15 November 2011
Posted in Pearls in Ophthalmology
by Ruben N. Sanchez, MD
I ask most Ophthalmology resident applicants, “Why do you want to be an Ophthalmologist?” Ninety percent of the responses involve cataract surgery and the impact that it has on the quality of life in one way, shape, or form. I agree completely. There is no other surgery that is quite so elegant or complex and being a cataract surgeon is one of my favorite aspects of my job.
At USC/Doheny, part of my job is to get our second year residents through their first dozen phacos: start to finish. Most of my colleagues think that I’m crazy for doing this and there are moments during these cases when I think that I could use a psych evaluation as well. This article is geared towards the novice cataract surgeon that is faced with performing their first few cataract surgeries. Yes, it is a nerve-racking situation, but if you take these pearls (and pitfalls) to heart, I think that your first few phacos will be one of the most enjoyable aspects of your Ophthalmology residency.
1. Know your patient. I cannot emphasize this point enough. All too often the resident cataract surgeon is consumed with getting the patient on the table rather than understanding the complexities of the case. From a general medical perspective, your patients should be low risk. If this is your first phaco, they will be under that drape for an hour or two. Make sure claustrophobia and back pain are not issues. Furthermore, your first patient should not be “referred” to you from retina clinic with the post-vit, soft, white cataract and a pupil that dilates to 3 mm. An ideal first phaco is a 2-3+ NSC in a normal length eye with a pupil that dilates to 8 mm. On that note, be careful of the patient that was handed down to you by one of your seniors. These patients need extra counseling. If one of your seniors did the first eye topical, clear cornea and it only took 25 minutes and you do the second eye with a peribulbar block, a prolonged divide and conquer, posterior capsular rent, and ACIOL, the patient is going to hate you.
2. Gain some familiarity with the equipment. At USC, our first year residents perform key aspects of the case (lens insertion, I/A, etc) with the Chief prior to putting their own cases on the lineup. You cannot learn to drive a car without sitting in one first, so try to observe or scrub in on some cases. Gain some familiarity with the microscope. If you have a simulator or wet lab, use it! USC residents spend 2-3 hours with me on the simulator before I let them stick a blade in someone’s eye. They get comfortable with me and I get comfortable with them. Practice microscope orientation and foot pedal positions, keeping the microscope centered and proper orientation of the phaco tip and second instrument. Bottom line, practice! “I’m on a hard rotation,” “OKAPs are coming up” or “I was post-call and couldn’t get to the wetlab” are NOT excuses. Remember, someone’s vision is in your hands!
3. Memorize the steps of the surgery. Whether you’re performing strabismus, trabeculectomy, or cataract surgery, you have to know the steps of the surgery. Nothing makes me more disappointed when a resident surgeon comes to the OR unprepared. As attendings, we are there to help you perform the surgery and achieve success. We cannot teach you if you don’t have any clue what to do. If you have put time into the wetlab or simulator, this will not be an issue. A good way for keeping the assistant’s chair warm and watching your attending do the case is to come to the OR unprepared.
4. Strive to be a better surgeon. Whether you just finished your first phaco or your 100th phaco, there is always room for improvement. Yes, capsules break, vitreous comes forward and lenses go back. Understanding what you did wrong, reflecting on it, and avoiding the same mistakes in the future are imperative. I used to keep a log when I was a resident. Here is an excerpt from that log: “Case #24. Scleral tunnel. Made tunnel too short, iris came out. Rhexis continuous but only 4mm. Dr. Kolin got mad. Ideal rhexis size 5.5mm. Quadrant removal difficult b/c rhexis too small. Too small rhexis can mean blowing out bag during hydrodissection.” I learned so much from that case and to this day, I never forgot the importance of proper rhexis size.
5. Stop means stop! No, I’m not talking about a first date! Phacoemulsification is a very dynamic procedure with very little margin for error. I fully expect that the beginning cataract surgeon will have difficulty with anterior-posterior awareness and use of the non-dominant hand. However, when the capsule breaks or is about to break, “stop” does not mean pull all the instruments out of the eye at once. Nor does “stop” mean continue aspirating. Stops generally means, come to foot position #1 (I am a big fan of continuous irrigation for your first few cases) and hold your hands still. This gives you and your attending time to assess the situation, switch, put viscoelastic in the eye, etc. Remember, if recognized early and handled appropriately, a rent in the posterior capsule can (and should) result in minimal vitreous loss and an excellent visual outcome.
Last but not least, try not to be too hard on yourself during your surgical training. Very few people are “naturals” at phaco. I was not nor were most of my classmates. Residents become excellent surgeons because they strive to become excellent surgeons and push themselves. Everyone falls off the horse a time or two in their training and even after their training. A good surgeon knows why he fell off the horse in the first place and gets right back on for the next case.
Dr. Sanchez is an Assistant Professor of Ophthalmology at USC/Doheny Eye Institute.