Ahh! The capsule!

[golgi]

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To second/third years/attendings: Out of your first thirty cataracts what percentage would you say involved posterior capsular complications requiring anterior vitrectomy?

 

[Jokestr]

If you've hit 1 or 2 in your first 30 I wouldn't worry about it....Part of learning. Everyone, including the "best" have a capsule problem now and again. If you've hit 15 or 30 out of thirty, I would suggest a different technique, or psychiatry 😉.

 

[HandofAlotia]

I didn't have any PC tears my first 30 (probably because of caution) but I think the rate has actually been shown to increase around 40-60 as your confidence outstrips your abilities. Although I didn't have a PC tear, my second case ever was a boxer who was hiding a little treat of missing zonules under his iris- I had the honor of soiling myself as the lens and bag dropped back into his vitreous- me left holding the nucleus cracker in horror. Of course, because bad things only happen to nice people, he ended up being the sweetest guy ever and thanking me the next day for "spending so much extra time on him" in the OR. "I could tell you really cared doc."

Anywho- PC tears happen to everyone eventually. I think your attending and technique utilized has a lot to do with your rate- if you're just sticking with cautious divide and conquer you'll probably have less to start out. I've done about 70-80 and knock on wood haven't had any- but my attendings encourage a VERY conservative technique. Posterior polar cat tomorrow so maybe its D-Day- we'll see.

 

[Wolverine98]

I didn't have any PC tears my first 30 (probably because of caution) but I think the rate has actually been shown to increase around 40-60 as your confidence outstrips your abilities.

That's what I've noticed at our program (both in my class, and those that came behind me).

Anywho- PC tears happen to everyone eventually.

Yep. I've seen just about every "big name" out there break one. It happens. The only way to guarantee you won't have complications is to stop operating.

I've done about 70-80 and knock on wood haven't had any- but my attendings encourage a VERY conservative technique.

This is going to sound backwards, but, if you're going to do cataracts for the rest of your career, you want to get a few in during residency. I do know someone who, quite a few years ago, did over 300 cataracts at Utah and never broke one, but he went into retina, so it didn't matter all that much. I can promise you that you don't want to be doing your first anterior vitrectomy and sulcus lens when you're out there on your own. Even if you've done a few, it's still nerve-wracking (thankfully, the first few I had to do as an attending were resident cases, not my own).

The problem is that, even though you want to get a few in during residency, you never want it to be the patient that you're operating on at the time.

 

[HandofAlotia]

Here it comes...

 

[HandofAlotia]

I couldn't agree more. While I never want to have any patient have a bad outcome, they are often the most helpful cases from a learning standpoint. One of the chiefs that came before me said "if you don't occasionally break capsule, you aren't being aggressive enough." His feeling was that to progress in technique you can't be paralyzed from trying new things by obsessive attention to capsule safety.

I'd like to learn new phaco techniques now in a safe learning environment rather than once I'm out in practice.