crack

[rubensan]

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as a beginning phaco surgeon, i've had pretty good success with a couple of nucleus splitters. my attending next week wants to "wean me off of that crutch." is there anything i should know/be careful when cracking the nucleus with the phaco tip and 2nd instrument?

 

[7ontheline]

as a beginning phaco surgeon, i've had pretty good success with a couple of nucleus splitters. my attending next week wants to "wean me off of that crutch." is there anything i should know/be careful when cracking the nucleus with the phaco tip and 2nd instrument?

Make sure your instruments are deep in the groove, so that when you spread them the nucleus cracks. Otherwise you will just be shredding the top of the lens.

 

[Wolverine98]

Make sure your instruments are deep in the groove, so that when you spread them the nucleus cracks. Otherwise you will just be shredding the top of the lens.

Yep, that's definitely the biggest mistake I see; not getting the instruments deep enough; also your grooves have to be deep enough.
When you're trying to get the crack, and it you're having trouble, try crossing the instrument, so you'll push to the right with the second instrument, and the left with the phaco tip (assuming right-handedness here). Sometimes the angle works better this way, and it can be a lot easier at times. The downside is that you can't see the early crack start, because the instruments are in the way.
Make sure you spread them far enough to separate the subcapsular area of the lens. It's fairly common to see someone get a great posterior crack, and then have all of the pieces still attached anteriorly.

Don't push the phaco tip too far into the periphery as you're separating the pieces. That's a nice way to get practice doing anterior vitrectomies.

Dave

 

[Wolverine98]

As a separate bit of information, some people are going to prechopping. In this situation, the instrument is similar to the nucleus splitter, except that the edges are sharper, so you can go directly into the lens without making any grooves. Akahoshi prechopper is the common name, but there are a lot of different derivations of style for the blades. The nice thing about it is that you can get the lens into quadrants before you've even put the phaco handpiece into the eye.

 

[ophtho1122]

I do stop and chop, so I do "crack" the initial nucleus. I have found it amazingly easier to get a good split without having to groove too deep by using the chopper along with the phaco tip, instead of a spatula. When I first started phaco, I used a Koch spatula, which I hated for splitting the nucleus. It was safe, but inefficient in my hands. A good way to get used to the feel of a chopper is to use it as a second instrument during divide and conquer. Once you get the hang of that, quickly move to horizontal chop on your soft to moderate nucleus and vertical chop on your white catracts. Good luck!

 

[rubensan]

like many aspects of cataract surgery, the principles sound easy enough, but the execution was tougher than i thought! can you just picture it? "okay, put both instruments into the groove and spread them....NO don't push down on the lens...horizontal movement...okay, keep the irrigation on...wait lets see, try rotating it again...alright well now you're just shredding the surface...put the tip deep in the groove!" and then for some reason my left foot decided to zoom in and everything went out of focus i gotta muster up enough courage to watch the video tape of the ordeal later. at the end of the day, the lenses were put in their respective bags and i didn't (fortunately) get any practice with anterior vitrectomy. i also did find crossing the instruments helful. i just feel like i'm going to have to do a TON of phaco before the movements become smooth and stream lined. i hope others feel this way as well??

Yep, that's definitely the biggest mistake I see; not getting the instruments deep enough; also your grooves have to be deep enough.
When you're trying to get the crack, and it you're having trouble, try crossing the instrument, so you'll push to the right with the second instrument, and the left with the phaco tip (assuming right-handedness here). Sometimes the angle works better this way, and it can be a lot easier at times. The downside is that you can't see the early crack start, because the instruments are in the way.
Make sure you spread them far enough to separate the subcapsular area of the lens. It's fairly common to see someone get a great posterior crack, and then have all of the pieces still attached anteriorly.

Don't push the phaco tip too far into the periphery as you're separating the pieces. That's a nice way to get practice doing anterior vitrectomies.

Dave

 

[Olddog1]

like many aspects of cataract surgery, the principles sound easy enough, but the execution was tougher than i thought! can you just picture it? "okay, put both instruments into the groove and spread them....NO don't push down on the lens...horizontal movement...okay, keep the irrigation on...wait lets see, try rotating it again...alright well now you're just shredding the surface...put the tip deep in the groove!" and then for some reason my left foot decided to zoom in and everything went out of focus i gotta muster up enough courage to watch the video tape of the ordeal later. at the end of the day, the lenses were put in their respective bags and i didn't (fortunately) get any practice with anterior vitrectomy. i also did find crossing the instruments helful. i just feel like i'm going to have to do a TON of phaco before the movements become smooth and stream lined. i hope others feel this way as well??

I agree with everything posted, but I would also rec continuous irrigation. It drives me absolutely insane watching the chamber continuously collapse because the resident is concentrating on the million other things to do during surgery. I know there are some attendings that are completely against this, although I have no idea why. I have the second years on continuous all the time, the third years can do what they want, but they better not lose the chamber. I you want to practice controlling the chamber do it during the I/A after the lens is in and you are clearing the viscoelastic.

 

[Visionary]

like many aspects of cataract surgery, the principles sound easy enough, but the execution was tougher than i thought! can you just picture it? "okay, put both instruments into the groove and spread them....NO don't push down on the lens...horizontal movement...okay, keep the irrigation on...wait lets see, try rotating it again...alright well now you're just shredding the surface...put the tip deep in the groove!" and then for some reason my left foot decided to zoom in and everything went out of focus i gotta muster up enough courage to watch the video tape of the ordeal later. at the end of the day, the lenses were put in their respective bags and i didn't (fortunately) get any practice with anterior vitrectomy. i also did find crossing the instruments helful. i just feel like i'm going to have to do a TON of phaco before the movements become smooth and stream lined. i hope others feel this way as well??

I would agree with continuous irrigation, per the last poster. As for getting comfortable, it's much like learning to drive a car. At first, you have to think about where the gas, brake, clutch, AND ROAD are, among other things. After a while, you don't have to think about it. For me, doing phaco, it was at around 40 cases when I realized that I didn't have to consciously think about where my second instrument was anymore. Your hands (and feet) begin to work together, and you can focus on refining your technique. By the time I got to 100 cases, it was becoming boring, unless the cases were complicated (e.g., high hyperope, posterior synechiae, gas bubble in back, etc.). Hang in there, and it will come to you. 👍

 

[Andrew_Doan]

I agree with everything posted, but I would also rec continuous irrigation. It drives me absolutely insane watching the chamber continuously collapse because the resident is concentrating on the million other things to do during surgery. I know there are some attendings that are completely against this, although I have no idea why. I have the second years on continuous all the time, the third years can do what they want, but they better not lose the chamber. I you want to practice controlling the chamber do it during the I/A after the lens is in and you are clearing the viscoelastic.

I agree with this completely! For the cases I attend, all first years have it on. Second years I recommend it highly until they can demonstrate control with all four extremeties. As a third year resident, I encourage them to have it off. It doesn't hurt to have it on as you're still learning the steps of chopping or other advanced techniques.

I am also a big supporter of a step-wise cataract approach to cataract surgery that I learned from Thomas Oetting, MD at the U of Iowa. For instance, I allow the first year residents to finish a partial irrigation-aspiration of the cortex and insertion of the IOL in a case that has gone well. When they can demonstrate proficiency in this skill, then I let them do the complete I/A of the cortical material on other cases. Then we progress to remove 1/2 of the lens nucleus with me in control of the second instrument through the paracentesis. After the resident is able to do all of the above, then I create the main surgical wound then let the resident do the rhexis, divide and conquer with me controlling the second instrument, and the rest of the case.

When proficiency is demonstrated the first year does the entire case using both hands. This step-wise method sets the resident up for success as they learn how to do cataract surgery when things are going well. They develop good surgical habits and techniques, and learn with less complications. There's plenty of time during the second and third years to learn how to deal with complications. Few young surgeons lose vitreous in their first five complete cases when taught this way.