Accommodation headache @ operating microscope

[Pike]

I hope someone might have a suggestion for a systematic way to set up the microscope to avoid getting accommodation headaches at the operating microscope. I'm well into my residency and have operated a lot but never experienced this problem until starting a rotation at a new site - I'm not sure if it's a difference in microscope at this particular site or if I'm doing something different without realizing it.

In case it might factor into the equation, I'm a -275/-300 myope (no astigmatism) and I operate with my glasses off with my refractive error dialed into the oculars. To start a case I usually hit the button to recenter the scope, then starting with the scope far above the patient carefully move it lower until my initial surgical plane is in focus (e.g. I stop when the cornea is in focus when starting a cataract). I notice that I do tend to focus down as the case progresses. Hmmm...I wonder if as I focus down for phaco I fail to focus back "up" as I bring the pieces up to the iris plane to phaco them away? I've tried dialing in less minus than my full refractive error by about a diopter, which I felt helped a little but I'm still having the same general problem of headache/nausea on a full OR day.

Any suggestions are appreciated!

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[OMD]

During the case, look up across the room periodically when you are changing instruments, moving from one step to the next, etc. and then focus down with your foot pedal after your accommodation is more relaxed. Also, at the beginning of the procedure, after you have made your corneal incisions and are ready for the capsulorrhexis, focus down with the foot pedal instead of relying on your young eyes. Alternatively, you could operate with a mean older attending who can't accommodate and gets mad because he can't see unless you focus with the pedals.

 

[MR1]

Here is what I do.

Start with the focus marker exactly in the center. Then zoom way down and actually move the scope to fine focus on the iris. The iris is in the middle of were you will be working so it may be better than the cornea to avoid focusing too much during the case.

Also try and be zoomed out as much as possible, during cataracts I always try and see the eyelashs to make sure I am zoomed out enough. This gives you the most depth of focus naturally. The only part I zoom in for is the rhexis, I then zoom out.

You really should try and not use the focus much during the case, that may be where you are having problems too.

 

[MstaKing10]

I agree with MR1. Start the case by maximally zooming the scope down then gross focus on the iris plane, then zoom out. This will have you perfectly focused on the anterior lens capsule for rhexis and most other manipulations. I do not fine focus very much at all during the case, maybe just in those cases with a poor red reflex to focus on my grooves.

The degree of zoom you need for the case varies from person to person, but if you are in focus, you should not have to accommodate regardless of zoom.

Have you tried operating with your glasses on? Shouldn't make a big difference but worth a try.

I personally do not like to take my eyes off of the eye I am operating on very much so would not recommend looking up across the room periodically during the case, but that's a personal preference.

 

[Pike]

Thanks for the suggestions. I do try to periodically look up during the case when safe to take my eye off the eye (e.g. when changing from phaco to I/A). I'll experiment next week with the zoom, etc. Thanks again.