Assuming that you're relatively young, one thing that can help is to fog yourself. On most scopes you can adjust your oculars, so put them at +1.50 or +2. This will reduce your tendency to accomodate; I've found that early on, residents tend to accommodate a whole lot. What makes it even worse is that once you start to really concentrate (ie, when things are going bad), they accommodate even more, blurring the image, and constantly adjusting the focus.
Another thing you can do is to simply make sure you're moving your point of focus deep enough into the groove.
As for capsulorhexis, a big part of that is practice. It's definitely related to the problem above. If you're not in great focus, it's hard to see. Also, obviously, if you don't have a good red reflex, it's tough to see. If the latter is the problem, one thing that can help is shifting the light source. On the Zeiss scope, there is a knob that let's you change from -2 degrees to +2. Changing that angle can make all the difference in the world if you're not getting a good reflex.
Last technical bit is to make sure that where your capsulorhexis forceps are in the wound is your fulcrum. You need to pivot around that point. This is one of the hardest things early on, and most residents tend to move the forceps, which does two things. One is that it rotates the eye, which will make it harder to see and make your red reflex worse and make it harder to reach the flap. The other is that it will cause corneal striae, which makes it much harder to see. If you're moving to 2.2mm incision, this is even more critical.
Several programs have taken a new approach to this step. When residents are starting, they'll use Tryptan blue on every case, regardless the state of the cataract. This makes it a whole lot easier to see the flap. This lets the residents get comfortable with the motions involved in capsulorhexis without having to worry as much about visualization. Then, when they do stop using it, they're much more practiced at that step, and it's easier to concentrate on visualization.
The other advantage to this is that it's easier for the attending to deal with a rhexis gone bad when it's already stained. 😉
Dave
