phacoemulsification experience/struggles/advice sought

[eyegal]

I am currently having several complications in phaco.

Does anyone share my experience?

If so any advice on how to handle it? Surgical expeditions? India? other?

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[Andrew_Doan]

Which steps are you having trouble with?

 

[eyegal]

most importantly the capsulorrhexis.

 

[7ontheline]

How many have you done? Are your hands shaky or are you not coordinated?

 

[Andrew_Doan]

most importantly the capsulorrhexis.

When I teach residents cataract surgery, most residents struggle with the capsulorrhexis.

Some pearls you need to consider:

1) Use two hands during this procedure.

2) Pivot your hands in the opposite direction that you want to have your forcep tips move. If you want to have your forcep tips move downwards, then your hands must move upwards. The cataract wound acts as a pivot point. I find that young surgeons push down on the wound when trying to move the forcep tips downwards. This results in the loss of viscoelastic, anterior chamber shallowing, and instability of the anterior capsulorrhexis flap.

3) If you lose viscoelastic, then inject more to maintain your chamber. When the chamber is shallow, radialization of the anterior capsule is more likely.

4) Watch the direction of your tear. If it is straight, then it will go out. If it is circular, then it will likely stay in a circular path. This sounds simple, but when young surgeons are focused on just the edge of the tear, they tend to forget to watch out for other things. If you find your rhexis heading straight out, then stop, inject viscoelastic over the tear, and then use the cystitome to make a sharp turn inwards to prevent radialization.

5) Zoom in with the operating microscope during this step so that you have a large view of the anterior capsule. Zooming in will also slow down your hand movements and allow better control.

6) Make sure the eye position and scope settings give you a nice red reflex. If it doesn't, then use Trypan Blue or ICG (more expensive) to stain the capsule.

Also, review these steps recommended by Dr. Oetting:

http://www.medrounds.org/cataract-s...10/chapter-3-phacoemulsification-step-by.html

Good luck!

 

[Visioncam]

Another tip, besides the excellent ones by Dr. Doan, is to cheat and don't let anybody see you do this one.

Some people argue that your elbows should be sterile. Hogwash. Turn the chair slightly so your elbow rests on the edge of the seatback. That gives additional stability.

 

[Andrew_Doan]

Another tip, besides the excellent ones by Dr. Doan, is to cheat and don't let anybody see you do this one.

Some people argue that your elbows should be sterile. Hogwash. Turn the chair slightly so your elbow rests on the edge of the seatback. That gives additional stability.

Using the seatback is a good idea. We use seatback covers, and you can ask the OR to cover the seatbacks for you. Then you don't have to worry about breaking the sterile field!

 

[eyegal]

thank you for all of your advise.

my hands don't shake, they get anxious or tense and probably exert too much force on the wound. i've done a little under 200 cataracts including residency. i know that i don't pivot in the wound well so i will note that advice. i do exert too much pressure on the wound edge. also i am continuously changing my nucleus emulsion technique. I've tried divide and conqeur, stop and chop, and am now trying one handed phaco with prechopping. Problems with the first 2 techniques is a leaky wound, and/or breaking capsule with the 2nd instrument. Problem with prechopping is I usually can get the nucleus almost in half (it never seems complete), then I struggle with getting the division into quadrants as cortex gets stirred up and the plate is not divided.

Any additional advice would be greatly appreciated.

 

[Andrew_Doan]

also i am continuously changing my nucleus emulsion technique. I've tried divide and conqeur, stop and chop, and am now trying one handed phaco with prechopping. Problems with the first 2 techniques is a leaky wound, and/or breaking capsule with the 2nd instrument. Problem with prechopping is I usually can get the nucleus almost in half (it never seems complete), then I struggle with getting the division into quadrants as cortex gets stirred up and the plate is not divided.

Any additional advice would be greatly appreciated.

I don't recommend changing nucleus emulsion techniques. Stick with one method and master it. I developed proficiency with divide-n-conquer where I can do a case under 10 minutes before moving to stop-n-chop. Stop-n-chop is nice because it reduces phaco times. Stop-n-chop and divide-n-conquer shouldn't result in a leaky wound unless your 2.75 mm clear cornea temporal wound has too short of a track (i.e. make sure your clear corneal tunnel is long enough) or you develop phaco burns from excessive phaco times or the wound being too tight.

If the wound is leaky, it's not the end of the world . Just place a suture and move forward.

Hope this helps.

 

[eyegal]

can you comment on what you meant by using both hands to do the rhexis?

 

[Andrew_Doan]

can you comment on what you meant by using both hands to do the rhexis?

Using your dominant hand, the thumb and index fingers grab the forceps. The non-dominant hand is there to provide additional stability with the thumb and index fingers bracing above the fingers of the dominant hand. This method allows the forceps to be very stable. If additional stability is required, rest the pinky fingers on the patient's face gently.

 

[7ontheline]

Don't take this the wrong way, but if you've done 200 cataracts and are still having these kind of troubles, I would be a little worried. You may not be a very coordinated or natural surgeon. Or, if you're tensing up, you may be over-anxious and psyching yourself out. In any case, it's never too late to learn surgery - if you are out of residency sometimes you can go watch other people do surgery and that can help, since it's not as possible to have people watching over you. Do you have partners? Maybe they can take some time to watch and give you some advice. Andrew's advice is good for sure also.

 

[Olddog1]

As someone who also teaches residents I have a few ideas somewhat different than Dr. Doan's. First, I try to get the residents not to use 2 hands on the cystitome, Utratas or the phaco. One reason is you are much less relaxed, and more importantly it is difficult to break this habit once you start. The non-dominant hand must be utilized to make the surgery faster and safer for things such as protecting the bag with a second instrument during quadrant removal and also to manipulate the lens when turning it in the bag or chopping. Also, when one progresses to topical I find it useful to place a closed pair of .12s or tyers in the paracentis to adjust the red reflex and better control the eye in people who won't look at the light. We also do some bimanual I/A to again make one more fascile with their non-dominant hand. Lastly, remember the wound can be used as a pivot, but don't use it as a fulcrum.

I would echo Dr. Doan's advice about divide and conquer. There are very few, if any, cataracts that cannot be removed with this techinque and it is great to fall back on when flipping or chopping doesn't work. Incidently, I have pretty much banned the pre-chopper because I want the residents to become comfortable with divide and conquer and then we move to horizontal chopping.

 

[ckyuen]

Also for leaky wounds from too much pressure try using discovisc. It stays in the eye very well, and makes doing the rhexis much easier. with just viscoat or a dispersive it's much harder to complete the rhexis, and with soft shell technique the viscoat can be more easily displaced when doing the rhexis. I had some other surgeons observe me who were having trouble with the rhexis and along with the advice from above, I recommended switching to discovisc and that really helped them. You can see the rhexis incredibly well with the discovisc, I have even performed cases of cataracts with no red reflex without t-blue b/c you could see the rhexis incredibly well. Also if you are in a market with a lot of asian eyes, for some reason they often don't have a good red reflex, so if you can't get one don't hesitate to use t-blue if you need it. When I have a caucasian patient or non-asian patient, the red reflex feels like it's blinding me now days. I think above all if your rhexis is not going quite right stop, assess the chamber and refill with viscoelastic if shallow. remember the viscoelastic also helps flatten the surface of the lens so when you tear it you should be tearing on a flat plane like a plate, you dont want to be tearing a circle around a basketball, b/c that will naturally run peripherally.

 

[sublingual]

thank you for all of your advise.

my hands don't shake, they get anxious or tense and probably exert too much force on the wound. i've done a little under 200 cataracts including residency. i know that i don't pivot in the wound well so i will note that advice. i do exert too much pressure on the wound edge. also i am continuously changing my nucleus emulsion technique. I've tried divide and conqeur, stop and chop, and am now trying one handed phaco with prechopping. Problems with the first 2 techniques is a leaky wound, and/or breaking capsule with the 2nd instrument. Problem with prechopping is I usually can get the nucleus almost in half (it never seems complete), then I struggle with getting the division into quadrants as cortex gets stirred up and the plate is not divided.

Any additional advice would be greatly appreciated.

With regards to nucleus dis-assembly, it is quite important to have fairly deep grooves prior to attempting to crack (this goes for divide and conquer as well as stop n chop and others- in order to stop the lens material from cheese wiring. These recommendations should assist you with this: Use low magnification to have better depth perception (you should generally fully see the eyelids and adnexa in your scope), judge depth using your phaco needle tip and groove 3 needle depths in the center and two in the periphery, watch the red reflex as you groove and dont attempt to crack until you have a good red reflex (often surgeons are too cautious about grooving too deep to the point they dont groove deep enough), use parallax to help judge depth (by gently moving your phaco tip side to side at the depth of your groove: the more shallow you are the more the opacities in the vitreous move side to side). Make sure the groove is also wide enough to be able to place both instruments deep into the groove prior to cracking. Hydrodilineating (as well as hydrodissecting) helps with disassembly as well: get a decent golden ring (unless the cat is too dense) then when you groove, just groove long enough that you enter the epinucleus but not well into it. Lastly, as you are aware, cataract surgery is a very delicate art and each step needs to be PERFECT in order for the case to go smooth. Read up on each step you are having difficulty with. Good sources are Barry Seibel's Phacoemulsification and Michael Colvard's Achieving Excellence in Cataract Surgery-- probably the former for the difficulties you are encountering. Furthermore, take a deep breath and relax It will come to you. Most people their first year out play with lots of vitreous, the key is to know how to manage your complications well-- most pts do great if you do!