Lecture: Learning Cataract Surgery in the Operating Room: Strategies for Attendings and Residents

Dr. Khalifa: Good morning, everybody. My name is Yousuf Khalifa from Atlanta, Georgia, Emory. Just pulling up my slides here. The topic for today is learning cataract surgery in the OR, strategies for attendings and residents. My financial disclosure is I am a consultant with Carl Zeiss Meditec. We’ll start with a question. What is the most important part of a resident’s cataract surgery training? If you can answer that question. A, is most advanced IOL biometric and formulas. B, resident/mentor relationship. C, state of the art phacoemulsification machine and D, wet lab and surgical simulator. All right. So the results are 20 percent said most advanced IOL bionic and formulas. 34 percent said resident/mentor relationship. 11 percent state of the art phacoemulsification machine. And 35 percent said wet lab and surgical simulator. In my opinion it’s B. The resident-mentor relationship. These other components are important but nothing is as important as the relationship between the attending surgeon and the trainee and that feeling of trust and, that happens between the two. This slide here is just showing how stressful cataract surgery training is. On the left is my colleague and on the right is me. One day after surgery I got a text message saying this resident really stresses me out. You can see the sweat marks and the next day I had the same sweat marks. Attendings suffer a lot of stress. And why do we do it? I looked back at my life and I think some of the things that happened in my life that made me enjoy teaching and I want to share three episodes from my life that make me enjoy being in the OR with residents and doing skills transfer with them. The first is, I remember clearly when I was young being fed up learning to ride a bike and my father running behind me holding the bike and me peddling and he wouldn’t let me fall. He made sure I was safe. He was interested in me learning and I was interested in learning to ride a bike. I think it’s the same feeling when learning and training to do cataract surgery. You’re enjoying seeing this resident blossom. They put in so much effort through undergraduate and medical school and internship and two or three years of residency and you see them blossoming into a cataract surgeon that makes me happy. I think the same feeling of joy should be in the resident. When things are good, there is a lot of joy. But even when things don’t go well there should be a sense of trust and if things don’t go well, we shouldn’t throw each other under the bus. The resident is not going to blame me for a complication and I’m not going to blame the resident for a complication. We both want to be successful. I want to transition them to independence. Meaning I’m not going to sit there running behind them holding the seat of the bike as they’re learning to do cataract surgery. They need to learn it and go out on their own. I can’t be constantly coaching them. There is a gradation of coaching and slowly I take the training wheels off. I take my hand off the seat and slowly I stop pushing. The next question, when a resident suffers a surgical complication what should be done. A, blame the cent for the mistake and write an incident report. B, embarrass the resident in front of others. C, review the case with the resident to identify areas for improvement. Or D, suspend the resident’s surgical privileges. So I think this was overly dramatic. Obviously, you don’t want to blame the resident for the mistake or write an incident report. Only two percent chose that. You don’t want to embarrass the resident in front of the attendings or other residents or the patient. Help them maintain their confidence. It’s important that we learn from mistakes and go back and look at the video and we assess where the mistake happened so it doesn’t happen again or at least we learned from the situation. And obviously we wouldn’t want to suspend the resident’s surgical privileges. 90 percent got that right. It’s emphasizing that we’re a team. I like to celebrate my residents so I put them on my Instagram and highlight the work they’re doing. These are the highlights over the years of my residents doing great cataract surgery. This is the second story that I lean on when thinking how to make my residents succeed. I turned 15 year-olds old. In the United States you start learning to drive at age 15. And my mom put her in her gray Volvo and she was next to me and my sister was in the backseat, she was five years old and she told me to drive. My reference of how to drive was the arcade games where you hit the foot pedal all the way down. So I push the gas all the way down and the car engine revs really high and we take off and my mom yells stop. And I slammed on the brakes and my sister flipped in the backseat. I didn’t have the right frame of reference driving a car. I was taking my experience from an arcade game and said this must be how you drive a car. Let’s do it the same way. It’s important this we take into account that we have different life experiences and perceptions and personalities. Sometimes they don’t translate into success right off the bat in the operating room. You have to calibrate the resident. Ways of calibrating the resident are wet labs so they can practice. A stimulator helps with developing appropriate hand motions and technique. I have found with unsupervised wet lab and simulator, sometimes residents learn to hold instruments incorrectly. So some supervision and making sure the time they spent in the wet lab is worth it. The next point, we all form a contract about how to do something new. You want to make sure that conduct is correct. Some get overstimulated and anxious and want to hold tight to the instruments and want to be in control by holding tightly. That is a frame of reference construct that is going to hold them back as they progress in cataract surgery. I’m going to give you the last of the three stories. I remember clearly being a resident at the Georgia VA medical center and operated on my first surgery. And it was an extra cap and I made the incision and put an instrument into the eye and felt a sense of being completely overwhelmed of being inside on eye with an instrument. I felt like the room was spinning and I couldn’t hear or see or process information. My attending was talking and I couldn’t respond to the prompts. You’re going to have a resident reach the extent, have them reach a point where they are unable to process the situation. The stress of the surgery is too much for them to deal with and at that point, it’s going to be really important that you realize it as the attending and take over it and get them over that stressful situation they’re in. So if you have reached the resident’s limit in their dexterity or mental capacity, they will struggle and be stressed and discouraged. And I think it’s important that you maintain a resident’s confidence as they’re going through training. And as I mentioned, many times, too much stress renders the trainee unable to process instructions or what they’re seeing. Their brain is shutting down. So, those are the three stories, I mentioned to you the first is riding the bike. There is joy, there is trust between the resident and the attending. I mentioned do you the story of me learning to drive and not having the correct frame of reference that I didn’t know how to drive a car and I assumed my arcade experience was going to translate. And the third was being overwhelmed in the OR as a new surgeon and being overwhelmed and not knowing how to process the situation. Another thing to keep in mind is you don’t know what you don’t know. The first couple years the residents go into the OR and squirt a cornea with DSS and think this is easy or whatever, and they think it’s simple. And they don’t know they don’t know. And very quickly after they start they realize they don’t know. They know that they don’t know. And hopefully, by the 50th or 75th cataract their skills pick up but they still don’t know they don’t know. And hopefully then they know what they know by — things to discuss with the resident front of mind. No. 1 pearl is visualization. Before you go into the operating room, the night before as a resident, you need to sit down and imagine yourself doing the surge. Close your eyes and hold your hands up and imagine doing a paracentesis or putting a cannula in, the lidocaine. Imagine making the keratome incision. Imagine the cystotome. The hydro dissection. Rotation of the lens. You imagine and you move your hands to recreate the scenario you’re going to be in the next day. Imagine your foot on the foot pedal and how you’re going to move the phaco probe and how you reduce the quadrants. I think visualization is important. Elite athletes spend a lot of time imagining what they’re going to do on the playing field. For a surgeon, it’s a great way to prepare for the operating room and improve your performance from day to day. The next pearl is watch all the videos and watch them over and over. Even the ones you think you did good on, watch again and see how you can improve. There was too much down time after I put in the lidocaine. The keratin excision, the blade should have been tilted this way or that way. The phacoinstrument. I moved too much. I should have been further back. I should have turned the bevel of the phaco tip. Watching the videos and I have two video conferences a month where the residents bring in the videos that I staffed and we watch them and I quiz all the residents into the room. We project the video and discuss the thought process, the technique, the hand position, how we manage complications, all those things are done as a group as well. I highly recommend that for you to set that up if your institution. Do a surgical video conference and review even straightforward videos. There are great learning points that can be highlighted for the residents. Another pearl that I didn’t put on here, it’s important that residents get to the operating room before they actually have to be the surgeon. I recommend that a resident come in and be the scrub tech for a few cases so they know the order of the instruments and how to pass the instruments and how to set up a machine. The next pearl is patient selection. Be careful when selecting a patient. Often times residents are going to be excited about signing up patients and want to do a lot of surgery and you might miss an epiretinal membrane or a dry eye or a retinal dystrophy basement membrane. And not done a good job explaining the outcomes with the patient. Poorly setting the patient expectations is you might do a good surgery but if the patient is unhappy after the surgery, even if it’s a good surgery, you’re going to have an unhappy patient on your hands and that hurts the psyche of the resident and hurts the moral of the entire clinic. Be careful who you sign up for surgery and make sure you’re doing surgery on patients, even if your mom, you would do surgery on your mom. This situation if my mom were in it I would take her to the OR to do surgery on her. Treat patients like family and make sure you see a good outcome for the patient. You might not know what a good outcome patient is going to look like on the front end but involve the attendings in the selection process. Pearl No. 4, make sure you know how to look at an IOL sheet and select the appropriate lenses for the patient. I want to stress now, it doesn’t highlight it here, but be careful of the minus 1, minus 2, minus 3 patient. If you take that patient and make them — sometimes, often, you’ll find an unhappy patient. You have taken away their ability to read without grasses and you’re reprogramming the brain to put glasses on for reading and they don’t like it much. The next pearl, do a meticulous prep or drape. The last thing we want is a complication or operating with lashes in the field. It causes a lot of stress when the speculum isn’t in correctly. Do a nice job prepping and draining and keep the lashes out of your field. The next pearl is important. That is doing a time out. Time out has multiple components to it. The first part of the time out is you know everybody’s name in the room. Know who the anesthetist is and the scrub tech and definitely know the name of the attending and resident. Before you start to operate? Student: You want to say, Kevin, please give them more anesthesia or give me more OBD, Rachel. Make sure the team feels included in the process. The other piece of advice, make sure you have the right patient and I know it sounds silly but there can be issues with bringing in the wrong patient, out of order for example or draping — prepping the right eye but draping the incorrect eye. Make sure you have the right eye prepped and draped. Look at the intraocular lens that you’re going to implant and come firm it’s the right power. I only want one out at a time because I’m worried about someone pulling the wrong lens. The last pearl, before you go into the operating room, go through all of the drawers and cabinets and make sure you know where every single thing is in that operating room. This draw has the ring, and this cabinet the CTR. This shelf has the Omed segments and this shelf has the iris scopes. This is where we keep the extra OVD and this is where we keep the cannulas and blades and extra lenses. You don’t want to be in a situation where you need something and it’s a new attending and they’re not used to operating in that room or a new circulator and you reach to get something and you can just help with that. For the residents and the attendings make sure you know where things are in the OR. Something more hands on, where do you put your hands during cataract surgery. As a resident, that’s the first hurdle to overcome. You got everything, you prepped and draped and we’re good and about to operate and you grab the instruments and don’t know where to put them. Pay attention to how the ring finger here is stabilizing the hand and the pinky or ring finger in the other hand is stabilizing. You never operate free floating. Your hands are always supported when doing something the eye. It’s a great way to unmask a tremor. You will also not be as precise. Rest your hand on the patient’s cheek and forehead if you’re operating temporally. Definitely don’t rest on the eyelid speculum. If you put your fingers on the eyelid speculum you will create posterior pressure and that will make the surgery difficult and give you the sensation that things are pushing up. The other piece of advice, see where the hands are positioned, if you move the fulcrum, this ring finger more towards the nose, place it here or more towards the brow or the bridge of the nose, you’re going to drive that eye towards the nose and you’re going to have that eye rotated towards the nose and you won’t be able to visualize the anterior segment well. Be careful where you place your hands. Deponent place it on the speculum and don’t get anxious and drive the eye towards the nose. The next pearl is eye centration. When I was a resident I struggled with eye centration. I remember feeling like I always had the eye near the nose. One thing to remember is your instruments are controlling that eye. When a resident says the patient — away. That is not true. If you have both instruments in the eye, you’re controlling the eyeball. Imagine you have a phaco in the keratome and a chopper in the paracentesis. You want to hold your hands back and push on the internal lip of that holding the eye back. So the chopper, if you imagine this is the wound the chopper is in, you want the chopper to push on this side of the wound. It’s pulling towards you to hold the eye centered in the field. When I move forward with my phaco the chopper moves against me. There is this motion here. If the phaco moves forward the chopper moves and holds it steady. Like pushing on a horse, if I release one hand, I pull with the other. When the instruments are in the incision F the phaco goes forwards the chopper pulls the eye back. If the chopper goes forward I lift the instrument up and pull back to hold the eye back as I go out with the chopper. A movement in one direction by one instrument is countered by the other instrument pushing on the wound in the opposite direction. That’s a really important concept. I find residents hold instruments way too tightly. You want to be like Muhammad Ali where you float like a butterfly. You have a nice light touch on the instruments and you make all these motions so you can pivot and go right, left, up, down. If you’re holding too tight you can’t pivot. Next, make sure you know how to set up a phaco machine. Make sure it’s the right tension. And putting on the sleeve. Going into the correct hole. And understanding that fluid, you have a Piezo electric crystal here and fluid is coming down the shaft of this phaco handpiece. Underneath the silicon tubing and outs of the side holes and the phaco needle is aspirating and oscillating. Foot position one is irrigation coming out of the sleeve. And position two is aspiration coming from the bore of the needle. And foot position three is phacoemulsification. I tell the residents all the time you nighed to know what the machine sounds are. You need to listen to the machine and understand what the machine is doing. You see there the — continuous irrigation going on. You hear the … Sound. That is aspiration. So the resident is operating under continuous irrigation here. You will see a chop motion. You will see the right hand go vertical. The chopper go out. Look how nicely centered the eye is. And listen to the phaco. Then you notice there is no aspiration or phaco as the chop happens. So the point of this slide is make sure you know what you’re listening for in the phaco machine. Understand what the phaco machine is doing while you make, while you change the position. Oftentimes when we go to learn cataract surgery we start with died and concur. This is a very dense lens and we’re trying to groove it. A couple things I want to point out. No. 1, you don’t want this to happen where you see the lens moving away from your during the grooving. You see these passes on very dense lens, what you want to do is increase — before we get to that. When you do passes, imagine this is the top of the lens. Here is the phaco probe. When you go down to do a pass, never allow the phaco probe to dive like a submarine. Don’t want it to go down into the lens and you lose sight of the tip. You’re not sure where the tip is. If I keep it on the surface like you’re a boat, you want the phaco to go across with some of the needle tip exposed at the top. You can do this or deeper like this. On softer lenses you take a bigger bite. The boat goes deeper into the water. In a dense lens like this, you want to take a shallow bite. Not deep. Something like this and not like that. And you want to go slower. At normal speed for a groove maybe like this. On a dense lens you maybe move slower. And the next thing is increase the phaco energy so you don’t see the translocation of the energy like you see there. That is very dangerous. The reason for that, when you see the lens moving like that, you’re stressing the zonules and ripping — and get vitreous coming up around the back like that. I wanted to review with you the mechanics of doing a groove. But when you’re first starting, you’re not going to pick up on the subtle signs. It’s really good as an attending to point out why you’re asking a resident to change their technique. Oh, look, there is translation of that lens. It’s moving. I’m worried we’re stressing the zonules. Increase the power, move slower. Take less of a bite. It’s important to give the resident surgeon the reason for why you’re doing something a certain way. And sometimes I’ll tell my resident, there are many ways to do this. This is the way I prefer and the way that I’m good at it. You should learn all of the techniques but right now let’s do it this way. Here is a case where we didn’t do what I was talking about. We went in and the needle tip buried into the piece right there. And when you bury the needle tip deep in and not controlling the foot pedal you go through the back of the piece and pop the posterior capsule. You see here we have vitreous. This is an old video and I didn’t see this vitreous and now you see the pieces crawling to the back of the eye. Reinforcing the concept, even when you do quad you stay on the top and not be aggressive. You can go through the back of the lens. And now it’s an open posterior capsule and a couple quadrants that fell back and segments in the anterior section. We talked about this a little bit. Where you place the incisions is extremely important on how you control the eyeball during surgery. So you need to make sure your incisions are reproducible. The first thing you do is pix the axis of where it’s going to go. I like to operate temporally and like my hands like this. I make a paracentesis here and a keritome incision here. There are different schools of thought on how to place the incisions. Make sure you’re consistent with it. Because the mechanics of holding an eye steady and the mechanics of grooving and chopping and all the different things change if we change the location of the incisions in relation to our body. If I’m sitting temporal and I’m operating like this, the mechanics of holding the eye centered and doing the manipulations I do are going to change dramatically and I’m probably going to have a complications because my incisions are not where I’m comfortable. You have to decide where you’re going to put the incision. You want the middle line there too far anterior and it’s difficult to finish the capsule rhesus or cleaning cortex sub incisionally. Too far posterior and you cut the conjunctiva and you get ballooning of it. You want to be just inside of the sclera here, really far posteriorly. Make sure when you do the incision, don’t push down. If you push down the blade catches the conjunctiva. You really float into the eye and there is no downward force on the eye. It’s a simple float in. Uniplanar, bi-planar, triplanar, whatever you want to do, the principal is similar. I prefer uniplanar incisions where you go in and out. They work well with my hands. Pearl No. 1, pick your axis. No. 2, pick the starting point. And No. 3, the wound shape. How you tilt the blade, right side down, left side down, heel down, heel up. You get a funny looking wound if you have a tilt in the blade and you’ll get a really long wound if you put heel down on the blade like this. You get a really short wound if you make a heel-up incision. You need to learn how to approach a cornea to get the correct wound shape. The tilt and the heel up, heel down. Okay. So going back to disassembling a lens, it’s really important that we get clean disassembly pieces, that the pizza is completely separated all the way to the middle and all the way to the periphery. We start with the divide and concur technique. Learning not to dive on a piece. Stay on the surface. And then we progress to stop and chop. We groove, we crack, we rotate and do a horizontal chop. And advance once you get that down, we advance to horizontal and vertical chopping and introduce pre-chopping throughout when we have a nice soft lens. And on dense lenses I typically have them do a my loop. A really important concept is pivoting in the wound. You have a wound, an instrument. If I want to go down, I don’t push down because that opens the wound up, to go down I need to lift up and drive forward to get into the bottom of a groove or into a chop position. So to lift up like that, imagine you’re sitting on the eye like this and operating, to go down, I have to pivot off my ring finger and lift my hand up. And now my instrument comes in like this opposed to coming in like that. So that ability to raise your hand up off of that pivot point, the fulcrum that you placed on the patient’s face, often, if you watch expert surgeons operating, they will be doing this to get deep. They raise their hands up and drive the phaco down into the bottom of the groove. So you have to be able to seesaw the instrument. Avoid excessive downward force. If I push this eyeball down, what is going to happen is I’m pushing into the orbit and you see conjunctiva balloon up around it. If you see the eye go down or out of focus, don’t push down on the wounds. Keep them neutral in all directions. Up and down and side to side and driving it forward. Be in tune to what you’re doing with the wounds. Okay. Let’s talk about cracking. I made the groove and I have my instrument. The typical way the resident will approach cracking is they push down to try to get into the groove like this. And that is — you’ll see that here — pushing down on the wound, you open up the wound and you get egress of the saline or the BSS and egress of OBD and the chamber will shallow. You don’t want to push down on the wound to go deep. Instead, you want to lift up and then drive forward in that wound to get deep into that groove. So you lift up and then drive forward with the instrument to go deep. That keeps the wound neutral. We talked about that. Now, for chopping, it’s a similar concept. So when you chop you want to lift the instrument up like this. You want to make contact deep on the lens. Then lift up. When I’m chopping, I have my chopping instrument here, is the nucleus, you make contact before the anterior capsule. Make contact with the nucleus and you have a little downward force on the nucleus. Make contact, make contact and drop off and lift to get the chopper really deep. Lift the hand outside of the eye to drive deep around the equator. I take my hands and lift up the phaco probe, the chopper, I’m lifted and go over the surface making contact with the lens before the anterior capsule. Contact, contact, contact. And then I lift, because what I don’t want to do is go, I lose contact with the lens as I go around the equator. I don’t want to pop the bag on the posterior capsule. Contact on the top, get underneath the capsule and as you make that turn around the equator, I don’t want to travel this way and pop the posterior capsule. So that lifting of the hands to get into chop position and getting deep and then that is really important, and algorithms on the chopper, lifting to make tracking on the anterior lens of the nucleus. And by making contact that ensures you go underneath the capsule. I worry about two spots, going over and chopping the anterior capsule. To avoid that you go over the lens and travel out. The next thing is you lose contact around the equator and pop the bag here. If I lose contact with the equator I can pop the bag here. That lift keeps the contact and now you can do a chop. Okay. There’s a question. What is the difference between full incision cataract surgery and — which is more advantageous for the patient? Both are good techniques. Manual small incision cataract surgery has excellent outcomes. Phacoemulsification has good outcomes. It depends on the clinical situation, where you’re operating. If where you’re operating is mostly M6 and doesn’t have phaco you need to be a good M6 surgeon. If you have phacoemulsification, you have to learn how to do really good phaco surgery. Which is better or easier for a surgeon to do? It depends on the mentor. If your mentor is confident in doing M6, you need to learn that. If your mentor is confident in phaco, you need to learn that. Moving on, say we disassembled the lens with whatever technique you want: Divide and concur, horizontal chop, vertical chop, whatever it is. We have four or more pieces. I find that we don’t spend enough time discussing how to get the pieces out. So the natural inclination for most new surgeons is to try to go deep — going deep on the piece and trying to engage here. I don’t want you engaging quadrants deep. When you engage deep, and pull it up, it will hit the other two quadrants next to it and doesn’t want to come up. You want to instead grab a quadrant at the top of the quadrant. That is important. When I grab it at the top it rolls out and it’s easier to get out. When I apply phaco energy, I want as much lens material between my phaco probe and the posterior capsule. If I start deep on the quadrant and buzz, I break the posterior capsule. If I start high up here on the quadrant, I have a lot of runway, a lot of space. I have a lot of material to buss into before I get to the posterior capsule. It’s a safety and an efficiency issue. When you approach a quadrant for quadrant removal, I think of it as having three steps. The first step in quadrant removal is purchase. I get a hold of that piece and the goal of purchase is to use as little phaco as needed but as much as needed. What I mean by that. I don’t want to just bury the tip all the way in and not pay attention that I didn’t need that much. Because now I’m increasing the risk of the quadrant removal. How do I decrease the amount of phaco. You maximize surface area. Imagine this is the bevel of the phaco tip. If I come in like this, I’m going to have to buss all the way to here to occlude the tip before I can built a vacuum. To use less phaco energy, I need to turn my phaco probe like this and maximize the surface contact of the open bore of the needle. If I do that, I basically have occlusion right as soon as I hit aspiration. On a soft lens it will come up and I’ll get occlusion. On a dense lens I might have to go a little bit of phaco to bury a little into the lens. That’s the first step. Getting a hole. There are three steps, the purchase, the hole is the first step. I get a hold of it and pull the lens out of the bag and into the iris plane. That’s called the travel. To do that you transition from the purchase where you go — and out. Now, if I imagine this is my anterior chamber, where do I want that piece sitting when I’m eating that lens material? I want the piece to be right in the middle of the chamber. That means my phaco tip is going to be a little behind that. You don’t want to be too far forward. What residents D as they eat a piece they move the phaco tip forward and you get closer to the posterior capsule and I have less material with me and I’m closer to the posterior capsule. As I eat the piece, I pull back. The first step of getting a quadrant out is purchase, getting a hold of it. The second step is the travel. Getting it out of the bag and into the kill zone. A safe zone right in the middle of the anterior chamber. The third step is going to be the kill. You apply phaco energy at that point to get it out. Apply the energy. Now, when I go to eat a quadrant in the kill, I don’t want to, again, go through the back of it. I want to turn and I want to stay above the piece. I want my phaco probe to be above the piece. Don’t go under it and phaco hard. You don’t know where you and you can bring the bag up. Stay high on the piece and eat it from the top. Not the bottom. A lot of times we break bags on quadrant removal because we’re not breaking it into three steps. The hold which is a different foot technique than the travel. Which is a different foot technique than the kill. The eating of the piece. Imagine your brain, quadrant removal has three steps. No. 1, hold the piece, don’t use too much phaco energy. I use the vacuum, keep it in position two. Travel into the middle of the anterior chamber and I a ply energy and make sure that I don’t push forward, I stay on top of the piece and not go under it and break the bag. Those are some pearls for quadrant removal. That is not how you want to do it, deep like that. You want to be high like that. Some tips for cortical clean up. Residents tend to go too deep. Imagine you have a bag and inside the bag you have a cortex. You have anterior capsule, anterior cortex, posterior cortex, posterior capsule. Where do you want to be. A lot of residents go way out here into the equator of the cortex. Instead, you want to stay here at the tips of the anterior cortex. If this is cortex, grab it up here. High in the bag. You try to get occlusion. I will aspiration and I’m just trying to get cortex to fill the hole, the aspiration port and build up vacuum. Once I close up the port with cortex material, now the vacuum is going to go up and I get a hold of the cortex. What I want to do is not eat it. I want to hold it and strip it out of the bag. So I don’t like to grab and pull to the middle. I want to grab and go around the edge of the capsule and pull as I go around, I increase the aspiration. And once I have four or five clock hours I pull to the middle and eat it. You want to wait to floor it until you’re in the safe position. Where I’m away from the capsule. So that’s my main tip. Now sub incisionally is where you get, a lot of people run into problems. The same principal holds true. If I’m sub incisional. I turn the port down and I want to stay high where the anterior capsule is and aspirate to a collude the tip with the anterior cortex. How to hold lens for chop? If you’re doing a straight horizontal chop, you need to get that phaco probe into the lens. You don’t have to keep vacuum when that happens. Once I’m deep, I get the chopper out and it’s a simple pinch. Different than vertical chop. What I’m doing is going down to the phaco and pulling the lens up with the vacuum. I have to keep position two. I take the chopper and dive in front of the lens and do a spread like that. For horizontal chop, you don’t need to be applying the vacuum. In my experience you can do a mechanical to see if the phaco probe is down. You do a mechanical chop like that. One thing when doing horizontal chop, a lot of people tend when they first learn to do it is to push the phaco probe forward. You don’t want to do that. keep the phaco probe stable and then the chopper is traveling. Notice the movement that I’m making, the phaco probe is vertical and goes down and the chopper moves and then you separate. I see a lot of residents doing that. You don’t want to push the phaco probe forward because the whole lens dislocates and you can break zonules. For vertical chop, go vertical with the probe, and buzz down and — like that. And then another question, before holding, do I have to stick the phaco tip into the fragment or can I stay further and let the aspiration bring the fragment to the tip. When doing quadrant removal, the main pearl is turn the bevel to maximize the surface area contact of the phaco probe to the lens quadrant. If you don’t do that, you have to do a lot of phaco energy to occlude. So, that is the main piece of advice I have for you on that. How to improve follow-ability. Even time I apply the piece, I do phaco and it flies around and comes back to the tip. Follow-ability, as I eat it, it just sits there. What is pushing it away is the phaco energy. What is pushing it away is aspiration and vacuum. If you get a lot of chatter, you want to increase the vacuum, potentially increase the aspiration. Or maybe using too much phaco energy to back off a bit. It’s a balance between the attractive force of the aspiration and the repulsive force of the phaco energy. I have been trained purely in M6, how easy is it to transition from M6 to phaco? M6 is a beautiful surgery. I wish I was better at it. I’m a pretty good phaco surgeon but not a very good M6 surgeon. It’s a different skill set. How to handle a phaco probe and using the foot pedal takes training. I recommend going to wet labs if you don’t have that training in your facility or going to a place like a fellowship to learn phaco. Do you prefer bevel down or bevel up during horizontal and vertical chop. I think people do different things. I prefer bevel up. I like to see where the hole is and what is going into the phaco needle. I think it’s fine to do bevel down as well. It’s just preference. I think we answered the questions. Perfect. So we talked about this. This slide is showing you need to be good with your feet. Go to your wet lab if you have one or got to the OR and put your feet on the foot pedals and get used to it and listen to the machine. I also recommend while pushing on the foot pedal. Bring the machine screen in front of you and watch the diagrams on the machine. What is going on. What is going on with the aspiration. What is going on in the vacuum. Where the phaco. I think that’s a really high yield thing to do. Push on the foot pedals and know how to use them. Take the machine and look at the screen and see what the foot pedal is doing. Summer pearls. I will start with a question. Which of the following is not a characteristic of a great cataract surgery mentor. An extrovert personality type. High emotional intelligence. Talented cataract surgeon, and four, wants the trainee to be better than they are. A, B, C, D. Pick one of those answers. 44 percent said an extrovert is not a great characteristic. You can be extroverted but it’s not necessary. High emotional intelligence is really important. That you’re able to look at your resident and understand their emotions at this point. Are they stressed, are they happy? Are they feeling confidence. Are they feeling not confidence. How are they responding to this situation that they’re in. And being able to manage their emotional state and finding some way to get them over the anxiety or the fear of failure that they’re experiencing at that point in time. I tend to try to talk to my residents about their hobbies and their families and kids and wives or spouses or significant others. Something to get them feeling like they’re more comfortable in the OR. I had one resident who was a big football fan. His favorite quarterback is Tom Brady and I talked to him about that even though I hated Tom Brady to calm him down. You have to read the resident and have enough emotional intelligence to tell where they are emotionally to do the surgery. It’s essential that a cataract surgery mentor feels comfortable getting the resident out of complications. It’s inevitable. Someone learning is going to do something wrong. Hopefully you’re watching them and catch the complication. Or they are going to do something wrong, there is vitreous or something else. You need to feel comfortable fixing the situation. I don’t want to take a resident who is learning and I miss something and they have a complication and then I make them feel like it’s their fault. It’s my responsible to make sure they don’t have a complication and if they do have a complication, I’m going to let them manage it if they’re able to emotionally, mentally, physically. But if they’re not able to handle it, I take over and make sure that patient has a good experience, as good as possible and that resident is able to recover from that situation. So being a talented cataract surgeon is important. And the last one is essential. When I look at the resident, my goal for them at the end of the rotation is they’re a better surgeon than I am. I don’t want them to be mediocre, I want them to be out standing. If you don’t have that fielding when you’re in the room with a resident, maybe you shouldn’t be staffing residents or teaching them. It’s an essential characteristic. Personality type of the attending I don’t think, whether you’re an introvert or talkative or not. A people person or not. If you have that emotional intelligence, you’re a talented cataract surgery and you want the resident to be better than you, those are the necessary ingredients. I put that here as well. Being cool under pressure is important. If you’re a combustible personality type where when you’re stressed you yell or throw things. I don’t think that makes a good resident training experience. I think the resident will be scared, afraid of making mistakes and afraid of learning. You have to be careful how you frame the situation for that residents. There is something that didn’t happen that was ideal, maybe a lens piece dropped. Making sure they understand, you want to drop more pieces. Make sure we have no traction on the vitreous, save the anterior capsule. Let’s talk about optic capture. Let’s talk about myostat. We have a lot of learning that can happen and reassuring them. We did everything appropriately and handled this appropriately. We have a retina specialist that will come in and clean up. And this patient will do fine and you help them manage the patient afterwards. This slide here is to show you how we rotate residents in our teaching institution. We have several teaching institutions. One at Grady and what I advocated for when I first started is my residents in senior year have one big block. Instead of doing one month here, one month there, one month there. I want all the months together and line them up. I don’t want someone learning how to operate with me and leave. I want four months of teaching. Like a mini fellowship. Our residents do 200 cases, maybe more, maybe a little less. But around 200 cases. Once they get to that number they are very talented cataract surgeons. People ask, how do you coach a resident? So during the four-month rotation. In month one, they do around 20 to 30 cataracts. I will hold their hands during the act surgery. I will see how tightly they are holding the instruments. I move their hands for them so they know how to move them. I look at hand position. I’m constantly talking. I am nonstop commentary on their cataract surgery. I don’t like how you did this, oh that was an awesome job, fantastic, really good, awesome, really good. , you’re taking with the realization there is an awake patient under the drape. So you have to be careful how you frame the criticism. But you, I’m very insistent for the first 25 cases, there is going to be hand holding. A lot of hand holding. Less as they get through the 25. And then the verbal coaching is constant for at least 50 to 75 cases. And slowly that goes away. I want by the third month they’re able to do surgery without me talking. I will continue to scrub in through the third or the fourth month but my goal is to not scrub in with them. Give them the feeling they are able to do the surgery on their own. When I leave, they are still able to do the surgery. And taking over when things aren’t going well. If things aren’t going well and they haven’t managed this complication before, I will take over so the patient has a good experience. Near the end of the four months, I start letting them have more leeway in managing the complications but the first three months are building a foundation and we want to maintain the resident’s confidence. I’m going to stop there. I have talked a lot. Let’s answer some questions here from the Q&A. How do you keep the wound neutral during cortical clean up? There is an important concept within the instruments. The way I keep the eye neutral with a coaxial eye piece, I lift the hand up and lock the wound and hold it back. When I’m doing this or that, I’m always putting some backwards for on the wound with my hand piece. That is extremely important. What is your preferred technique for soft nucleus? There are many ways-over dealing with this. If there is a young patient in their 30s with a diabetic cataract we go in with the hand piece and not use the phaco. If it’s denser, a pre-chopper. Divide and concur: You have to be careful on the soft lenses, you can take a lot more with the phaco needle than you anticipate and there’s a risk of breaking the posterior capsule. Soft nuclei can be challenge. You can move the whole thing and pop the bag without realizing what happened. Next question, does the difference in tip and sleeve phaco affect the process of different sizes. The principles are the same. If you use a different keratome blade and different sleeve, acceptable. Make sure you’re using the correct sleeve for the incision. So there are different sleeve sizes that fill the incision. What you don’t want is to use a small sleeve on a big incision and that incision is leaking and you get an unstable chamber. All the different sizes are acceptable just pick the right sleeve. When making a keratome incision, you need to go in and out on the same track. Don’t widen the wound as you come out. If you do, the sleeve is not going to close off the wound and you’ll get too much leak. How do you maintain the eye centrally? We talked about this. You have two instruments in the eye. If I’m pushing forward, the left hand is pushing against is that motion. If I’m moving the chopper forward, I pull back on the posterior aspect of the wound. Pulling back with the phaco as I go out with the chopper. How to do cortex aspiration under main incision safely. What happens sub incisionally, this is the capsule, a lot of people go too deep with the hand piece. You want to be very high. Right at the tip of the anterior capsule as I’m going to aspirate the cortex. That keeps you far away from the posterior capsule. We do capsulorhexis from the incision or side port or main port. You can do it from the side port. The next question is uveitic lens may pose difficulty to dislocate. Uveitic cataracts are a whole separate lecture. I did a fellowship in uveitis. We can schedule another talk only about that. Does this procedure apply to known diabetics. If you have a patient who is diabetic, uncontrolled and their vision is 2400 this both eyes I don’t wait until the diabetes is controlled before doing the eyes because they can’t see. If they have one eye that is seeing okay and the other eye has a bad cataract, I probably hold off on the cataract surgery until the diabetes is better controlled. But you have to make sure the patient is able to follow their medical regimen. My clinic allows only one act surgery per week for a resident. Do you think that is enough or find another clinic to learn the surgery? I find that residents pick up learning as they do multiple surgeries in a day. I like the resident to do four a day or more. Eight a day or ten a day: We’re reinforcing teaching points from one case to the next and they’re picking up a lot of skills. I think the repetition on the same day is important. How many days a week are the trainees in the OR during this 4-month period? Two to three days. Monday, Wednesday, Friday, and the other is Tuesday, Thursday. And then they switch. And then the next question is how to handle polar cataracts in beginners? I typically don’t. So residents who are just starting out, you want to book more bread-and-butter cases. That is not something I want a resident doing on their first 25 to 50 cases. They have to have some foundation. I would book that with a resident that has more experience or wait on the surgery. How do you involve as a mentor with the resident fail at surgery? As the mentor you don’t allow the resident to fail. You are there coaching and monitoring and controlling the environment. If a complication happens you take over and fix it. Fail at surgery, that would damage my psyche if someone allowed me to screw up a surgery. We want to generate surgeons who co-do surgery. It’s important that we prevent residents from having complications and if they have complications, taking over and making sure they have a good experience. What is your recommendation for the prevention of iris prolapse during phaco. That’s a really good question. On patients who are on an alpha blocker, we put them on, we put epinephrine in the lidocaine as one preventive measure. We make sure that we’re careful when doing hydrodissection. Not forceful because they will cause iris prolapse. The key is when going in and out with a phaco probe or a hand piece, don’t go in irrigating. You go in, no irrigation, close the wound and then turn on the irrigation. When coming off, turn off the irrigation while you’re inside the eye and make the eye soft by pushing on the paracentesis incision or come out slowly and allowing it to leak around the sleeve very slowly and come out. You don’t want to come out and go in under high pressure. If I do get iris prolapse, the first thing is I decrease the pressure in the eye by burping the paracentesis. If I can’t get it to burp enough fluid or OVD, I will take the cannula go into the main room over the iris and push down and get material out that way. Once I soften the eye, I will irrigate the surface and massage the anterior lip of the cornea to get that iris to reposit back in. Give tips on IFIS management. We talked about that. Can you explain the trick to insert the iris hook, please. Unfortunately, we’re out of time for the last few questions. We can book more time to go over these questions. Thank you so much for being so interactive and taking the time out of your days all across the world here. I appreciate your time and hope you found this beneficial. Thank you so much.