Learning cataract surgery during ophthalmology residency is critically important for many reasons. It is the most widely performed ophthalmic surgery, it teaches intra-ocular surgical techniques, it helps to develop surgical judgment, and it can restore an amazing level of vision to our patients. Even if you are planning on specializing in just vitreo-retinal surgery, the skills from cataract surgery will prove very useful to you. There are quite a few pitfalls in learning cataract surgery, and I have found that the same types of mistakes tend to be made early in the learning curve.
Mistake 1: Not knowing your patient inside and out
Remember that it is not “just a surgery” but rather it is an invasive procedure that will change the way your patients see the world, every waking moment, for the rest of their lives. Being prepared ahead of time allows you to have a smoother and safer surgery. If the patient has a white cataract, you will know ahead of time to have the trypan blue dye ready. If the patient has pulmonary disease with orthopnea, you will need to adjust the bed position as well as your phaco machine settings. If the patient is a poorly controlled diabetic, then postoperative healing can be compromised and the complication rate can be higher. You must know the complete ophthalmic history of your patients as well as their systemic conditions that can affect the surgery and the outcome.
Mistake 2: Not setting up the equipment ahead of time
The microscope needs to be set for your pupillary distance and refraction. The stool and foot pedals should be positioned ergonomically with enough clearance from the patient’s bed. The phaco machine must be programmed with your individual settings for your specific technique. You can even designate different settings for dense cataracts vs. softer ones. Your patient list and orders for the day need to be neat and orderly in order to ensure that you will be placing the correct lens in each patient.
Mistake 3: Poor draping and positioning of the patient
The patient should be positioned so that the iris is parallel to the floor. This will allow better visualization and easier access while keeping the patient comfortable. The head can be positioned so that it is closer to the surgeon to avoid having to reach. Some surgeons elect to temporarily tape the patient’s head to the operating room table for added security. The draping of the lashes away from the surgical field is critical because it is the typical source of bacterial flora that can cause endophthalmitis. In addition, by using a plastic drape around the lid margin, the oil-producing glands can be blocked from contaminating the ocular surface.
Mistake 4: Making a poorly constructed incision
The incision is more than an entry site for the cataract surgery — it is a large factor in the fluidic balance of the eye, the astigmatic effect of surgery and the barrier to postoperative infection. Care must be taken to make the incision with the proper dimensions to match the phaco tip sleeve. For my resident surgeons, I recommend making the tunnel length of the incision about 2 mm while barely nicking the limbal vessels for the best long-term sealing. Incisions that are purely in the clear cornea should be avoided because they are completely avascular, which means that they will not permanently seal in the future. A poorly constructed incision will also lead to instability of the anterior chamber during phacoemulsification. This will increase the risk of surge and rupture of the posterior capsule, resulting in a complication that can significantly reduce the visual potential of the eye.
Mistake 5: Not keeping the eye in primary position and not pivoting
Once you have instruments in the eye, the position of your hands and fingers will determine if the eye is in primary position looking straight into the microscope or if it is being pushed into the nasal canthus. The surgeon controls the eye position by hand movements and the ability to pivot within the incision. Think of our eye instruments primarily as pivoting tools. In a rowboat, the handle of the oar will move only about 2 feet, but the paddle end, which is in the water, will move 8 to 10 feet or more due to the pivoting action. Our instruments are like this in reverse: We move the long handles of our instruments 30 mm outside of the eye, and then using the incision as our pivot, the tip of the instruments moves 1 mm or less inside of the eye.
Mistake 6: Failure to learn from every surgery
Athletes review footage of their performance so they can learn from their mistakes and figure out ways of improving. Surgeons should do the same, and with modern digital video equipment, it is possible to record all surgeries that are done. These videos should be studied later with a focus on what could be done better. You should always aim to improve your surgical skill, even after having done thousands of surgeries. Also remember that it is more so about judgment, skill and finesse rather than a specific technique because that aspect will change in the future. The way we do surgery today will certainly evolve in the years to come, and we need to keep up with the latest advances. Finally, make sure you see your own post-operative patients so that you can see the direct effect of the surgery and their healing response.
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