Analysis of a Resident’s 60th Cataract Surgery

As we get close to starting the academic year in the USA (which runs from July 1, 2019 to June 30, 2020), our residents are advancing in their training and becoming more proficient in cataract surgery. Today we are evaluating the performance of a resident’s 60th cataract surgery. At this early stage in the learning curve, the emphasis is on the basics of the procedure in routine cataract cases.

The anonymous video shown here is quite good. This resident has excellent hands and will certainly blossom into an accomplished surgeon. There are aspects of this case which are good and there are others that need improvement.

here are my suggestions:

  • incisions
    • paracentesis: too long of a tunnel length
    • main incision: good construction and architecture but would be more exact with an appropriately sized keratome (instead of sawing the incision to enlarge it)
  • capsulorhexis
    • excellent with good control using just the cystotome
    • very good size and centration
  • hydro-dissection
    • good technique with specialized J-cannula leading to partial prolapse of the nucleus out of the capsular bag
  • nucleo-fractis technique
    • not performed in this case, instead the surgeon uses a tilt-and-tumble technique which works well for a mild degree of nuclear sclerosis like this cataract
  • cortical removal
    • well done with care taken to polish the capsule
    • adjustment of the I/A sleeve is recommended to give better fluidics
  • IOL insertion
    • smooth and controlled with good delivery
    • capsulorhexs overlaps the IOL optic nicely
  • viscoelastic removal
    • thorough job, but for future cases learn to go behind the optic as well
    • consider doing an angle sweep to check for retained viscoleastic
  • sealing of the incisions
    • appropriate hydration done on the well-constructed main incision
    • suggest using the weck-cel sponge from an angle to avoid blocking the view of incision

Overall, this is a strong performance for a resident who is so early in the learning curve. The most important suggestion is to work at learning nucleo-fractis techniques such as phaco chop, stop and chop, or divide and conquer. In the future with a denser nucleus, it becomes important to divide the nucleus prior to facilitate removal.

Click below to learn from this resident’s 60th cataract surgery:

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