When I first started teaching residents about 20 years ago, we would have the residents do about 10 surgeries of manual ECCE (extra-capsular cataract extraction) with a large incision. This helped build the skill set of the resident before proceeding to learn phaco-emulsification. As the years progressed, we moved away from this rule and we now allow residents to go straight into phaco surgery with manual ECCE surgery learned later during the years of training. I’m not sure that this is a good idea. Fortunately, in Brazil, the residents are learning manual ECCE surgery prior to moving to phaco surgery. And this case is done by a second year resident, Dr Andrei Melo, who is at Governador Celso Ramos Hospital. I want to thank him for sending this case to us for review. He did an excellent job and I know that in the near future, he will become an accomplished surgeon.
This patient has a dense white cataract and virtually no vision from the eye. The surgeon, Dr Melo, attempts to create a capsulorhexis but runs into some difficulty. This white cataract is also intumescent and this causes the capsulorhexis to radialize. A lot of time is spent carefully constructing the anterior capsular opening to allow the nucleus to be removed while preserving the integrity of the posterior capsule. The key here is to use the cystotome to create a can-opener capsulotomy for the remaining anterior capsule and then to use Vannas scissors to enlarge the opening. This allows for sufficient room to remove the nucleus, place the IOL, and then conclude the case.
For a surgeon early in the learning curve, the result of this surgery is excellent. More important than the technique is the desire to learn more and to be even better. The fact that Dr Andrei Melo sent this case for our review shows that he is the type of surgeon who will become better and better every case. He has the drive and determination to become an outstanding cataract surgeon and I look forward to learning from him in the future. In my grading system, he gets an A+ for his drive and determination.
Click below to see the management of this challenging case.
