You are still really early in your case numbers. It may take thousands of cases to see every permutation, but within a couple hundred cases you will feel comfortable with most situations. Start with the basics, you are talking about a tremor. Make sure you are starting with your hands in a stable position. You should be using your nondominant hand to stabilize your instruments for your rhexis and for sculpting. Focus on your breathing when the tremor arises to bring your anxiety down. When you start using your non dominant hand with a second instrument, make sure you have a stable base. Hold your instruments firmly, but make sure that most of the motion is being guided by the finger tips. Once you have mastered holding the instruments and figuring out how to get them to move the way you desire, the rest is simple.
1) Consistently aim for a 5-5.5mm rhexis. Don’t go overboard and get a rent. Take your time if you need. Keep the utratas low and it’s easy to maintain control.
2) Get two good fluid waves at a minimum. Tap the opposite side of the lens from your hydrodissection to help the wave pass all the way around. Take your hydrodissection cannula all the way out to the edge of the lens and don’t lift up on the capsule (fluid will escape). Once the wave starts don’t slow up watch it cross. If you don’t see a fluid wave and can’t rotate the lens, do a hydrodelineation to protect the capsule and zonules (honestly this can be a good thing while learning generally).
3) don’t be afraid of your phaco pedal. You don’t need to floor it, but you shouldn’t see the lens moving as you make your sculpting passes. If the lens is moving, you might be stretching zonules. Make sure your passes follow the concave curvature of the posterior capsule. After three solid passes, you should be almost deep enough to crack a moderate nucleus (2+). If you note 3-4+ NS, know that you are going to need to get through 80% of the lens thickness for it to crack easily. You shouldn’t pick something that dense early in your cases if you can help it. Seeing a glow of red reflex through your posterior plate tells you that you’ve grooved deep enough.
4) Rotate the lens from outside in slow steady movements. That will protect your zonules.
5) Reach into the bottom of your groove when cracking, if you are too high, the forces won’t crack the lens, but could damage zonules.
6) Use your second instrument to feed yourself quadrants. They tend to jigsaw at first, so take a Seibel and use it to create a space for the first lens fragment to come out, stay in the iris plane and don’t worry about the capsule as much for the first 2-3 fragments. Once you are down to 1 fragment, be sure to protect the capsule with your second instrument.
7) Get the subincisional cortex first, the rest will be much easier to get later. Having a well formed rhexis makes this easier.
8) Once you feel decently comfortable with divide and conquer, try stop and chop. It’s way more flexible of a style in my opinion and lowers overall energy. I like it because it allows me to toggle between chopping and divide and conquer relatively quickly depending on how the lens I’m working on is responding . Softer lenses are often easier to chop up and scoop out with a safety chopper if needed. They don’t usually crack as well which can make you nervous in the early cases.
Hope some of these basic tips help. Don’t get discouraged. It takes time to get comfortable.
