Lecture: Setting Yourself up for Success During Your Phaco Journey

In this interactive webinar, Dr. Coleman will present some key hand positioning and ergonomics for maximizing your comfort and success as a microsurgeon. He will cover many tips and lessons learned that will help with visualization, surgical techniques, and preventing orthopedic injuries for successful long-term surgeon health. Dr. Coleman will also highlight key points from the cataract basics video series. This webinar will be a surgically based and video-intensive presentation that will cover critical, and often overlooked, points that cannot be found in textbooks and are not usually covered at any point during a surgeon’s career. (Level: Beginner and Intermediate)

Lecturer: Dr. Wyche Coleman, Ophthalmologist, Willis-Knighton Ophthalmology, USA


WYCHE COLEMAN: Okay, good morning, everyone. Thanks for tuning in here to Cybersight. This is a talk on a couple of things related to cataract surgery efficiency. We’ll talk about positioning yourself in the OR. I realized, when I started training residents, I was trained at LSU in Shreveport by the program director, a great cataract surgeon. I think I got great training. But the one thing that was left out that nobody ever mentioned was how to position myself correctly at the microscope. I spent the majority of my life as what I thought was a good surgeon. Our fellow does about a thousand cataracts, we realized early on one of the key things to getting them efficient and safe in the OR is getting them in a good position. My previous fellow joked it was primarily a positioning fellowship because when I would come in the OR with him I would talk about how they were positioned at the microscope more than I talked about their technique for cataract surgery because it may be as important, perhaps more important. We’re going to go through a few points that have and then get to a few cataract surgery videos and talk about some techniques after that, and then do a Q&A. So we got a few polls. The first poll, I wanted to see who had had training during residency, any formal training on positioning yourself for cataract surgery. I’m curious if I’m the only one out there who never got told anything about this or whether that’s a common occurrence. Okay, guys, Lawrence and Andy, you can let me know when this poll is going to be done. I’m going to go ahead and click. Okay. It looks like 37% yes, and 63% no. So the majority have not heard anything about this. So I’m with you, that’s how it was for me. Maybe I had a few points here and there, but I think it’s sort of a mixed bag. Every time you walk in the OR with the resident, I feel like they’re in a different position. This helps me a lot. I can relate this to — pretty much everything, to flying. In flight training, if you get someone flying a very regular pattern they do a lot better landings. I think positioning yourself during cataract surgery is sort of a similar concept. So we’ll get started on that. Let’s see. Okay. Here we go. So just an overview. There’s a lot of cataract surgery that needs to be done. Obviously the mission of Orbis is to train more efficient surgeons so we can conquer some of the cataract induced vision loss worldwide. I think we have to be efficient in order to do that. So let’s start. We’re going to go through a few points. Number 1 is positioning your body. Number 2 is positioning the scope. Number 3 is positioning the patient. And number 4 is positioning your hands. You’ll hit those points and get to a few cataract surgery videos. This is a shot of me in the OR. I use Ingenuity exclusively now, it leads to a much better position. There is one location I operate at that I do not have 3D, I’m still looking through the microscope. So I do both, but 90% Ingenuity. The first point is to position yourself in the chair and have good lumbar support. Obviously there’s a bunch of different types of seating you can use. I use a couple of different chairs. My favorite is the C-arm, my partner uses what’s called a throne. No matter what you sit on, make sure you get good lumbar support and a place to rest your elbows so you’re not floating all the time. I feel like if I’m in a chair that doesn’t have anything for me to rest my shoulders on, my lower back will get tired by the end of the day. The OR, we do 30 or 40 cases a day. I used to do 40, now it’s more common for me to do 30. A little tiny amount of poor positioning makes me completely worn out after a dozen cases and I’m unable to make it through a day of 30 if I don’t have an excellent position in every case. So I start with making sure that you have lumbar support. Hopefully you can see my mouse. I feel it pushing into my back a little bit. I don’t want it so far forward that it’s sliding me off the seat so I don’t have enough contact with the seat. I want it far enough forward that I can feel it giving me some definite lumbar support. Okay. I think the second point is positioning your feet. And this is really as it relates to chair height. So once you have lumbar support, you want to try to get your height correct. So, you know, this is basically depending on how tall you are. I think most cataract surgery ORs were really probably designed for tall people. I’m 5’6″. I think it’s easier if you’re taller because you can raise the height up and not have it touching your legs and feel like it’s encroaching on, pushing down and compressing your legs. The shorter a surgeon is, the more critical it is. Ingenuity has changed the game for me because I feel like I can operate through probably a 12-inch height difference. If the patient is very high or very low, it doesn’t really matter because I don’t have to be able to reach the scope. But with the traditional scope, it seems critical that I have the height exactly right, probably down to the inch. So I start out with my feet on the floor. I do operating boots, it’s a little bit of a weird thing, it works for me. So I start out with my feet on the floor. You want your femur to have a slight down angle when your feet are on the floor because the pedals will raise your feet up a couple of inches. Ultimately you want them to be about later, femur parallel to the floor is the position that I like. I think this was the position that Dr. Alan Crandall was a proponent of, he was probably the best cataract surgeon I ever saw in person for sure. So, slight down angle to start with. Set your height. And then raise your feet up on the pedals, get them in a comfortable position. They should be just about parallel, maybe with a slight down angle. I feel like a slight down angle enables me to maneuver the bed and gets me slight lower so I don’t have to reach my neck up to be aligned with the microscope. Now we can get to positioning of the pedals. Let me look at my notes right quick and make sure I did not miss a poll. No, we don’t do another one till slide number 9. There’s two components to pedals. One is how widely they’re spaced apart, the span. And the other is how far away from you they are. So this is a common thing that I see in residents where they tend to get the pedals too close to them, especially the shorter residents. I don’t know why it’s more common, I think tall people just have to get their feet further away because there’s no place to put them close. But short people tend to get the pedals close. Once you get the pedal too close to you, I feel like you don’t have good articulation of your foot. When you drive a car, the gas pedal is out in front of you you. I think the phaco pedal should be in a similar position to like a gas pedal in a car. You have better fine motor skills and control of your articulation if the pedal is slightly further away from you. The image on the left would be an example of getting the pedals too close. I feel like this crowds me and I don’t have good foot control. The middle image would be an example of not wide enough of a span. So spread your legs out to where you feel like you have the pedals in a comfortable position, comfortable width. Obviously you’re somewhat limited by the bed on the left side, depending on which eye. You’ll at some point come in contact with the bed. I get it as far out as I can, basically bumping right up against the bed, and the rollers for the bed. So the right image would be an example of what I would call correct positioning of the pedals, a correct span. That is adequate to have good foot control and a good comfortable position. I wanted to make a point, because we’ve gotten a few new phaco pedals lately. And they come with some little plastic rollers in these threaded holes here. This thing, when I got it from Alcon, and I never had this happen to me before, it was basically like an ice skate, you could slide it across the floor. I use the phaco pedal to anchor myself. I don’t lock the chair in position. I basically have my heels resting on the pedal so they’re slightly pulling me forward and whenever the pedal came with these rollers in it, it made me unable to do that. So the first thing to do is remove those things or at least screw them down so far that they’re recessed and you have the rubber portion of the pedal resting on the floor so it can anchor you in a good position. Okay. I think it’s time for our next poll. What’s the most common cause of disability in ophthalmologists? I think this one is not a multiple choice. You can just type an answer, we wanted to see what people would come up with. This is an image from the ASERS website, up until about a month ago. I saw it and I thought, wow, this poor lady, if she stays in that position, she looks like a young ophthalmologist, her neck is not going to last her her whole career, she’s going to have cervical disk disease. I thought, if that’s on the ACRS website, I thought this was a common problem that’s probably causing an issue for a lot of people. I don’t know if our short answer poll worked, but one of the most common causes for sure is cervical disc disease, it’s common for people to have to have their neck operated on and become disabled and not be able to operate anymore. That goes back to the point, we would like to be as efficient as possible but we also want to have a long career because that helps solve the global cataract problem, if we can operate for more years. I think this is an example what have not to do. You can see this is a scope that’s very level, it’s totally flat, it’s not tilted towards her at all. And she’s sitting in a position where her torso is slid back from the table that she’s operating on so she’s forced to lean forward with her head. I think that’s the position we don’t want. Okay. Let’s see. So we took a few images. I actually will post a video with all of these topics, narrated. We’ll probably post it on Cybersight also. I’ll post it on my YouTube channel. These are some screenshots from the video. This is an example of the scope angled at zero degrees. The scope is flat here. When the scope is flat, you have no choice but to lean forward in order to see through. The right image is a scope angled at 16 degrees. This is my preference. So if I’m operating and looking through the microscope and not using Ingenuity, 16 degrees is the most comfortable angle for me. And I’m not saying that’s an exact number. That’s just sort of a ballpark to get you close and certainly you can vary it per your personal preference. Our next poll, I was going to ask, how many people currently tilt the scope or set it? I guess really the concise question is, do you set an exact degree angle or do you operate just however it happens to be when you go in the room? So we’ll let everybody vote on that and take a look at the results. I was curious. Hopefully I’m okay to go to the next slide. I’m going to go ahead and click one slide forward. There we go. Okay. Do you currently operate with a tilted scope or specific angle or operate with it level? It’s about a 50-50 split. For the 50% that don’t operate at a specific angle, I would suggest you try, I think it will make your life easier. I find with the residents and fellows, once we get the scope in a good, comfortable, consistent tilted position, that it helps them a lot. Really important with mgs too. Basically this gets my neck straight up and down and not leaned forward, which I think is a more ergonomically advantageous position. How do we position the scope? So, you know, I’ll run a video here, this is the way I do it. Certainly you could use a fancy level. This is just a level on the iPhone. This is an Lumiere 700. Basically you could use it across the objective lens too on any microscope. Then you can tilt and measure the angle. 16 degrees, and you’ll see on my scope, I made some marks. You have to have the Z axis, zero, for these marks to work. I found a way to mark a Lycoscope I use. On this scope I have zero, 4 degrees marked. Let me rewind. There we go. I’m getting ahead of myself. So we can see that the oculars, as you go closer to a zero degree tilt angle, they’re pulling away from you. As you go towards the 16 degree angle, they move towards you in space. So that’s the basis behind the idea that you don’t have to lean your neck forward and put yourself in an uncomfortable position if you tilt the scope toward you. Let me rewind in this video. I want to get to the spot where you can see all of my marks. So you can see one at zero, one at 4 degrees, one at 16 degrees, one at 31 degrees. There’s actually one that we saw just for a second there that went to 35. So when I first started doing mgs, the suggestion from the rep was a 35 degree angle. I think 31 is better for me. Zero is what my partner uses for Ingenuity, he likes it totally flat. We’re not concerned with that position then because we’re looking at the TV screen. I find a slight offset gives me better reflex. 16 is what I use for non-Ingenuity cases. 31 for mgs. Pick the angle you like, mark it in that way, you can consistently go to it every time. That helps our fellows have good visualization of the angle. We had one more question here. How many people, I was curious, we’ve switched to Ingenuity, how many people are using 3D? Ingenuity, Artevo, there’s about eight of them out there. I was curious how prevalent that is worldwide. Okay. 13% are yet and 88% are no. One of the reasons that I got into this positioning topic was really deep, because we got Ingenuity, and I thought it was the best view I had ever had in my life, the day that the rep was there. And then the rep left, and it was very difficult to replicate the position that the screen was in, to have it perfectly perpendicular, 48 inches away from my eyes. I created an alignment system, hopefully we’ll see that on the market at some point, that replicates perfect positioning. I would encourage anybody not using it, if you get access to it, of course they’re expensive, try it. I think it’s a better way to operate long term. Let’s see. And certainly produces some beautiful videos. Okay. So the next topic is positioning the patient. You know, when I walk in the OR, when I’m scrubbing in, gown and glove, I always take a glance over at the patient and I say, what does the tilt of the head look like? I try to key on their brow and cheek, and I say, what is the relative angle of brow to cheek? I think if the brow is elevated above the cheek, especially if your main incision gets blocked by the brow, that’s quite problematic for me. So I want to lower their head to where basically you have an approximately level angle between the cheek and the brow. To me this is optimal. I don’t want them tilted way back. And I think that people tend to have — they have a tendency to tuck their chin down towards their chest, this is true more for LASIK than cataract surgery. In general you probably want to start out with the brow level or perhaps a little bit down, because they’re going to tend to go back towards level by tucking their chin down towards their chest as the case goes on. So I take a glance at that as I’m scrubbing in and I ask the circulators in our staff to reposition the head. Sometimes if I don’t have an OR staff that understands what I’m talking about I do it myself before I scrub in. This is worth taking 30 seconds of your time to make sure you’ve got the head in a good position before you start the case. Okay. So we’ll move on to the position of our hands. This is equally important. You don’t want to be floating. And I would say that, you know, no matter how poor your position is, the patient’s position is, in general, you can get through a couple of cases like that. You can suffer through just about anything. I have had a couple of patients that we had a really tough time positioning because of COPD, congestive heart failure. My partner did a case where they could not get the patient out of a wheelchair. They tilted the head back and he basically stood at the microscope and made it through the case. You can almost get through anything for one or two cases. I think that all of this positioning talk that we’re going into and the emphasis on it is to try to be able to do a whole lot more cases. Surely you can’t do a lot that way. So, hand position. I like to have a lot of contact with the head. I want to be — you know, contact with the cheek, contact with the forehead, with the back side of my fingers. I relate this to, you know, people who shoot, like professional snipers, they say you should exhale so you have maximum contact with the ground if you lay down in a prone position and shoot. It’s the same sort of idea, that we want maximum contact between your hand and the patient. And I think this puts you in a safer position because if they move unexpectedly, you tend to move with them. If you don’t have good contact and you’re floating in space, they can move and your instruments are staying stationary, you have a lot higher tendency to rupture the capsule or do some damage when the patient moves rather than moving along with them. I surely have had to make a lot of unexpected movements over the years. I tend to get away with it and not rupture capsule, it’s only happened a couple of times, because I have good contact and I’m moving with them. So here’s a couple of positions, examples of positions to avoid. And I think that when we have good hand position, we have good contact with the back of our fingers, then you’re using your fine motor skills, your fingertips to rotate the second instrument and the phaco handpiece. And I think we want to avoid doing a lot of elbow movement, doing a lot of risk movement. Most of it is in the fingers. That’s where our fine motor skills are. I think we become better surgeons by utilizing that to the maximum potential and not using larger movements to try to get in a good position. So the left image is an example of resting your fingertips. This is common. This is a hard habit to break for me with my fellows. Really both images are an example of that. I think sometimes you’ve got to rotate into that position, perhaps during sculpting, perhaps if you’re trying to get very deep with the second instrument, you have to rotate some with your fingertips resting on the brow and the cheek. But I think we always want to go back to the baseline of the back of our fingers. So if you do this all day, you will get tired, you will not be able to continue and do 30 cases with great regularity. At some point your fingers are going to get exhausted and you’re going to become unstable because of the way you rest. Again, this is another example of the first image I showed. To me, this is an ideal baseline position to be in. That maximizes contact, improves stability, and prevents fatigue. Okay. So we’re going to plug the basic cataract surgery course, titled Basics of Phacoemulsification, a video course that are my surgical videos created with Cybersight. We’ll go ahead and do the poll while I talk through the background of this. And by the way, we’ve completed the positioning talk. So I wanted to see now what people’s average time is, where are you now. So, positioning, I’ve sort of exhausted that subject, I think, and we’re going to move on to a few surgical videos. So the videos in this course are basically ten random cases from a given OR day. It’s the same day, they’re not laser cases, they’re not refractive cases, just straightforward cataracts. I think they’re a good example of a usual day for me. We took the cases and we divided them up. Okay. Great. Here’s our poll. 5%, less than five minutes. Looks like most people are greater than 15 minutes. That’s where our fellows start, everyone starts, you know, doing cataract, and I’ve spent a lot of time with the fellows now, in making these videos, also it made me a lot more aware of where I’m using my time up. Making these videos made me a slightly better cataract surgery. We broke them down into steps. In my own YouTube channel I broke those down into separate categories, here they’re together. I don’t think it’s that important, it works fine either way. But what we noticed was, is that the nucleus removal, that takes up the most time. We see this with residents and fellows, we always say you can only do your incision making, you can only speed your time up so much. Let’s imagine it takes you 30 seconds or it takes you 5 seconds to create an incision. Nucleus and cortex removal can take anywhere from 2 minutes to 30 minutes. So I think that most efficiency is gained by compressing that timeline, by having a very definitive plan for nucleus and cortex removal and trying to execute that plan with great regularity. So another basis of this video series was that I think that people post all sorts of super complex cases. It’s probably a video that represents the best case they’ve ever done in their life, they edit it highly and put it on the Internet. These cases are the exact opposite, and that’s by disdain. They’re a random assortment from a single surgical day. They don’t represent necessarily my best work. And I think that’s good for cataract surgery training, to show some examples of an average case. On all the videos I post, I try to post a lot of just whatever my average case is. The next video here is going to be, you know, the exact opposite of that. Here we go, here is our — if you want supplemental material beyond the Cybersight course, this is our YouTube channel, the Cataract Fellowship, that’s my fellow carrying me around the OR. Here is an example, I wanted to run through this one so you could see my technique from start to finish. This is the exact opposite of what I preach about. This is an example of maybe one of the fastest cases I ever did, I think it was about 3 minutes and 42 seconds. I have trouble replicating that. This was not representative of a usual surgical day. I use a 15 degree knife, it’s nice because you can choose the size of your paracentesis. I prefer it over the blade. You don’t have to make the exact same size incision every time. We use sugarcane on every patient. The only reason not to that we can come up with is, my theory is you’ll use a lot less Myostat if you get adequately dilated people from the beginning. I puncture the capsule, I use Utratas to create the capsulorhexis. If it’s later than one minute, then I’m moving too slow. I think that the key to doing that is basically just to not fiddle between steps. You want to keep moving. You want to keep moving with a pretty regular cadence. One of my OR patients, I do not have very experienced scrub techs so I have them set up a tray for me with the instruments on a Mayo stand and I grab them myself, it’s easier than having somebody you don’t trust not stab you. I use a modified divide and conquer technique. I think it’s a teachable technique. My partner and I both learned at the same location. We both use essentially the same technique and our post capsular rupture rate is one in a thousand or so. A couple of years and maybe 3,000 cases, I thought maybe I’ll never rupture a capsule again, then I ruptured three in one week and got right back on track with the one per thousand number. The law of averages catches up with you one way or another. Our fellows usually start at about one in a hundred and hopefully they finish somewhere around less than one in 500. I think part of it is because of the technique, because most of the phaco’ing is done about at the level of the intracapsular leaflet or iris. I think you can get away with it most of the time but if you want really great regularity and safety it’s better to phaco a little bit more interior. There could be a reason to phaco deeper. But in most cases, you think it’s fine. So lens insertion, one of the things I’m trying to do to lower my surgical time currently is to do hydroimplantation using a 21 gauge cannula, I don’t know how common that is. I’ve seen people do it before. We don’t have a great one-handed injectable lens that works well with hydroimplantation, it seems to work pretty good. This is what I’ve been using, the plunger is not quite long enough. I have some videos online of hydroimplantation, a little bit of time can be saved because you don’t have to remove the scolasa at the end and probably have less pressure spikes as a result of it too. Okay. So we’re finishing this one up. You’ll see the time here is about 3:40. And we’re done. This was a very efficient case. Again, that is not absolutely typically for me. I would say — whoops. I would say that my average time is around 5 minutes, 5 minutes and 30 seconds. Okay. So one of the questions, and we can just put this in the Q&A at the end, is for future presentations, what would you like to see more of, if you can just write that in the Q&A, I’ll get to it once we finish this. So back to what I said before, I think the step that can be improved the most from a timeline standpoint is nucleus removal, nucleus and cortex are the two combined. I think nucleus is probably the one you can see people take 30 minutes or 1 minute. It’s largely due to how well you planned it to begin with and how well that plan is executed. So I’m going to play my nucleus video and talk through some of the key points of that. This is the one that is from the basic phacoemulsification series that is on Cybersight. This video is about 14 minutes. So I’m not necessarily going to talk through the exact steps as they’re playing on the video. I’m just going to talk through some concepts. As we get down to the last like three or so cases, it’s a series of ten, again, then I’ll talk through some of the specific points as they’re going on the screen. So this is — you know, my basic theory is, again, a modified divide and conquer. There’s all sorts of names for techniques during cataract surgery. I have residents and med students come through and they’ll reference some of them to me like flip and chip and this, that, and the other thing. I’m not even sure I call this the right thing. To me, this is a divide and conquer. If I misuse the term, you’ll have to forgive me. Basically I do a trying to have. And I wanted to trying to have maybe two-thirds through the nucleus, get it deep enough to get a good crack. I use a Connor wand, the best second instrument I’ve ever had, I feel lost without it. It’s hard to do damage with a Connor wand because it’s got a nice round, polished tip, you can rub the capsule with it and you’re not going to go through. I don’t like sharp instruments. I never really learned chop well. Dr. Crandall showed me some when I was in Haiti operating with him once. I was never totally comfortable with it. If it’s a dense enough lens that I need to chop it, I’ll probably just use a Myo Loop. The modified divide and conquer that I use, I think about it in my head as, I want to first get a good trying to have and a good crack. I want to crack the nucleus in perfect halves, as close to perfect halves as I can get. If you divide and conquer it and end up with one-third of the nucleus and the other portion two-thirds, the two-thirds portion, it’s hard to lift it into the anterior chamber in a safe position to then break it into quarters. I’m trying to break it into a definitive half. Then I want to take it as close to pure quarters as I can. And when I say pure quarters, once I have half of the nucleus and I lift it in the anterior chamber I try to make sure I don’t crack off one sixth or one eighth. And the reason for that is that then I have too big of a piece that’s left in the cap, in the bag, to be able to handle it easily and bring it up and take it as a smaller piece. So we want pure quarters as closely as we can get to them. So, you know, the key step is the initial crack. I tell my fellows all the time, you’re in big trouble if you don’t get a good crack to start with. And always remember, the phaco tip is about 1, 1.2 millimeters, depending on which one you use. Average lens is going to be at least 3 millimeters, probably greater than 3.5, most are probably closer to 5 by the time they’re a sufficient cataract. So you get three passes with impunity. You get three full thickness passes. I see people, I see residents that are very timid with the first pass. So that takes a long time. One of the ways you can improve your efficiency is to remember, you get three passes in total safety. So you can do those quick. And then you can slow down, watch for a brighter red reflex, move slower. The first three passes you can do quickly. Then I try to get my instruments deep. I want the Connor wand to lead the phaco but I want to get the Connor at the very bottom of the trying to have, as far rally as I can be. I don’t want to start my crack by positioning my instruments in the center of the trying to have. I want to go distal to the main wound, get the Connor in first, it leads, it’s always the deeper of the two instruments, the phaco is slightly behind it. Remember, once you crack, you can hit it with the phaco. I want to crack distally first and make sure that I see good red reflex behind the crack. And then I’m going to move proximal underneath the main wound, get the Connor deep there, same idea, then the phaco goes behind it, the Connor is slightly deeper than the phaco, then I pull the instruments directly apart. And I think care should be taken to make sure that one instrument is not moved more than the other, because then we end up moving the whole nucleus bag complex around, and that’s not good. What we want to do is move them in a completely equal amount so we end up with a crack with minimal zonule distortion. Once that crack is complete, I tell my fellows also that if you get off track, let’s imagine that you don’t get a good crack or your crack is, you know, two-thirds/one-third crack instead of equal halves, or whatever happens where you deviate from this plan, in my mind I’m always thinking, I want to get back on my normally charted path. I want to try to figure out how I’m going to get back to my normal divide and conquer technique. If you deviate, try to find where you’re going to get back on track. Once you take that one-third of the nucleus, try to bring the two-thirds up, tilt it into the anterior chamber, break it in as clean halves as you can and try to get back on track with the method that is displayed here. So let’s talk through a few cases as they’re being done. I will make a note before I do that, I’m going to catch up to this and talk through the cases as they’re done in just a second, but I would say when I groove, I divide, I get a good crack, try to take it in quarters. The second half of the nucleus, I’m trying to engage it with the phaco, tilt it up into the anterior chamber. If I’m unable to do that, if I feel like you didn’t get a good hydrodissection, or for whatever reason that second half of the nucleus just is not easy to get into the anterior chamber, and sometimes it’s a soft nucleus and you just don’t have much to engage with the phaco, so you risk eating your way through it and rupturing the posterior capsule at that stage, my rule is if I try to engage it three times and I cannot bring it into the anterior chamber and tilt it up or you can’t engage it very well three times, then I’m going to rotate and use the same method, rotate it 180 degrees, lift it up with the Connor, and use the same method that I used for the first half. I don’t do that as a standard. But that’s my backup plan. I do not show that in this video. I do have a supplemental video on my YouTube channel that shows about five cases of that where I’m unable to lift it after three tries, rotate 180, use the same method that was used for the first half of the nucleus removal. Okay. So we’ll talk through a few cases as they go here. You’ll notice this is about — I think about a minute and 15 seconds, is the average for nucleus removal, which I think is a good target. You know, look at your own cases. See what your nucleus time is. And that’s a great place to start from. Another good reference point is you want to be at capsulorhexis, you want to be making the rhexis at one minute. Our current fellow, that helped him a lot, to have a target in his mind, it took him three or four minutes to get to the point of making the capsulorhexis. He wasn’t really doing anything wrong, he was just not moving in a regular cadence. He would make the paracentesis and 30 seconds later inject some sugarcane. I want it moving in a regular flow. Once he’s done that, that brought his case time down from 12 minutes or so to sub-10 minutes. When he leaves our fellowship in a few months, he’ll be at around 7 or 8. Here I’m trying to engage the second half of the nucleus, cant it up into the anterior chamber, give it some tilt. Once there, the temptation then is to go ahead and crack it. But what you want to do is get the Connor, and I would let go with the phaco. Once I have it tilted in the AC, it’s stable there, usually. It’s not going to fall back in the bag. Then I want to support it with the Connor from behind. I want to take the phaco and let go, release, disengage. And then move both instruments down on the nucleus half. And I say in my video, I want they will optically aligned. That means I want the Connor underneath the phaco, where you can’t see it, where the phaco is blocking it. Then you pull them straight together vertically. And I think that leads to getting a larger piece off, a more complete quarter, rather than taking off like a one sixth or one eighth or little sliver, because when you cant it up in AC, you’re usually engaging it probably two-thirds of the way down that nucleus half. And if you bring the instruments together there, you’re just going to knock off a little sliver and you’re still going to have a big piece in the bag that you have to bring up after that and it’s not as efficient as bringing up just a quarter. Let’s talk through that portion as we do it so I’m taking the first half done, per the AC, letting go with the phaco, then bringing both instruments together where they’re on top of each other. Then my last piece as a clean quarter that rotates up in the AC and comes out no problem. Here is a little epi nucleus. If it comes easily I’ll take it with the phaco and protect deep with the Connor. If it does not come easy, I’ll take it with the eye, even if I have to push it with the Connor some. I would rather do it and be safe than push a bad situation with the phaco. So I go and bevel up, try to be careful to have enough of a down angle where I don’t tear the endothelium at the wound edge. And then I rotate to bevel down. And it’s worth noting that I almost never rotate my phaco bevel to the right, it’s always facing to the left, and I feel like I can get 99.9% of cases done without spending a lot of time rotating the phaco around. There is the temptation when you have a piece of nucleus that’s over to your right side that you need to rotate the phaco tip 180 and face the bevel in that direction, it seems like it would take it a lot of easier. I find that to be not necessary. And I think that represents an excess step that just burns time. So here again, the nucleus was canted in the anterior chamber. In this case I released with the phaco, slid the phaco and Connor down. So I was able to get a clean quarter. Now I’m left with just one quarter in the bag. So I also think about, from a safety standpoint, obviously we want to minimize post capsular rupture. From a safety standpoint, when you have lots of nucleus in the bag, let’s say when you’re taking the first quarter, you’ve still got three-quarters sitting in the bag, it’s going to be pretty hard to rupture the interior capsule. It’s just not going to come forward with three-quarters sitting in the bag. Once you engage that first quarter, you can floor it with the phaco. When you get to the second quarter, now you’ve only got half of a nucleus in the bag. That’s still pretty good protection. But I’m slowing down a little bit at that point. Now, once I get to the third quarter and the last quarter, I’m progressively moving slower. But in general, the first quarter, don’t worry about a capsule rupture, it’s almost impossible to do it. Second quarter, you’re at slightly higher risk. Third quarter, slightly higher risk. The last quarter is when I’m being very conscious to protect deep with the Connor, to raise that quarter up into the anterior chamber and make sure I’m not going to rupture the capsule in that step. The speed that you use should be proportional to how much protection you still have in the bag, how much nuclear you have remaining. I always say that, you know, on the steps that you’re very safe and you have a low risk of capsule rupture, take the opportunity to move fast. That’s where efficiency can be gained. When you get to steps that you’re at higher risk of capsule rupture, polishing the cortex or the last church of nucleus, that’s when we need to slow down, we need to be careful with the foot, we need to protect with the Connor and move slow. But I don’t think you need to move slow always because you’ve got to gain efficiency somewhere. So remember, when you’re safe, that’s when you should move fast. When you’ve become unsafe, or when you’re at risk of a capsule rupture, that’s the same to slow down, be very gentle with the foot. If you have a 30-case day, the last thing you want to do is rupture a capsule in one. I would rather do 12-minute cases instead of five-minute cases and never rupture a capsule. I’ll still move faster on average during my day with a low capsule rupture rate. I think that’s a key part of efficiency and also a part of safety. So here I got a little bit off-track. I didn’t get a great crack. And I didn’t get that nucleus canted up in the AC like I wanted, I ended up bringing the proximal portion up in the AC. But I’m going to try to get back on track now and bring up my second half, slide my Connor down, release with the phaco, break off a clean quarter, okay, now I’m being more careful with the foot, slowing down. I’ve got no nucleus sitting in the bag anymore. I’m at higher risk of a post capsular rupture, protecting deep with the Connor. And that concludes the nucleus removal. Let me get to my Q&A. And that’s the only segment that I did today. So you can go to the Cybersight website, to the basic phacoemulsification course. The same idea as what you just saw, those same ten cases, broken into pieces. I’ve got some narrated audio there to give some tips and pointers and then some more supplemental material on my YouTube site with some different cases, with small pupils, nucleus removal, several examples of weakness with tension ring. Okay. So I’m going to get to the Q&A now. Thanks for the questions. I’ve got, what is femur parallel. Okay. If you think about the floor is level, and your femur — let me go back to that slide so I can answer that one. That’s the great question. I think it’s probably better to just show the picture. It’s basically the idea that you’re not going to be standing on your tip toes, that you’re going to get — so if the chair is too high, let’s imagine that we start to raise the chair up, and your feet are sitting on the floor. Then your femur is going to end up with a more of a down angle. Let’s imagine we lower the chair as low as it can possibly go and your feet are sitting on the floor. At some point, they’re going to have an angle up. So I just use that as a gauge to say, am I sitting too high or am I sitting too low in general? And the image on the right in this slide is where you can see just a slight down angle of my femur, of my thigh. I would use that as a gauge to say am I too high or too low at baseline when you sit down. Let’s see. Okay. So, how to tilt the scope as I tilt only the binoculars. Can you elaborate on that one a little bit? How do I tilt the scope as I tilt only the binoculars. I’m not sure I understand that, if you can elaborate a little bit. I’ll come back to it. Would you mind sharing your phaco settings for hard versus soft cataract. I can definitely show you my settings. They should be on the video through the Ingenuity. I do not alter my settings for hard versus soft cataract unless it’s a super dense one and then I’ll switch to procedure 2, I’m on the Centurion, and that turns up the phaco energy. I can definitely show you my settings. I’m going to make myself a note to post a video talking about phaco settings specifically. I’ll make a video and I will post it on Cybersight where we switch from procedure 1 to procedure 2. But in general, I do not alter it. I just try to say, let’s have good foot control. So I think — you know, that’s an example of like using the setting for epi nucleus, for example. I never use epi nucleus, because it’s slowing everything down, it’s making your maximum phaco energy much lower, it’s making your maximum bag slightly lower. If you have good foot control you can emulate that and sculpt or quad. You basically just use less foot. I think if you have a soft cataract, be very gentle with your foot. If you have a harder cataract, floor it. So that’s the reason I alter the settings, based on the density of the cataract. But I will get you a video with specific settings. Okay. So how to prevent corneal edema, keratopathy after phaco. Keratopathy is still the most common cause for needing a PK or a desic. Did I quit screen sharing? Okay. I think I’m still online. So I think that part of the key to that is not phaco’ing too anterior. People make the argument to do in the bag phaco. For the purpose of preventing corneal edema. Obviously you want your total phaco time to be as low as possible in every case. I think that we did a study in my office, and my average phaco energy was 5.1. Obviously you’re in the U.S., we’re doing cataracts in an earlier stage, it’s going to be higher internationally. But in general, I think don’t phaco in the anterior chamber until you’re taking the last piece. What I would say is, I think it’s probably a misuse of the time “iris plane,” I want my phaco handpiece, I’m coming through my clear corneal incisions here, the iris is down here distal to the main position. Basically most of my phaco, three-quarters of the nucleus I want to take pointing at the iris, a slightly down angle. It’s definitely not aiming up. So you’re not blasting phaco energy directly at the endothelium. If you take three-quarters of your nucleus, point it slightly down, then basically go level, what would be true iris plane, for the last quarter, and protect deep with your second instrument, then typically there’s not a lot of corneal edema post-op. Most of these people are 2020, 20/25. I would say if you have a dense cataract and you have access to a Myo Loop, that can help mitigate against corneal edema. What about sitting superiorly? I know a lot of people sit superiorly. I have operated superior a few times. I did some cases in Trinidad, everybody sat superior. I was able to adapt to it. As far as the head position goes and your position in the chair, as far as lumbar support, all those things should be transferable to the superior position. I have to say I’m not an expert on it. I feel a little bit lost superior. But in general when I did cases that were superior, because that’s how their OR was set up, I know international, that’s pretty common, I tended to position myself exactly the same way, I tended to position the patient exactly the same way. And I think for a superior position, it’s obviously totally critical to get the head tilt enough that you don’t have the brow blocking your access. But in general, I would have to probably leave the answer to somebody who operates superior all the time. I almost never do it. I did the other day, I had a pterygium that was so large, the only place I could get access was superior. So I did completely move myself to a superior position. But certainly it is an exception, not the rule in my own practice. Okay. Do you have any tips for residents who are currently doing MSICS and want to transition to phaco? So that’s a great question. I have only done probably a couple of hundred of MSICS cases. I try to find them, they’re hard to find in America, to have a case that’s too dense to phaco. Phacos have gotten so good and the cataracts are softer over here. A couple of weeks ago I actually did an MSICS, which is a great technique. If you’re transitioning from us, most of us in the U.S. are transitioning from phaco and trying to learn MSICS for dense cases or if we go operate international and don’t have access to phaco. I think probably the key thing is to have a good method, a good plan, how I’m going to approach this, what method you’re going to use. If you’re doing an MSICS, a divide and conquer is pretty similar to that, you know, if you’ve been used to cutting the nucleus in house, getting it in two pieces, divide and conquer is sort of the same idea. Instead of getting it out at that point, we’re just going to take it with the phaco. So I would encourage you to watch the basic phacoemulsification course. It was specifically directed at people who are brand-new cataract surgeons or people who are transitioning from MISCS to phaco. I think that if you use that technique, it’s a pretty good place to start. Obviously everybody’s going to go on their own path and learn their own techniques. But I think it’s a great place to start. Watch the videos. I hope they’re helpful for you. It was completely designed for people that are in that exact situation. Okay. Briefly summarize the whole cataract post operative care from day one after surgery until the eye heals. So, you know, I see people postop, day one, week one or two, and at one month. Our postoperative drop regimen, I do not do any intraoperative steroid, I don’t like the idea of it. If you end up with a pressure at 50 and you injected Kenalog into the eye, you have a problem that’s difficult to solve. Like topical drops better. We use Prolensa, Pred Forte QID. I think there’s not data to say it has a lot of role because we do use intraoperative Vigamox. Do QID for a week, daily for a week, and then stop. It’s a one-month taper, stops antibiotic at the end of one week. And I use the Prolensa nonsteroidal for one month. I have a really low rate of macular edema with that. That’s our postoperative plan. I think that these people do so well with modern cataract surgery, you could probably just follow up at one day and one month and we may go to that at some point. The plan that I give a co-managing optometrist is the one I just told you, a day, a week, a month, and a one-month Pred Forte taper. 5% of people, if they have rebound at one month, I’m putting them at three month taper, if they have rebound after that, I may continue one drop per day for up to a year, that’s probably about 1% of people that have residual inflammation from an uncomplicated cataract surgery that persists beyond three months. Okay. How do you prevent the patient’s head from moving during phaco? So we use Versed and fentanyl in the OR. Basically the answer is, my scrubs help me a lot. I don’t like taping the head, it takes too much time and sometimes that’s uncomfortable. We try not to sedate them so much where they fall asleep and they wake up startled. If you get one or two grams of Versed, they’re able to cooperate and not move but not so sedated that they’re going to fall asleep and wake up, that’s the worst thing you can do. If you’re going to have them totally asleep, keep them there, and if you’re going to have them awake, keep them totally awake. For me, I tilt the binocular itself. There may be some scope specific questions as to how you tilt a particular scope. I believe every scope I’ve ever used had the ability to tilt the body of the scope. If the ocular is in the objective lens, you had the ability to tilt that axis and that in general brings the oculars closer to your eyes so you don’t have to have a lot of forward lean. There may be scopes out there that don’t have the ability to do that. Then I would say the key thing is, almost like with the slitlamp, if you get a longer slitlamp, you’re in a more ergonomic position in the clinic, you don’t have to lean your head forward to examine the patient. If you can get an extension for the oculars, if the scope will not tilt, that would be another way to put yourself in a better position as far as your cervical spine goes. Let’s see. But I do think that some of those things are scope specific. That’s why I try to show on the video that you can use the iPhone, you can use any level to try to find that consistent position and however you can mark the scope to go back to that position every time you operate, you know, consistency is the key there. Let’s see. The next one, can we take a soft cataract only by irrigation aspiration? Definitely. That comes up with refractive lens exchanges. Young patients, you know, in my own practice, I almost never start out with just an irrigation aspiration tip. Even if it is totally soft and my phaco energy is going to be zero. That’s when I’m going to bloop the lens into the AC, bloop it up, go in with the phaco and just irrigate. So you may have a total amount of phaco energy of zero and irrigate it out. Still use the phaco because just from a time standpoint you can take it in five seconds with the phaco, and no matter how soft the cataract is, it’s going to take several minutes with the eye tip. As long as you protect deep with your second instrument, I think it’s better to go ahead and use the phaco because you can be done in just a couple of seconds. Let’s see. It’s advised to move the phaco probe during emulsification for better — so this is an interesting question. My current fellow, one of the things we worked on recently is, he felt the need to move it a lot, to try to swirl things around and get the nucleus coming to him. I think in most cases, for most of the cases, you can watch my own video and the one we just looked at, rewatch it, I don’t move the phaco tip much. I don’t think you need to. I think the fluidics do most of the work. You can use your second instrument to then bring the portions of the nuclear in front of the phaco tip to engage it. And not a lot of movement is used there. I tell my fellows a lot, you know, use your foot, not your hand. And I think in general, a lot of movement is unnecessary and probably slows us down. And I think you’re better off holding a relatively stable position and then using your foot, adding pedal to create flow and bring the nucleus to the tip rather than taking the tip through the nucleus. Okay. So the next question, thank you for watching, by the way, I’m always the flattered when someone gets on these. A short surgeon. So, you know, I consider myself to be in that category. And I think that, again, positioning is more critical for someone who is shorter. It’s easy to get positioned if you’re tall. Of course tall people may say the exact opposite thing. I’m 5’6″ and I think I have about a 1-inch window as far as bed height goes. And really where I’m trying to judge bed height, I’ve tried a bunch of methods and have an alignment system that is a series of crosshairs that intersect at a point of space in my OR and that allows me to position the patient at the X, Y, and Z axis. Hopefully that will be commercially available at some point. Until it is, I try to get myself in a seating position where my femur is almost parallel but slightly angled down. I slide myself into position with the scope. I have the bed raised or lowered to the point where it’s just barely resting on my leg. And I think that that’s the best way to get in position. I want the bed as low as it can go because that allows me to get the microscope as low as it can go and not feel like I’m stretching like this, because that’s one of the most uncomfortable positions to be in if you’re trying to make yourself taller during the case by stretching your neck. I think that’s a terrible position, it tends to make me exhausted. And I would say that the scope tilt is critical. I think that the taller people had the ability to not tilt the scope and be in a good position, but the scope tilt seems to be critical to me being a shorter person, that I’ve got to get that angle exactly right every time, and then that allows me to get the bed at the exact right height where I don’t have to have the scope higher than it needs to be. As we move the patient’s bed up, the scope has got to move with it. I would say also, an objective lens, you could use a 1.75 or a 2.0, you have to use a 2.0 with the Aura to have enough space to operate, to have enough space at the bottom of the Aura and the patient’s eye. If you do not have an Aura, make sure you’re using a 1.75 objective lens because that brings the scope closer to the eyeball and makes the ergonomics a lot easier for a short person. Let’s see. How to ensure holdibility in a soft cataract without causing a punch hole. So, you know, I think that’s where it’s key to really feather the foot pedal. I would say there are some cataracts that are going to be so soft that there’s no way to hold them with the phaco. It’s even the smallest amount of energy of aspiration is going to suck the whole thing in. And really, if they’re that soft, and I would say that goes back a little bit to technique. So it is tempting to bloop a lot of cataracts. Blooping, so I define that correctly, is where you use the hydrodissection fluid to rotate the whole lens through the rhexis. I call that a bloop. I always say that there are more times, a lot more times that I bloop and wished I would have divided and conquered than when I divide and conquer and wish I would have blooped. You can never go back. Once you get the whole lens canted in the anterior chamber, you’ve got to use that method now. I would say the majority of lenses, it’s easier to divide and conquer. What will happen is you’ll end up with a dense cataract that’s now rotated all the way up in the anterior chamber and it’s difficult to take with that method, it takes longer, you’re going to end up with more phaco energy, you’re going to end up with more anterior phaco energy and more corneal edema. So I would say on the very soft ones, it may be impossible to engage them. It may be impossible to bring up a half, because every time you get any phaco energy to engage, you’re going to phaco right through it. When that’s the case, use your second instrument to just lift the whole nucleus up into the anterior chamber. If it’s a very young person, it’s a very soft nucleus with nothing but a PRC, whatever, bring the whole lens in the anterior chamber. That’s the time to use the bloop method. I use it on approximately 1% of cases. So if you’re doing it 50% of the time, you’re probably slowing yourself down on cataracts that were really too dense for that and should have been, you know, divided and conquered. Let’s see. How to avoid phaco tip hard occlusion on lesion Alcon patients with a black cataract. So I’ve seen that a few times, where you get a cataract that is so dense that it’s just basically unable to be phaco’d. You know, and boy, it’s awkward to end up in that situation when you’ve already made a 2.4 millimeter clear corneal incision, you’re sort of committed, it’s hard to go back and CS that. If the cataract looks dark and black, you know, I’m going to go ahead and make a scleral tunnel incision so that I’m prepared. I still in those cases may try to phaco. And this is rare for me, this is rare in the U.S. I seek out cataracts that are too dense to phaco, and they’re hard to find. Every now and then I’ve gone through a 2.4 millimeter incision and I’m unable to phaco the lens. That’s a tough situation. At that point if you’re truly unable to phaco it, you’ve got to go ahead and convert to scleral tunnel, bring the thing out whole, in an SSCS type method. That’s not a common issue for me. I don’t hardly ever have the phaco get stopped up with the nucleus. I’ve seen it once or twice, I’ve converted to SSCS and it’s gone fine. How to rotate well the nucleus. So that’s a good question. So I think that when you’re trying to rotate the nucleus into the correct position to lift a half and break it into a quarter, the first half or the second half or let’s imagine that we’ve tried three times to engage the second half, bring it in the anterior chamber, and break it into pieces, and we’re unable to, it’s a soft nucleus and we’re unable to engage it with the phaco, that’s when I’m going to rotate 180, use the same technique I used for the first half, lift it into the anterior chamber with the Connor. I want to make sure I get my second instrument as peripheral as I can get it, because you’re going to end up with a mechanical advantage by reaching out peripheral. We don’t want to try to rotate by pushing pretty central. You almost want to go as far as you can see, maybe slightly further beyond the pupil margin. And that’s going to give you the mechanical advantage to get a good rotation of the nucleus. And I think you can see some of those on some cataract videos I have posted, where I’m unable to lift with the phaco and I end up rotating 180 and using the same method as the first half. But I would say in general, reach as far peripheral as possible, give yourself the mechanical advantage. Let’s see. Are we doing — I think we have time for two or three more here. It’s 9:10. Lawrence, you can tell me how we’re doing on time. We have a compounding pharmacy that mixes it, if there’s an allergy, yes. We used to use vancomycin a few years ago. I did have a case of a bilateral proliferative vasculitis, it’s terrible. Double Lidocaine increases corneal edema the first few days? No, I have almost zero corneal edema and we use sugarcane. At one time preservative free was hard to find. I washed it out, didn’t see much corneal edema with that. What’s your maximum CDE — let’s see. Okay. So we’re saying we got five more minutes to go. I’ll get to as many of these as I can. It’s 9:11 now. We’ll cut off at about :16. Maximum CDE. I don’t like to go above 20. If I go above 20, that probably is one I must have my looped and not done phaco. I’ve seen a resident end up with a CD of 100. I thought for sure we could sign them up for a desect next week. The cornea cleared up. It was amazing. I think in general if you go over 20 or 25, that’s probably something that you should have used a different technique on. Let’s see. Noncooperative patient. Get someone to help you hold them down. That’s when the anesthesiologist really comes in handy. And occasionally, I have a patient that is so uncooperative I say, we’re just going to do an LMA, general anesthesia, put them totally to sleep. I understand if you don’t have the ability to do that, that’s a problem. I will say in general that some people with a small amount of Versed become less cooperative rather than more. So some people do better with no anesthesia. But I think in general it’s rare for me to have a patient with the technique that I use and not be able to get through the case no matter how uncooperative they are. But there have been a couple of times where I said I’m going to stop, I’m going to undrape, I’m going to let them do an LMA, put the patient completely asleep. We have the ability to do that in our OR, it’s our backup plan. Otherwise hang on for the ride. Let’s see. Can you tell if a cataract is for SSES or phaco just by having a look at the visual acuity? I don’t think so. There’s light perception cataracts out there that are not super dense that can easily be phaco’d. The ones I really worry about are the ones that have light perception or hand motion vision and they just look black or they’re very, very dark brown appearance. I think the darker brown they are, the more difficult they are to get a red reflex through. That’s what I’m starting to think maybe this is a better SSES case than a phaco case. Again, in America, we have some pretty dense cataracts using a Centurion, or any modern phaco for that matter, I think about 99% are greater of cataracts can be phaco’d. I know international, that is not the case. On the trips I’ve been on, maybe 50% have got to be SSES. All of those have that dark brown to black look to them. Those are the ones, if you see that, at least start with a scleral tunnel, that way you can convert to SSES if you need to mid-case. How to avoid side port main port hydration. I don’t think — I’m not sure I understand that one. I’m moving to the next one. How to continue surgery uncontrolled hours — that’s a good one. So, you know, iris prolapse is occurring because of fluid flowing in the eye and, you know, what goes in must come out. So it’s a flow problem. So if you have uncontrolled iris prolapse, you know, you almost never want to go to position zero with an instrument in the eye. The anterior chamber collapses, that’s bad. You always wanted to stay in position 1 with the pedal. I don’t use continuous irrigation. And the reason I don’t is that if you have iris prolapse, that’s the time you want to go to position zero. So the iris prolapse is caused by flow into the eye. So a few strategies to prevent prolapse are — and once it’s occurred, it’s very persistent, the iris, once it comes out of the wound, it’s going to want to keep coming out. Number 1, make sure you have your phaco sleeve sized perfectly for your wound. Number 2, if you noticed iris prolapse, be aware it’s going to happen the whole rest of the case. Once you get it back in the eye, when you’re coming out with the phaco, you want to go to position zero and let everything settle and let the flow stop, and then come out quick. So you don’t want to make a fast movement, and you want to go to position zero to — because it’s the flow, it’s the active flow of the BSS going in, coming out the main one that’s causing the prolapse. If you see prolapse during hydrodissection, stop hydrodissecting. During hydrodissection, you want to remember we want a pulse with low volume and high pressure because it’s the volume that causes iris prolapse. If you see a floppy iris, definitely you want to use less volume when doing hydrodissection than a normal case. Those are a few strategies to get through it. Can you explain active fluidics and gravity fluidics? If you’re using gravity fluidics, if you’re just hanging a bottle at a height, you want to make sure you have consistent positioning of your bottle. I would say that goes back to the iris prolapse question. That would be a time to lower your bottle height, lower your IOP. If you notice iris prolapse, try to lower it as much as you can, because it’s the flow that’s causing the prolapse, and in lowering the bottle height, it can be very beneficial there. Okay. I think we’ll take this one as the last one. Is an angle kappa or angle alpha necessary? There’s a lot of talk about this, measuring angle alpha, cord mu. Obviously you want them on the visual axis. I don’t think measuring it is that important in my own practice. I probably do about 40% of my cases for multifocals, almost all pan optics now. I don’t worry too much about measuring pre-op. If you have coaxial lighting on your and hope most modern scopes do, then you’re going to have three light reflexes reflected on the cornea. The patient can see three distinct light. I usually have two temple and one nasal. I say I want you to fixate on the more nasal of the two. Let’s imagine I’m operating on the left eye. I tell the patient, you can see three lights, two of them are slightly further to your left, and one of them should be slightly further to the right. Usually they can confirm they see that. And then I’ll center the center button of the multifocal lens on the more nasal of the lights. And I think that leads to excellent alignment and total correction for any angle kappa that may be present and good alignment without using fancy equipment. We can measure pre-op and I know there’s a lot of — Alcon makes a marker, I’m sure there’s other ones out there, that show visual axis real time on the scope. I feel like those things are unnecessary. I don’t think you have to have them to get good alignment on the visual axis. Okay. I think we’ll wrap it up on that. Thanks for tuning in. And make sure to check out the basic phacoemulsification course on Cybersight’s website and our YouTube page is The Cataract Fellowship, search for that on YouTube for supplemental material. We’ll keep adding to it. Thanks everybody for watching.

Last Updated: February 23, 2024

2 thoughts on “Lecture: Setting Yourself up for Success During Your Phaco Journey”

  1. Great webinar.
    I would like to know when Dr Coleman will post the video of this phaco settings on Cybersight plataform please.
    Marcela Crespo

    • Hi Marcela Crespo,

      Thank you for your comment. We are glad that you are enjoying Dr. Coleman’s webinar.

      I have forwarded your request to Dr. Coleman. Should there be any updates regarding phaco settings, we will post the video to our Cybersight Library.

      Our Cybersight Library offers an extensive number of free, online resources where you can explore our recordings of previous Cybersight Live Webinars, surgical videos, Test Your Knowledge quizzes, textbooks and manuals, and simulation resources. More information can be found here: https://cybersight.org/library/

      Do alert us with any further questions via email at [email protected].


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