Feeling defeated - cataract surgery complications

[i-doctor]

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Age wise— the sweet spot for a cataract surgeon is probably 45-55. Experience counts for an awful lot. Obviously there are great surgeons who are much younger and also those who are older and still great.

 

[JMK2005]

did not read through the whole thread yet. my one tip in this situation is that post vitrectomized eyes tend to be more psc type. even if the capsule was not compromised during the surgery, i take care to be more care when rotating the nucleus because the psc and cortical components can more more sticky. if it does not rotate easily, come back in to hydrodissect or hydrodelineate some more.

having a complication is always tough. you're doing the right thing to process it and learn from it.

 

[eyedoc27]

Thank you all for the help. I tried using an angled Sinsky as my second instrument and it actually seemed a bit easier to crack than with a drysdale. But, I was a little worried because the end seemed a bit sharp. Maybe I will try the Seibel next time.

 

[i-doctor]

Thank you all for the help. I tried using an angled Sinsky as my second instrument and it actually seemed a bit easier to crack than with a drysdale. But, I was a little worried because the end seemed a bit sharp. Maybe I will try the Seibel next time.

Try an angled Kuglen also

 

[The Doctor]

Thank you all for the help. I tried using an angled Sinsky as my second instrument and it actually seemed a bit easier to crack than with a drysdale. But, I was a little worried because the end seemed a bit sharp. Maybe I will try the Seibel next time.

An angled Sinskey hook does sound quite sharp to me to be using for a second instrument. I typically will only use the Sinskey hook for opening arcuate corneal incisions or reopening a paracentesis if I return to the OR. I use the Lester lens manipulator for rotating a toric IOL as it is safer and less sharp and gets a better grip. The Lester can also be useful for positioning a malyugen ring. The Connor wand is a really great and safe option for you to use as your second instrument if you have not tried it.

Cracking is a skill that took me several years after residency to get more comfortable with. I typically go into the surgery knowing the lens thickness from the IOL Master and density of the lens to have an idea of what to expect while sculpting. If it's a young diabetic with mostly PSC, they will have a smaller and softer lens that you could easily sculpt right through. An 85 year old with a dense brunescent cataract will require more time and energy to sculpt.

I have found that good sculpting sets you up for good cracking. Make sure you get a good hydrodissection first so the lens hemispheres will be mobile. Then sculpt all the way across the lens and make the groove about 1.5 phaco tip diameters. I try to make my sculpting go all the way across the lens as close to the equator as I feel comfortable with, "downsculpting" downwards close to my main incisions and "upsculpting" across the eye as I come back up out of the groove. These downsculpting and upsculpting moves are done very carefully almost like shaving ice. Same thing for for your final sculpting movements at the bottom of the groove. Watch for the ridges in the lens to go away while sculpting and try to get as deep as you can safely go. This is a judgment call and you get a better sense of it over time. I reach very deep to the bottom of the groove in the very middle and push my phaco tip and connor wand apart. If there is absolutely no cracking motion, then you go back and sculpt just a little deeper and try again. Sometimes you will get a little separation of the lens hemispheres in the middle but the crack does not propagate. You can then re-position your second instrument and phaco tip towards either edge of the lens and try to broaden the crack in those directions. The more you can thin out the groove by downsculpting, upsculpting, and thinning out the bottom-middle, the less material will connect the hemispheres and the easier the cracking process will be. If there is a leathery focal attachment that won't break, focus your two instruments in that area and then separate.

If all else fails, there is an instrument called the Akahoshi pre-chopper that is a cracking forceps inserted into the eye with two halves that look like the drysdale that can be used to crack the lens, even before sculpting.

 

[eyedoc27]

Thanks all. I used the Seibel and had a much easier time cracking, I think with less pressure on the bag as well. I’m going to stick with that. In the future I may try chopping as well.