1797: experienced surgeon asks for help

This surgeon needs the collective help of our 50,000 subscribers. S/he has sent in this video with a request that we help improve the surgical technique. This is a routine case and the surgeon requires 30 minutes to complete this cataract surgery. I have sped up the video to 4x (or more) speed in order to show the whole case. It goes fine without complications, but the case is inefficient and the movements are awkward at times. Our goal in watching this video is to provide helpful, constructive criticism and useful advice to help this surgeon. Please post your comment below giving your best advice for this surgeon to improve. Per the email, this surgeon has always done about a 30 min phaco case, every week for the past 30 years. This time, however, there is a desire to improve and bring a higher level of care to the patients. Let’s work together to help this struggling surgeon.

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  1. Larger rexhys, less passage for grooving…but in general less inefficient movements will help. Take your own time is anyway a good move… it is very important not to break the capsule trying to reduce the time of the surgery.

  2. He’s constant adjusting the microscope to have the surgical field in view. If the patients head isn’t taped it should be. He has so many wasted movements. Lidicaine injection should be done once and swiftly, he should try to limit the amount of grabs on his rhexis. The phaco passes should be deeper and fewer. The phaco needle opening is about 1mm in diameter and the lens is only ~5 mm deep. 3 solid full passes with the needke buried should be enough. He should use both instruments to spin the nucleus in one movement. Groove again with 3 – 4 passes, crack then segment removal.

  3. Surgeon does an excellent chop. Larger rhexis and learn a pop n chop… forget about the groove… flip it, chop it and go. Also maybe use a curved IA tip. The bulky disposable tip does not get subincisional well.

  4. Overall nice surgery. Consider teaching your scrub tech to load the iol. Try to request the same scrub tech (or two) to develop better chemistry with him or her. I think sometimes fear makes the case inefficient—for instance, fear of rhexis running out resulting in too small a rhexis, fear of blowing out the posterior capsule and hydrodissecting inefficiently and ineffectively, fear of grooving too deeply resulting in slow grooving and possibly too shallow a groove. Each of these issues can make everything that follows less efficient and more difficult. I think for the rhexis, get a good chamber fill with a dispersive viscoelastic like Viscoat. Get a mental image of how big you want to make the rhexis by doing a measurement. Often, 5 mm is a good size. This can be done by measuring about 5 mm with markings you can make on the utratas, or with a ruler (?helveston ruler) that you can insert in the ac, or with calipers, but measure slightly larger (~5.5 to 6mm) if measuring outside the eye to compensate for corneal magnification. The deeper the ac, the more magnification you would get—that’s why things can look so off with a hyper-deep ac with loose zonules or with reverse pupillary block, so keep your acd in mind. With the hydrodissection, it’s a balance between pushing the bss not too vigorously but not too softly. There are some cataract coach videos on it where dr. D shows how far the fluid should squirt if you were exerting the appropriate amount of force. Sometimes a 90 degree canula (?chang canula) can allow you to start your hydrodissection close to the subincisional area thus possibly making subincisional cortex removal a little easier. With grooving, keeping the lens thickness in mind (actually check it on the iol master) vs the diameter of your phaco probe can help gauge depth. Initially can go faster, and then slow down a little as you get deeper. Keep in mind the posterior lens curvature as you are doing this. As you seem fairly comfortable with chopping, maybe just chop to begin with rather than doing stop and chop. Also, optimize fluidics. Maybe a higher flow rate balanced with a higher bottle height/ac pressure may be helpful. Dr. D has a good fluidics tutorial section that you can consult. Overall, keep working on efficiency and let speed come naturally rather than forcing it. Safety first before speed.

  5. Very beautiful surgery,
    flip and chop is much more easier and safer.
    The other parts were perfect.

    1. Appropriate surgery..and yes..lots of scope for becoming more efficient..my opinion stems from the fact the surgeon has had complications while trenching (most likely posterior capsule rupture) ..so all the guarded maneuvers (eg. small rhexis for placing sulcus iol.. hesitant hydrodissection.. shallow trenching)..
      My two cents..if the surgeon gets the trench and chop right.. confidence to speed up and do the rest should be easy..so here goes..
      trench only to the halfway mark (an imaginary line dividing the nucleus to a temporal and nasal half).. slowly trench deeper but preserving the nuclear wall ahead..there will be subtle changes in the colour and texture (keep looking at it)..what goes round comes around (the shallow nuclear, epinuclear, and cortical colours will re-emerge at the bottom..of course do not wait to reach epinuclear level..phaco bury into the wall ahead..stop and chop..
      All the best 🙂..

  6. Good surgery, well done. Speed generally increases as you do more cases on a regular basis as you stop overthinking what you are doing and go into autopilot mode. Hence the caution I think with the sculpting. Try changing things around, say with primary horizontal chop as you are obviously good with the chopper. After a bit of hit & miss with the primary chops, you will discover that eureka moment when it’s more hit than miss! Your surgical skill level is no different to the majority of cataract surgeons in my view, just some minor adjustments and preparedness to go out of your comfort zone required and try new things. I think this will make a huge difference in surgical time. I would suggest watching some of Neto Rosatelli’s beautiful videos as well – watch him sculpt trenches in a soft lens and you’ll see what’s possible!

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