if it's really really tough but it wasn't necessary and We really don't have any good system to judge you know to really quantify the amount of zonular laxity in cases I don't know of any article that's really done well with that There was one fairly recently that with a proposal, but there was a lot of criticism about it And so you just have your own feel for this right and if you've got a pincushion effect And you can see the bag kind of move with me a little as I get around and probably the reason we're seeing so many Bad lens subluxations now as we're getting so good at surgery that despite very diffuse and significant zonular laxity We're managing to get these cases done in an uncomplicated manner and here I'm making no big movements to try to Maneuver the lens you know to free the lens or spin it and I'm doing Multidirectional hydro dissection another thing that I recommend in these loose zonule cases and of course in the Miyake lab You know they've shown us all the terrible things we can do to zonules from the back You know particularly with rotation and so on and your lab is just the greatest for for adding to the literature on these subjects so here I'm going to go ahead and do my regular fecal and even though it hasn't spun I always do I haven't sculpted in a millimeter in years a Vertical chop, which is really very friendly. You can see the bag waft all around in the back there And that was kind of a posterior polar as well You can see the attachments around that area, but it did polish off nicely And I always support the chamber coming in or out with irrigation with irrigation through the side port a kind of a poor Man's chamber maintainer because I don't want chambers to collapse and here you can see I'm very gently Delivering the cortex. You don't want to just strip the cortex out or you'll see equator And if at any point I can't get it free and I start to see the equator then I'll back off and I'll put capsular retention capsular expansion rings in order to perform the The removal of the cortex, but here I am successful and little by little and I think it's really important also in these cases that you Start subincisionally and then be very Methodical about every clock hour. I like to go one direction then come back subincisional and go the other supporting the chamber And now I'm going to put a CTR And we want to just gently lay that in to the periphery and feel the proprioception of not putting any pressure on that That's a whole nother lecture or we could put something through the The leading islet to not put pressure now I'm checking that I have a small enough anterior capsule arexus because I'm intentionally now that I put a CTR in the bag Going to put a three-piece lens in the sulcus and optic capture Through the anterior capsule arexus and my theory Was and is that basically the lens is supporting the bag the bag is supporting the lens and more importantly the optic Is a stent to prevent pymosis of the anterior capsule? so that Here you'll see and it's a little more difficult in these cases because you can't just push sometimes it even needs a Bi-manual technique because these zonules are so lax, you know That it can be a little difficult and you want to get you don't want to leave a lot of OVD in the bag because you have an Intact posterior here, but I've successfully optic captured and I'll show you the pictures afterwards and what they typically look like After I show you in this video. I will come out as an hour. That's okay with everybody I assume I'll be showing you a more a zonular loss case here in this particular video and And we come out with a result that is incredibly stable I think if you're good if you're in the clinical field you recognize and here's of course one with missing zonules So in this case, we're definitely going to use After completing that we're going to place Capsule suspension hooks. I don't like to use the Iris hooks because they're not properly polished and they put all the pressure in one place These are the Yamaguchi ones which are kind of like a hammerhead shark and here you can see I've taken any pressure off by having a Suture that I can pull so I can pull it around the equator without any pressure on the equator and here we This is now another case a post vitrectomy case and it just shows the optic capture anteriorly so much better I voice this over a little more contemporaneously, but you can see how easily that is so here's the fellow I have a patient with the standard bag in the lens with the CTR And we have to go do anterior capsule relaxing incisions With the add laser in order to hopefully prevent Phymosis and who know and here is what the eye looks like After optic capture the fellow I with that that very one with those loose sonials that you saw and this is what We're trying to prevent and you'll be amazed if you do this procedure That you'll see no pseudo fecogenesis in the eye where you succeed and put the lens in the bag and have a nice CTR You know if they're loose you're going to see this little bit of shimmer And if it's in the sulcus optic captured solid absolutely solid with no Phymosis So I did that for a number of years and was very happy with that And so here you can see the Phymosis of the fellow I and maybe not I should move this over so you can see the Whole thing, but basically you can see how beautiful this looks When it's optic captured now because of that experience and another experience this was a paintball injury case From long ago, and I'm just going to speed it up a tiny bit because I take forever getting the lens in because I'm very cautious This was a paintball injury with an irido dialysis and a traumatic iridoplegia and actually had an open posterior capsule from the trauma And after we got everything cleaned up I decided in putting this implant in that I could use that Fibrotic posterior capsular opening that was there from the trauma as well as my perfect anterior Capsula rexes and in this case I decided I wasn't so comfortable just leaving it in the bag Because of the fact that there was was some zonular compromise, and I wasn't going to sew the bag to the wall of the eye And so I thought that if I Capture both through the anterior Capsula rexes and through that posterior opening That this would lead to a nice stable implant, and you'll see that in fact it does and I followed this patient for this is probably 10 years ago And he did very very well You'll see Just speed up through here just a little bit, but basically We've got the whole thing in now, and we're going to in the sulcus, and we're going to optic capture both through the posterior Fibrotic opening as well as the anterior capsule and I won't bore you with every little manure. I suppose Well then again, maybe I will At any rate you can see that it takes a little bit of force in this case because it wasn't an ideal poster opening But you can count on the fact and this is a very good teaching video because of the fact that when you have Fibrotic capsule from old openings you can count on them being very very strong And you can use them for optic capture when you have subluxated lenses rather than have to so The wall of the eye or do large of atrectomies So that's how I managed this case and between thinking about Stopping bagel and subluxations stopping having to do enter of atrectomies in children Stopping needing to rupture the enter hyaloid in routine cases 20 to 30 percent of the time with secondary cataract I came up with the concept of a routine procedure that would address all of these issues and Basically, we have a five millimeter anterior capsular rexis. We remove the bag contents as usual We may or may not need to vacuum or polish the anterior capsules And that remains to be seen in some of the research. We'll be doing Menopati doesn't think so with this technique I've asked him and then we have our posterior capsule rexis with the intact hyaloid because of forming burger space sulcus implantation then of a three-piece lens and after we sulcus implant then we optic capture through both the anterior and the posterior rexis Now I don't think anyone has ever suggested that that is my unique idea and they for routine procedure And the concept is that we both stent the anterior capsule from the point of view of phymosis And we prevent PCO in every case and we sequester like the bag in the lens all lens Epithelial cells from touching the optic except right at the haptic optic junctions minutely and we sequester all the antigenic material and I Suspect that in addition and this is not my case because I came up with this just after I retired actually from patient care, but my friend Kathleen McCabe did this and This was actually her first PCCC So it's a little bit small that she had made and she's putting the lens in the in the sulcus and you can see our optic capture And I think that an extra bonus of all of this is going to be That there's just a chance that we might see accommodation if we're sulcus implanted and We have a unit which still keeps all of its zonular attachments together Including the posterior zonules and we have a capsule that does not become fibrotic or ever need to be lasered Might that not move with the right lens design and that's what I'll be working on in the future here also with Dan Goldberg who if you haven't read his his studies of Expanding Helmholtz's theory of accommodation you really should he has probably the seminal article in JCRS on that So here she has rather handily in her first case of PCCC By by optic captured and this patient was a macular degeneration patient that she chose for her first patient You know, I'm in just a dry AMD. So anyway, he's doing great, you know, but nothing to write home about more Amazing to me. I gave this lecture as the wolf lecture at University of Iowa about four months ago and Tom Odding decided he had a patient who was a monocular eight-year-old JRA patient who had had all kinds of problems with all sorts of Phymosis and inflammation after her first on uneventful cataract surgery in her first eye And he decided to use my bi capsulatomy technique sulcus bi capsulatomy and at four months to six months now I'm not sure about the six-month follow-up because she's lost in retina land according to her him however He said it was a perfectly clear opening and he has made two more attempts But the problem is that it's rather technically challenging and there are very few people who want to do a manual posterior Capsula rexis and so the learning curve and how to make this accessible to the average anterior segment surgeon is Where I'm at right now and why we're here in the lab that we're going to do with monosis today And I want to explain that a little bit. So I think I'm pretty much on time here So to take a breath then one of the possibilities is to use the femto laser and I I actually had some experience with Flax or however, you want to call it these days Before retiring because I saw Burkart Dick make a posterior Capsula rexis in a child off label Of course fooling the machine as to what all the gates and parameters were and that's what I wanted to do but unfortunately the FDA Decided to change their language of art so that all of the femto lasers are labeled as contraindicated under age 22 try to get that through an IRB yeah, and Also in court would be rather untenable even though there's no evidence that it's bad There's just no indication and they've decided to use the word contraindicated for that and My OR wouldn't let me put my surgery center didn't want me to put it in the OR because of the Logistics of using you know the ORs the two hours that we had which is required if you're going to sterile redock under general anesthesia And use this technique, but it's interesting that without going back to optic capture in adults He in his first series was able to see in 68 percent of people right after a routine flax when redocking He could actually see the distinct posterior capsule in the anterior hyeloid and he was able to do a posterior Capsillotomy with the femto laser and 68 percent of patients without rupturing the hyeloid and with a perfect opening And it's interesting that that flap Whizzened up out of the visual axis completely where you couldn't see it by day one post-op and every one of those patients He said now here is Abbe Vesaveta making with the lens X Burkhart was working with the catalyst and this is the lens X And I was on the surgeons advisory committee for catalyst, but I'm no longer obviously it's a mo And you can see that he's made a perfect posterior capsule arexus right here Which he chose to make smaller than I would But anyhow here's the anterior and the posterior capsule and that's all he sent me But it does it is quite possible to do it now There are economic barriers to doing this routinely for everybody right with a femto laser and only 68 percent could see that without And if you want to post her optic capture then you have to undock and then go back in the eye and optic capture Which you'd have to do in children to do this and it's doable I thought perhaps we could have centers of excellence Pediatric ophthalmologist could be credentialed to do this procedure and you know all the kids Stuff would be at least kids would be done there and that But it's really a premium surgery to never ever need to have a YAG laser again for adults You know to just get your quick femto done, you know afterwards but For the all those reasons, it's not practical here comes the reason for our lab and The menosis company has something called the Zepto perfect precision Capsulotomy maker which has a soft clear suction cup with a nitinol tubing inside of it and It can fit through a 2.2 incision because of this rod that makes it go flat and then open up again inside the Eye and they're in 510 K For ancheria capsulotomy and I went to them and said look we got to study this for posterior Capsulotomy and the way it works is without a thermal effect it because it sucks onto the capsule and makes the capsule kind of Kind of curl up around it when this proprietary DC current is applied It explodes the water molecules in the membrane that causes this simultaneous perfect continuous Capsulotomy and it turns out that it's extremely strong In paired eye cadaver studies, they found interest oops. I'll go back to that second. They found interestingly that Femto had the same strength as Manual don't forget these cadaver eyes don't move which is probably with you know The slight movements that we have with the even if it's a second to do a femto capsulotomy You know, it's not as strong and so many of the articles that we've seen and the The this capsulotomy was significantly stronger than either manual or femto Probably because the edge curls over and this is our ex vivo rabbit lab in California that I did with menosis This is me doing the surgery and you can see we are just applying the suction and then the Then you can see this perfect capsule of the anterior capsular flap This is of course open sky and an ex vivo rabbit and you can see how it hyper stains And that's really because on SEM you can see the edge just kind of curl over so that you're actually got a double edge That is continuous And that's why it hyper stains like that and is stronger than any other Method and here in this ex vivo eye. It was so lax and loose It was really hard to make a tear in the posterior capsule Of course in the human you saw the posterior capsule didn't move when I did that But it was a challenge just to get a little hole in that posterior capsule and then here I am putting OVD and nobody really knew till now even is there a burger space and a rabbit or what it's like We're going to find out a lot more at 2 o'clock today because we're going to be working to try to use this posterior To make a posterior capsulotomy and look at the pathology of it With rabbits that will be sacrificed right after the study. So here The anterior capsule is done. I've made the hole in the posterior capsule. I've Inflated burger space with OVD and now I'm putting the Device into the capsule and of course it's a tad big for this little rabbit eye, but it's working and And I let it go Round and then we're going to apply this suction like we did before and this is the anterior capsule right over here And what we ended up doing was actually getting an almost perfect capsular posterior capsular rexis Which you'll see here in a moment Probably because of the angle sub and you know where where I was used to being subincisional even though I was open sky I might have had a slight angle. So we have a nice PCCC.  Okay that we did manage to capture it So that's the first time anyone ever tried that for further investigation today. We'll be headed to try to Elucidate how we can do this some more so that we can put something that they're saying might be a hundred dollars a case And keep in mind that if we have to capture we're saving Socialized medicine tons of money for Yag lasers. I mean millions billions of dollars And then I hope to do a subsequent live rabbit study where I compare the standard pediatric case With enter of a trectomy to standard buttonhole to my concept of SBCCC and I want to see what happens to fibrosis Which is a good animal model for that though, of course We can only infer what might happen as far as bag lens subluxation and we can't study accommodation in this model So disadvantages there's a learning curve manual femto laser Zepto There's something out there called a capsule laser that's being worked on that might do the job and newer Technologies may make this technique more at hand for people Lens exchange may require a pars plaintive attract me. Hopefully we won't be exchanging many lenses in the future There are femto technologies where we can write different Refractive indexes into the cornea and the lens Where we can without healing response without Deapothelialization right now we have the ability and you would still have the ability to piggyback, okay a lens Here because we have have it back, okay? So I'm hopeful that we could piggyback that would be another experience another experiment potentially But I would think the way to exchange a lens would be to Anterior irrigation posterior approach for a pars plaintive do a small enter of a trectomy poke the lens forward and then From above put viscoelastic to cover the area and then you could exchange the lens, but that would be a small disadvantage Elimination of course, there's always LASIK elimination of fee-for-service income That's beyond my scope of worrying about that and in fact might be a huge advantage Economically and imagine in the third world where people just manage to get one surgery But can go blind functionally blind again from PCO and may not be able to get that advantages zero visual access Opacification, I'm no doubt it may eliminate back lens subluxation I have hope Permit Toric lens use if we have especially if we have a one piece at three pieces a Toric lens Which we don't currently have we can only optic buttonhole a one-piece lens We wouldn't want to put that in the sulcus for a bi-capsulotomy capture But it would permit that with proper lens design And I think this technique if it proves to be useful may well drive lens design especially towards something that might accommodate We'll decrease dysphotopsia because there's no reason on earth to have a square edge anymore, which is just to retard PCO Which increases dysphotopsia will have quieter eyes is since length eyes since lens proteins are sequestered and Perhaps will decrease consecutive glaucoma in pediatric cases We will have an intact hyaloid for life You won't have to have people coming and complaining of their floaters after yag lasers you won't have CME or increase in RD and Also, it's better vision even if you have a 20-20 eye It's been shown that stray light is significant from the intact clear Polished posterior capsule compared to no posterior capsule manapachi has some nice literature on that as well So it will be clearer a better vision from the get-go and forever space for secondary refractive piggyback I hope and Then Maybe we'll have accommodations. So those are the holy grails This gets my juices flowing and hopefully others will as well And we'll see if maybe there could be a new future that would be different from the last 20 to 30 years That kelman offered us in a big leap. There has no been no big leap for a very long time and These are the people who I thank very much for their encouragement and help and knowledge and building my thoughts and I did just write a An article in the August eye world and hope to publish more hope to publish the case with Tom Odding That he's done and thank you very much for your attention and for showing up at such short notice Yes Right well, I I think that we're collapsing the capsules I mean time will tell and I guess the only real concern would be if the summerings ring would grow so thick that it Might intrude upon the haptics in the sulcus and push it forward I think that's you know, I mean that's why I didn't tell Tom Odding to do this on a Monocular eight-year-old J or anybody did that's why I want this rabbit lab to kind of see what's going to happen to these eyes and The same thank you for mentioning that I should put a slide Yeah, men Apache studied this very well for posterior optic capture not nobody studied it for by its capsule But for posterior optic capture it doesn't become even significant at all till you're up above 30 diopters And then maybe a quarter of a diopter because the posterior capsule is so flexible that it's basically the haptics in the bag that are controlling the The power and when you put it in the sulcus, it's the anterior capsule is so Unflexible that it basically keeps it in the bag So they're pretty similar and so I'm thinking that we would end up at the back plane with by capsule But there's no data needless to say Right Well, I haven't seen it happen. It hasn't happened to me It didn't happen to men Apache in over five or six thousand cases That he's I mean, I know he did five thousand cases of some time back And in his first hundred and fifty that he wrote about on that article it didn't happen So the point is that we're putting it on top of a bed of OVD Which is delimited by Weigert's ligament So if you had totally ruptured the hyloid, yes, that's possible But don't forget you need to put the haptics in the bag or somewhere else If you put the haptics through the posterior capsule or X's it's gonna drop. Okay, but the optic won't so There's some technique to it. No question about it And and so that's why you want to carefully injecting or you're not going to be shooting stuff with a tunnel assist You know into these into these eyes with open posterior capsules But it's extremely doable because after you get the rex is done if you want it in the bag Then you just blow up the bag with OVD and it's very obvious where your haptic is going And as soon as that leading haptic goes in the bag you're pretty much safe Yes Good question about a post-patrectomized the question is Why not now you wouldn't have to do all that business with you wouldn't put OVD into the posterior segment because it would just fall down There's no way to to complete it, but you can certainly do a PCCC and that would be the way to Center a lens in a retracted eye that still had zonules, but no anterior capsule question good thinking Yes So what that's about when you have a really loose zonules a truly sublexated cataract Or whatever you can do a cross-swords technique So what you're doing is you're just taking a tiny little blade from either side and and and yeah Just or to anything really and and you just sort of trap it between them and that way you're not you're not depending on Movement of zonules you're you're you're fixing it with it, you know with the Oppositional forces of your two instruments, so it's a way to deal with a really recalcitrant capsule for opening it Yeah, the problem is that you don't know if there's any space at all between the hyaloid and the capsule So you will at some point rupture your hyaloid and you'd have no way to know it really until you see vitreous coming So if you're lucky enough to see it, yeah So so that's why you just don't want anything that goes down So all you it's just a 30 gauge bevel up needle and that way you can kind of snag it a little and lift it up Slightly and then just give it a little zits. Thank you. Have a great rest of your day and hope our lab goes well Thank you