Lecture: Staffing My First 1000 Phacos

Do you teach surgery? Through this lecture, you will learn to be a better surgical teacher and decrease trainee surgical complications. Fewer complications are good for trainees, great for patients, and wonderful for your mental well-being. Come along to learn from the experience of master surgical teachers and their first 1000 (or 10,000) teaching cases.

Dr. Sherleen Chen, Massachusetts Eye and Ear, USA
Dr. Tom Oetting, University of Iowa, USA
Dr. Jeff Pettey, University of Utah, USA
Dr. Saras Ramanathan, University of California, San Francisco, USA


[Jeff] Good morning and welcome, everyone. Wherever you are in the world, whatever time it is, we are honored to have you. As educators, we understand the challenges and unique challenges in our journey, as we try to help the next generation of ophthalmologists. I’m joined by some extraordinary panelists, they’re each master surgical educators, I can say that confidently. They are at the top of my list and they came independently recommended by many. I’m going to go ahead and get my screen sharing set up. Tom is unmuted, so Tom, why don’t you go ahead and give us some pearls to start us off.

[Tom] Hey, thank you so much for setting this up, Jeff. And I’m excited to be with Saras and Sherleen , who I’ve worked together with in the past. It’s exciting to have some content in this area. This is one of the areas, that I think, in ophthalmology we can use more formal content. And I know that when I was starting off training residents 30 years ago or whenever it was, I really would have craved this. So hopefully there’s some people out there who are interested in some of the tips from us. And if not, I’m interested in tips from y’all, so at least I’ll get something out of today.

[Jeff] Well, thank you again. Thank you, everyone, for joining us. Going to do a brief introduction of the faculty, a little later I’ll give a slightly more formal introduction to each of them.

No financial conflicts of interest, other than I do make my living teaching surgery. First of all, from left to right, with Dr. Sherleen Chen, she’s joining us from Mass Eye and Ear, again a master surgical educator. Tom Oetting, he’s the residency program director at the University of Iowa. Saras Ramanathan, she is a professor at University of San Francisco, also the residency director there. Each of them have won numerous teaching awards. They’re all on numerous academy education committees and have devoted part of their careers to training the next generation of ophthalmologists.

These are my trainees, these are my ophthalmologists that we work with right now. And I can tell you, seeing this photo, looking at each of their faces, it does change the dynamic for me. Remembering that each one of them are unique individuals and they really do need a tailored approach, in many ways. We have our own comfortable style and yet from person to person, there may be times we need to perhaps adjust or perhaps even just have a little different conversation along the way.

Preview of some of the pearls. A surgical teacher’s best friend is? A blank threshold for taking over briefly? Should you have a high? Should you have a low? And some sort of drill can improve complications and complication outcomes? Just a little preview we’ll get to that.

One of the things we know in phaco, if you have a posterior capsule break, stay in the eye. If you have a posterior capsule break, you stay in the eye. Put in viscoelastic. We train this, we teach this, we train this, and we teach this. And yet, there are times, when for some reason, we, as is going to happen right here. There’s a small posterior capsule tear right here. We see it, we know it, we identify it, and immediately come out of the eye. Again, just a little bit of slow motion. This is a silicone IE tip. This is a polishing procedure; it’s simply a case where the resident had elevated too much while they were engaged. And again, I said, “You just broke bag.” He said, “I did, I see it, oh my.” And of course withdrew.

So why do we do this? And this goes for experienced surgeons, but certainly, certainly younger surgeons. I want to introduce the concept of amygdala hijack. It’s not an original idea. This idea came from this author, an author of a book, “Emotional Intelligence.” And while, perhaps, if you’re a neuroscientist you may take some issue it’s a really nice construct to think about this.

When we’re calm, we’re able to use our judgment, our higher cortical function, we’re able to think and anticipate 3-4 steps down the line what’s happening. For us, as educators, we’ve sat with multiple residents over the years, we tend to maintain this higher cortical function even when things start to go bad. We can see what’s going to happen, we know the next steps.

Now of course, a new trainee, they may not even be in this higher cortical state. They may have already had their amygdala hijacked and they may simply be reacting at this point, even without a complication. Just because surgery is stressful, this is brand new, they’re worried about so many things. So think about this, the more that we can do to make sure that our trainees are in the proper state of mind, the better off they are going to be, particularly when they have a complication. You need them to act in a certain way. But often we have some bad habits and we put them into this amygdala hijack.

Here is a classic, well-known worldwide, this is the head butt by Zinedine Zidane. In the World Cup final, after the Italian player had said a few things to provoke him and indeed it provoked him. Head-butted him, red card, France loses the World Cup. Can’t say it’s a direct cause but at least it didn’t help. And again this was a perfect example of just losing your mind in that one moment.

What do we do? A lot of it is how we ask questions. A lot of it is our tone, a lot of it is our emotion. And frankly, we all know of surgical educators who are just mean and not proper, and almost thrive on putting someone in this state of anxiety. And I can tell you, if our goal is to have them think of surgeons, we’re really undermining ourselves with this.

So without further ado, Dr. Sherleen Chen will be our first speaker today. Go ahead and stop sharing, Sherleen, so that you can begin your share while I do an introduction.

Dr. Sherlene Chen she’s the Director of the Comprehensive Ophthalmology and Cataract Consultation Service at the Mass Eye and Ear Hospital. She served as the Chief Resident Director of the Eye Trauma Center of Mass Eye and Ear. She, again, is a master surgical educator, teaches medical students, residents, clinical fellows, research fellows. Has been on multiple committees, education committees, journal editor for JCRS, et cetera, et cetera. Bottom line is, the most important thing, she’s someone who teaches, is passionate about teaching, and she can teach all of us how we can teach better.

[Sherleen] Thank you so much, Jeff. It’s a real pleasure to be a part of this Cybersight program and a member of this esteemed faculty panel. We’ll just go ahead and kick off with a poll question for the audience. What is your level of experience in teaching cataract surgery? A, no experience. B, less than 100 cases. C, 100-499 cases. And D, over 500 cases. Please enter your answer and we’ll display the poll results.

[Jeff] I really do like this question, while we give them a little time, because there really isn’t evolution in surgical teaching just as there’s an evolution in some of the learning how to do surgery. And I’m really interested to hear some of the pearls from you as we move forward. Things that we do differently now that we did previously.

[Sherleen] That is so true. There’s so much experience that we gain, as teachers as well as phaco surgeons. All right, It looks like we have a nice range of experience. Some with none at all and some with over 500 cases. Great. So let’s dive on in.

I’d like to focus my comments today on three low technology strategies that I have found helpful throughout years of teaching cataract surgery. And the first is to look under the microscope. Oftentimes when trainees are struggling with a particular task, I find it helps to look outside the microenvironment of the eye.

Poor finger grip on instruments is a contributor to poor dexterity. So a common issue is having too many fingers on the instrument. This achieves nice stability but at the expense of mobility. And this is often the case with the second instrument, which sometimes trainees don’t move very well or even at all because the instrument is locked into this very secure, stable position that’s not flexible. So what I like to do is ask trainees to practice writing with their non-dominant hand. The dexterity required for writing really focuses a more precise, flexible grip and helps to train the fine movements that are needed for micro surgery. And this is why I don’t prefer to have residents or trainees practice brushing their hair or brushing their teeth, as these are more macro movements.

Other issues include extended fingers that are very stiff, holding the instrument too high on the shaft, having very extremely bent wrists, that limits your range of motion. And sometimes we even see all the fingers of both hands on one instrument. Movements can also be tethered if we have the cord or the tubing wrapped around the hand or the wrist, instead of draped freely over the hands.

Trainees often struggle also with microscopes’ concentration and focus. And as we all know as surgeons, good visualization really is key to safe surgery. So if a trainee is sitting with their leg at 90 degrees or less, this requires a lot more quadrisect and core activation to actually move the leg. So that here the foot pedal may likely not be used as often, minimally, or maybe the body needs to shift to move the leg, and sometimes there’s even pressure applied to the eye itself. So we aim for a more larger angle here at the hip and that permits ease of movement of the leg.

Other seating issues include hiked shoulders which tends to push the eye nasally. Sometimes the oculars are in a position that forces an odd position of the neck. So these issues will throw the body out of alignment and balance.

Finally, positive pressure can cause a shallow chamber and result in a domed anterior capsule that makes the rhexis want to run out. And particularly, this can be specific to the eye itself but also sometimes it’s iatrogenic. If we have a patient who is more heavy set or maybe has a thick thorax, I like to actually raise the thorax and then level the eye by lowering the headrest. And in this way we prevent positive pressure. And another common source of positive pressure is actually pushing on the speculum itself, which then transmits pressure to the eye.

Moving on, you’ve likely heard the adage that viscoelastics are a cataract surgeon’s best friend. I would like to specify that dispersive viscoelastics are particularly helpful. An oily tear film can really interfere with our view, especially centrally. So you’ll see here, that this oil is just streaming across the cornea right where the light is reflecting off the apex. It’s really blocking where we’re trying to work in terms of judging the depth and cracking. It’s hard to rinse off and it reaccumulates quickly. So if we apply a thin film of dispersive viscoelastic, you can see that it really helps clear our view. And even though there’s still a lot of oil in the tear film, the corneal light reflex is much sharper and we get a better view. And this is another example of, again, the oil streaming across our view right in the center we’re trying to work.

It has the added benefit of allowing us to focus more on the surgery rather than rewetting the cornea. We’ve all heard about the Arshinoff soft-shell technique of endothelial protection with a dispersive viscoelastic. I often, during surgery, especially if we have a dense lens, a very old patient, or if there’s a lot of irrigation or we’re working close to the endothelium, we’ll refill the endothelium further.

Dispersive viscoelastic also helps protect the capsule. In this situation, we have just a tiny residual nuclear fragment and it just won’t come to the tip. It keeps getting fluttered around and it lodges undo the capsule and in this very dangerous zone. So if we go out with a phaco probe we really could risk some damage. And it happens repeatedly, over and over again. Rather than chasing it out into this dangerous zone, if we inject a dispersive viscoelastic to protect the capsule and then push the fragment centrally, then we can perform this step much more safely.

This is another example. Here we have a softer nucleus and the training is actually ending up bowling out the nucleus. So now that all remains is a thin rim of nucleus and again going out as more dangerous. So if we inject the dispersive and collapse that fragment centrally, it can be done more safely.

This patient had a bungee cord injury and a traumatic hyphema. During surgery, it becomes apparent that there actually is a zonular dialysis here as well. So every time the nuclear flab fragment comes centrally, the dialysis is actually getting worse. What we do is inject a dispersive viscoelastic to push that capsule away, and then while we’re trying to bring the nucleus centrally, then we continue to inject the viscoelastic, to act as a soft second instrument to help protect that capsule.

This dreaded complication when we have a PC rent or zonular dialysis, we use dispersive viscoelastics to push that back that vitreous, plug that PC rent. And also it can help to pack any nuclear fragments into the interior chamber angle as described by David Chang in what’s called the visco trap.

Finally, I’d like to talk about a filtered air bubble as an adjunct for surgery. So here if we inject Trypan blue directly, what we end up is an 8 ball dark eye. And any entry into the eye is a blind maneuver. This risks the endothelium, the iris, or the capsule. Instead, if we first inject an air bubble, followed immediately by Trypan, you can see that any excursion into the eye is completely visible. So this viscoelastic cannula can be directed all the way across the interior chamber angle. We inject the dispersive viscoelastic and it chases out any residual air and Trypan. And if we put it in one single syringe, like we have here with the air and Trypan, that saves a maneuver into the eye, which is always good with trainees. I find that beginning surgeons do find Trypan very helpful especially over cortical spokes. Or if you’re sitting at the side scope and the view is very poor or it’s dim.

All right. So we often encounter Decemet’s flaps or tears at the wound. This typically is not an issue, but sometimes with stromal hydration that flap extends and starts to get worse. Rather than having it flap in the breeze, if we inject a filtered air bubble this helps to tamponade that Decemet’s against endothelium, that way we can hydrate without worrying about it extending, and then the case finished easily.

And then finally, this is a case where we had some vitreous to the paracentesis site. And this is where our capsular tension hook was placed, so there’s a little strand of vitreous, which we clean up with vitrectomy. With dilute triamcinolone we verify there’s no vitreous to the wounds, but we can also use a filtered air bubble.

In summary, I found these techniques helpful in teaching cataract surgery cases. If things aren’t moving well, look under the scope, dispersive viscoelastic can be very helpful in different situations, and a filtered air bubble is a low technology way to help visualize and support tissues during surgery. I hope you found these tips helpful and good luck to you. Thank you.

[Jeff] That is really brilliant. Look under the scope, away from the scope, what a brilliant tip. Dr. Oetting, Dr. Ramanathan, if you wouldn’t mind, just comment and then we’ll put a poll question up.

[Tom] I thought that was a great talk, Sherleen, thanks for sharing. The one thing that I’ve always felt that was weird in a way that I teach, is that I almost never let the residents drape. And it seems like draping is the simplest thing. But to me, draping is one of the hardest things and I want to tee the resident up for success by really paying attention to that. So honestly, the residents, I don’t trust the residents to drape the case until like 100 cases in, maybe a 150 cases in. So I totally agree with that.

I set the head up, I cut the drape myself, I put it on myself on those first 100-150 cases. Because I’m uptight, maybe? But I do agree that that’s so important. You think it’s funny, I let the resident do the whole case, but this is what I’m worried about is the draping and the head position.

So I totally agree with Sherleen, that paying attention to details, beyond what you see in the microscope, is a big deal. And the other thing is, if I see a finger in the microscope view, it just scares me. It freaks me out! There should be no fingers in the view. And Sherleen had a couple of situations where there’s some people that have their fingers in the view. And I always tell the residents, “If you see a finger in the view, you should be scared, there’s something horrible going on, it’s like a monster coming into their view.” Anyway, I agree, Sherleen, thank you for sharing those tips.

[Saras] I have to, I don’t know what it is about the three of us, Jeff you must have selected us that way. I agree with the draping. My residents know that they have somehow made it if I let them drape the patient. And Sherleen, I totally agree with the chest up. Every patient, I make sure they’re not flat, nobody should be totally flat, you don’t need it as long as the head can be parallel to the ground.

I also love that idea of a soft second instrument with the viscoelastic. I would addend, that you want to make sure that you are irrigation is on. I have, once, seen that viscoelastic go up the sleeve, block the irrigation, and cause a phaco burn. You want to just make sure you’re irrigating. But that viscoelastic in the second hand is awesome!

[Sherleen] And not to overfill the eye too, right? Yes.

[Jeff] We are going to go to a poll question now. We can continue some of the commentary during the poll question. This, essentially, who are you? Where are we? And please go ahead and vote.

The concept I really like, as we’re talking about the draping, is this all builds on itself. If you have a bad wound you know how challenging that can be. And anything we can do on the frontend, to make sure that we’re not having compounding errors that, all the sudden, puts the person in a position of high-high risk. And the draping is such a simple thing to do for us now, that puts them in a position to be successful, and not be worried about the lashes, cutting lashes, pulling lashes,lashes in the way. Thinking endophthalmitis, is it going to go in my wound, is it not? If it looks perfect, if it looks consistent, that’s going to set them up to be successful.

All right, brilliant. A lot of ophthalmologists, have some faculty, department chairs, some program directors as well. Residents, I can tell you this is really good insider info. It’s like being a little spy in a faculty meeting to hear all these tips, so you’re doing a great job by being here. I’m going to go ahead and let Dr. Oetting, Tom, cue up his slides.

Tom’s the Rodolfo N. Perez Jr, MD, and Margaret Perez Professor in Ophthalmology Education. He’s a Deputy Director in the VA Medical Center Surgical Service at the University of Iowa. He is also the Ophthalmology Program Director. There’s a term, at least commonly used, it stands for original gangster, it is a very esteemed and honored term. Tom is the OG, the Original Gangster of cataract surgery teaching. Perhaps that because he’s the oldest among us, but certainly one of the wisest I know. Take it away, Tom.

[Tom] Thanks a lot, Jeff. I’ve got a question to start. Maybe you can see it on your screen there. And the question is, for everyone here, which of the following is the cataract teacher’s best friend? The paracentesis, a tight main incision, a Chang chopper, or low bottle height? Which of these, if you’re teaching cataract surgery, should you just dream about, and think about and be happy for?

So let’s see what people think.

[Jeff] When we teach, we start arriving at many of the same places, even though we were never taught. And I won’t give away the anwer, but a couple years ago I realized this is spot on. You’re actually right this time, Tom.

[Tom] (laughs) If you do enough, you eventually get something right.

Let’s see what people said. Well, this is wonderful because we have some disagreement! Because I do not agree with the consensus of the audience. So hopefully I’ll have an opportunity to move the opinion. In my opinion, the paracentesis is so powerful. Can you guys see that slide? The next slide? Okay, good.

[Jeff] Slide looks good, audio’s good.

[Tom] The paracentesis, to me, is really the most important trick that you have when teaching cataract surgery. Now this didn’t come to me at the beginning. This is something that I realized with time. So here, if you look at this curve with data that I totally made up, but is still true, is the likelihood that I will help on a case as I’ve gotten older. And when I first started teaching I thought, well, I should be all hands off and I should let them do their thing and let them learn and stuff. And I do not believe that. I think we should help people succeed.

And let me tell you a quick little tip, and that is that it’s better to be part of a good case then do the whole bad case. It setss people back so far when they’re part of the bad case, that your job as a teacher is to make sure as many cases as possible are good. And one of the tricks you have up your sleeve is to help little bursts of helping here and there. It’s very powerful.

So on the right yesterday in the OR, I took a picture of all the things that I stuck in the paracentesis on that case. Here is viscoelastic, different kinds, BSS, the cystotome, which I helped out on, several hooks, the chopper, which I took out and put through the paracentesis. All while I was not the primary surgeon, but all in an attempt to help the resident succeed and also partially because I was giving this talk.

Here’s an example of a case from a week or so ago, just to show you some examples of intervening. Look how much viscoelastic is being lost at the wound here, in the surgeon that’s got about 20 cases under their belt. Look at the viscoelastic pouring out of the main incision. So you know what, you could put some more in through the paracentesis. So make sure you have a paracentesis that’s easily accessible if you’re the teacher. So that you can see, I’m just feeding the viscoelastic in there. Viscoelastic is relatively inexpensive compared to your heart cells. Use viscoelastic and don’t worry for a second about it. Secondly, the Drysdale, which is such a sweet instrument to get in and out, is my teacher’s pet. I’m telling you, because it’s so easy to get in and get out. So here I’m just going to rotate the lens, this resident has only got about 20 cases under their belt. Their second hand is not very useful and my second hand is much more useful than theirs. And so right now, I’m going to actually use another trick and that’s just use fluid. Fluid is super powerful to the paracentesis to redirect the flow inside the eye. Here I’m going to do the polishing of the capsule while they just hold nice and still. And now I’m going to use a little bit more fluid to look for residual lens material. So during the case, I intervened at least 10 times, maybe 15 times, through the paracentesis and helped this resident succeed.

Now this is a video, hopefully the sound is working on this, we’ll see, if not. But here’s an example of a resident just doing their second case or third case or something. And it is shocking, it is unbelievable how much of the case you can do to the paracentesis. You just tell the resident, “Hold that phaco still, just hold it still, and then maybe go forward a little bit, and then reach over there and grab it.” And you’ve changed the setting on the machine. “Just hold it still. Step on the pedal.” And it’s shocking what you can do with a paracentesis. You could almost do the whole surgery through the paracentesis if they’ll just follow a few instructions.

It reminds me of this movie that many of you probably haven’t seen. It’s too old school. You hear the sound, it’s called “What About Bob?” It’s about the cantankerous fellow that was getting in trouble all the time.

[Bob] I’m sailing! I’m sailing! I’m sailing! I’m sailing! I’m sailing!

[Tom] I’m phakoing! I’m phakoing! I’m phakoing!

Here’s a trick that I just love and that’s using these little eddy currents. And so instead of just using an instrument, you can use fluid to get so much done. So here’s a great example, it’s a big piece, probably too big. The resident’s going to swiss cheese through it, all of the sudden the fluid flow is all messed up inside the chamber. And just a little jet of fluid through the paracentesis, and amazing things will happen because all the sudden the fluid changes within the anterior chamber. The little null points go away and a little stubborn areas of nucleus that’s not going to the tip change. Just try this, it’s amazingly powerful as a teacher. Right now it’s swiss cheesed though, it’s not coming in right, it’s stuck in that weird space behind the needle. And you just place some fluid in there, two seconds later it’s done. Nobody even thinks about it. You move on forward, everybody’s happy, including your heart cells.

Don’t hesitate to put another paracentesis in. Paracentesis are cheap. I’ve had cases where I’ve put nine paracentesis in, it’s no big deal to add another paracentesis. Here’s a resident that’s got maybe 20 cases under their belt, they’re going to have a hard time putting the lens in with all this residual material. And so I’m not worried about it, we’re just going to make another paracentesis. I’m going to use this cool cortex extractive cannula which is like a Simcoe cannula. It costs like $0.15, this cannula. And I’m just going to make another paracentesis in an area that’s convenient. I’m going to take this little cannula in there, I’m doing this. I’m just going to move this out. The whole time I’m talking to the resident about this. “Isn’t this interesting? No big deal, it’s not a failure here, we’re just getting this material out. Here, you suck it out. You suck it out, there you go.” It’s such a great technique and it’s just one of the many things that you can put through the paracentesis.

In summary, the paracentesis is super powerful. You should use it as faculty, you should always have one. If you’re doing a left eye or something, make a paracentesis for you. I don’t care if the resident’s got 200 cases under their belt, make a paracentesis. You can manage so much through the paracentesis and it’s still their case. Almost any instrument that fits through the paracentesis you can find a use for during surgery.

Here’s a case where we’re having a hard time finding the paracentesis that are resident made. And so don’t worry about that, we’re just going to put some ink on a Drysdale, the teacher’s pet instrument. And now you can see it. So make sure you can see it too, because you want to be able to get in slick and get out slick.

So anyway, those are my tips after many years of experience. Hopefully it’s useful to you, Jeff, and your team there. Thank you.

[Jeff] It’s really brilliant. Why don’t we go ahead, Sherleen, and then Saras for some comments.

[Sherleen] That was great, brilliant. There’s so many years of experience and years of wisdom in what Tom was saying. There’s a saying that I think Tom has coined that I really think holds true of teaching, which is you want to set up your residents for success. And that really was evident in your video there. I think, as teachers, we’re kind of like parents or maybe mentors to our trainees. And our job is to make them look good and make sure that they succeed in their surgery. Like you said, it feels terrible to have a complication. And while you do want to learn how to manage complications, ideally it’s a patient’s eye and you want people to succeed. That was beautiful and I love that side port, all the things that you can do through. Often with a subincisional cortex, if you don’t have that cannula, we have a bimanuel type. But an extra paracentesis can save you in so many instances and it gives you a better range of motion .Beautifully said. Thank you.

[Tom] thank you.

[Saras] I agree, I think the more cases I attend, the less I wish to move from my seat to the resident’s seat. And I find I can just reach around and go in through their incision or better yet, go in through their paracentesis with all kinds of different tools. I love the idea of making a second or even a third paracentesis, why not? It’s much easier than trying to contort your instrument. And it also teaches the resident that it’s okay to make another paracentesis, get to where you need to go. I think it’s terrific.

And especially if you have a surgeon who’s handedness, the learner who’s handedness is not the same as yours, I think Tom you showed us a case in there of the left-handed surgeon and there was a second paracentesis that you can manipulate. I think it’s super, it makes everyone feel safer.

[Jeff] To build off of Sherleen’s comments, it’s been alluded to a little bit. There’s something I fundamentally disagree with and that it’s residents need to have complications, particularly early. And this is the reason why. The management of a complication is one of the most complex things they’re going to do with both hands and they don’t even know how to use both hands, for perhaps even the first 50 cases and in some instances. The time that I want a resident to be doing a vitrectomy is when they’re actually in the latter half, almost to the end of their training. I want them to do a lot of wet lab, I want them to know how to set it up, I want them to theoretically know what to do. They can practice that over and over. But the first time where it really matters to a human being on the table, I want them to have the skills that they need to be successful. And so again as time has gone on, increasingly increasingly I have stopped, taken over, shown them what I’m trying to tell them, instead of just throwing more words at it, over and over, and they’re not getting it, they’re not doing it. So I really do appreciate that.

We do have a couple of questions. I’m going to ask one and then we’ll go to Dr. Ramanathan. You can go ahead and get your slides cued up during this.

The rhexis can be done with a microutrada in case of narrow anterior chamber. Thank you, completely agree. The question is, do you agree with me that after 100 cases, that’s when the complications start? Tom, why don’t you tell us what we know from one or two of the published studies on the complication learning curve.

[Tom] If you look at most of the learning curve studies, there’s an inflection point. On our study it was 60 and the Emory study it was 80. So there seems to be an inflection point around that number of cases, where there’s more complications early. But if you look at the way out data from Campbell study from Canada, where he looked 10 years after residency, people are still learning and this continues after residency. So I don’t think there’s anything magical about residency as opposed to a time of all learning. I think the learning curve continues later.

And in my experience it’s tremendously variable. I think it’s shocking how different people are. So there’s some people that have a lot of complications early and they seem really, really good in the end and there’s some people that have this no complication thing, and then they really level out and don’t grow as much. So I think everybody is different in that regard. But I think statistically, if you look at the studies you’re more likely to have capsular complications like capsular rents, dropped material, in the first cases, And that’s why, I think, as I’ve gone further along, I’m so quick to take over in those situations.

Just yesterday in the OR, I was getting that bad feeling, that denial feeling was creeping into my head and I knew something bad was happening. And so I told the resident, ‘You know, I’m going to take over because I have this feeling that something bad is going to happen and I want it to happen to me instead of you.” And so that’s the way that I approach it now. To get to Jeff’s point of view, there’s plenty of opportunities to learn how to do vitrectomy, but I think early on is not a good time to learn vitrectomy. When you can barely, you don’t even know how to use your second hand and you can barely use two feet.

[Jeff] Thank you, Tom, really, really helpful. We’ll continue to monitor these questions, really good comments and questions coming in.

I’d like to introduce Dr. Ramanathan. She is the director, Medical Director of Comprehensive Opth, the Residency Director there. And she specializes in treatment of cataracts, particularly complex cataracts. Again, a master educator, she’s been awarded numerous teaching awards. And one thing I really loved in her bio, this captures an educator, she has been rewarded by the success and achievement of her former residents and what a beautiful thing to say. Without further ado, Dr. Ramanathan.

[Saras] Thank you so much. It is such a pleasure for me to be here as part of this very prestigious panel. Thank you, Jeff, for inviting me to come. First, let me say that I have no disclosures.

We all know, as teachers, but it is important to meet the student where they are, meet the learner where they are. And sometimes that means that they haven’t done even the first case. So that means meeting them in the wet lab and leveraging whatever simulation we have. I totally agree with Tom on this idea of step in earlier, just briefly, step in early, take care of some little thing that’s about to lead to failure, and redirect the learner onto a path of success.

I love the idea of using what we call educational scaffolding to advance that learner to the next level. So what does that mean? When we have a huge task that feels impossible to perform, if the onus is upon us, as teachers, to break that task down into manageable segments. What we’re really doing is we’re scaffolding that climb into smaller platforms and ladders. The platform is the skill set that the learner already has and the small ladder is the skill set that they’re trying to learn. And this way, that learner is able to get to a successful place. Each one of those ladders is an opportunity for us to provide success or help them gain success.

Again, I totally agree. This is the difficulty of going close to the end where everyone’s already stolen all of your thunder. (laughs) And not surprising, we have such awesome people on this deus.

I thought of all the different pearls that I could come up with and I decided to pick three. Trypan blue, a mini-groove for transition to chop, and this concept called a rescue tool kit.

We all have probably experienced the usefulness of Trypan blue to see what we’re doing in the eye. I always use it for my early learners, even for my late learners. The early learner, of course, is going to need to see where their capsule is. When I have a white cataract I’m definitely going to use it. I’m going to show you another video. This is a little bit of an older video,, excuse me, but that’s because I don’t have this happen to me anymore. Where I have a learner who’s pretty skilled, they put that chopper in and look, they put it over the capsule. And I say, Wait! Stop! I can’t see that little blue film over your chopper! Stop! Come back, put it in again, now I can see that very faint blue Trypan-stained capsule over the chopper.” And I know that we’re in good shape. So the Trypan isn’t just for them, it’s for me too. Especially later in the year when I don’t want to scrub in. I just want to sit at the video screen and watch the video, I really can see.

My scaffolding technique number two is a mini-groove. So here’s a learner who’s never done horizontal chop before, but she has done divide-and-conquer, so she does know how to make your groove. So I say, “Fine, make half a groove, a little baby groove,” I often call it. And that way you can stop using your phaco hand and just concentrate on the left hand. So once we have a mini-groove, we know what depth the phaco tip has to go to. We can put the phaco tip on the floor of that groove, and then the right hand, the phaco hand, doesn’t have to move. The left hand can come in with a chopper, be exactly where it’s supposed to go. “Look at me,” I tell the resident, “No, I want you to be more tip down.” Get to the floor and then the left hand comes in, or the chopper hand, second hand comes in and meets the right hand where it is and is able to chop. The phaco foot pedal doesn’t have to do anything. We’ve already achieved the depth that we want, we don’t have to do three things at once, left hand, right hand, foot. Instead, we can finish, we can separate all those steps, the foot can be still, the right hand can be quiet, only the left hand has to learn. Since we’ve broken that big lift down to doable steps to allow the learner to learn one thing at a time, before we asked them to put everything together.

The next pearl or scaffolding technique that I would offer is to have your rescue tool kit already prepared. Be ready to do whatever it takes to get your learner out of trouble. When do I use this tool kit the most? When the capsulorhexis is spiraling outward, when the resident or the learner is unable to get pieces out, unable to aspirate their epinuclear chunks, inability to remove that epinuclear shell or subincisional cortex, and for posterior capsular tear.

So here I’m going to ask my colon question. I know you all have something in your rescue tool kit and so I would like to know what you would like, what you use, to get your learner’s out of trouble when they are trying to do a capsulorhexis and that capsulorhexis sort of spirals outward? You’ve been there, you know what I’m talking about. And you want to get them out of that hole that they’re about to create. And then be able to give the case back to them. What do you like to do? You can convert to a can-opener capsulotomy, or maybe you use a Brian Little capsulorhexis rescue technique? Maybe you abandon that side and complete the capsulorhexis from the opposite direction? Or maybe it’s just time to phone a friend and call a colleague and have them come and help you? What is your rescue technique of choice? I’m really interested to see the answers that everyone comes up with.

Awesome, awesome! I love the phone a friend one, that’s always good, by the way. I have been known to call a friend in the middle of a case and say, “What would you do?” So that’s never bad either. This just tells us that people have all kinds of techniques and you should have multiple ways to solve the same problem. Here, I have an errant capsulorhexis. My resident is rapidly spiraling out into the periphery and so taking a page out of Tom Oetting’s book, I say, “Hey give me those capsulorhexis forceps.” And here I am, coming through the resident’s wound. I haven’t changed places, but I’m able to take that capsular flap, lay it out flat, pull along the tangent line. And once I have tension, then I come in and come inward toward the center. And you see, I had to do it again. And here I just finished that so I can hand the case back to my resident.

Sometimes I have to do that little technique in the opposite direction, so you have to be ready to make your capsulorhexis in both directions. You have to be ready to do a little maneuver in both directions. Sometimes you have to go back in and make a new scratch, a new flap, either with a cystotome that I showed here, or even I’ve been known to make a new paracentesis, go in with some sort of scissor, usually a retinal scissor, and cut a new flap. All of which helps you get out of your trouble and into a more safe space where the resident can take over again.

I love this technique for nuclear tumbling. Sometimes, especially for new surgeons, they just can’t aspirate that nucleus. And so you have to go in and literally tumble it out of the bag so that they can get to it. This helps the learner understand where the periphery of that nucleus is, how far can I go out with my second instrument. I don’t need it all the time but I like it, often at the beginning.

Sherleen Chen already talked about this great technique, see what I mean about stealing your thunder. (laughs) Viscodissection is such a useful technique for removal of epinuclear shell or even a subincisional cortex or even little chunks of nuclear fragments.

In review, my scaffolding techniques to maximize learner success are using Trypan blue, not just for them, but for me too. I like to see it. I love the idea of a mini-groove or baby groove for transition to chop, and I always have my rescue tool kit. Little maneuver capsulorhexis in multiple directions, tumbling the nucleus out, viscodissection of epinucleus and cortex. And I didn’t show it to you, but of course, the ability to comfortably perform anterior vitrectomy with three piece IOL in sulcus.

I agree with my colleagues that it’s fine to have a really low threshold to take over for a very short period of time. Don’t wait for them to dig in a gigantic hole. As soon as they take out the shovel, you step in and take that shovel out of their hands so that they can be successful in their surgery.

Thank you very much and good luck to all of you in teaching your learners.

[Jeff] Tom, I see you’re on mute if you want to make a comment. During the changeover to the next slides I wouldn’t mind if Dr. Chen would just comment on when do you take over? That is such a fundamentally important question. So Tom, any comments? Then we’ll go to Dr. Chen.

[Tom] The only thing, I just love the scaffolding framework for this because I think it’s such a powerful way to think about it. One of the, just an example, one of the things that we do is we have what we call deliberate practice of the rhexus. Where this great surgeon of ours, Tim Johnson, who just won a teaching award last year, all he does is have the residents do the rhexis on his cases. And so it’s as if they’re stuck at this one place, this one level of scaffolding, but it’s a very important level where they’re really fine-tuning the details of that sort of work on that particular scaffold. And the thing about Tim, is that he does just what you did, Saras, he reaches around and uses the main incision.

And I think Tim, I wished Tim was listening because I would say this to him. I think Tim is a little bored by ophthalmology, he’s been doing it as long as me. It’s so easy for him to do cataract surgery and so he’s almost excited when it starts to go out, because then he can solve the problem in a million different ways. And so I do think that’s a great technique is to say, okay, if you’ve got a big enough program and you can do it, say this particular person is responsible for this particular level of the scaffolding, to use your analogy. And it’s that sort of deliberate practice has really been powerful. So after they leave his rotation, knock on wood, we don’t have any rhexis issues. They’re like femtos. It’s a great way to know that once they pass that level of scaffolding, to use your analogy, you don’t have to worry about that anymore as they go further up. Anyway, thanks for your talk, I enjoyed it.

[Jeff] I couldn’t agree more. Sherleen?

[Sherleen] Yes.
[Jeff] When do you take over?

[Sherleen] Yeah, that’s a great question about when do you take over? I think a principle that I’ve started following for myself, is that I let the trainee progress to the point to which I can still save them. So that’s going to vary with the level of your trainee, it’s going to vary with your experience as a surgeon, and it’s also going to vary with the patient’s eye. If you have a very tough eye, really shallow chamber, so everything’s crowded, you might not feel comfortable letting them proceed as far, as if you had a big open eye, great view, if the patient’s monocular, that’s another factor. So basically to the level that you feel like you can still save the case.

Again, like everybody said, briefly step in to bring it back to a safe zone. And then give it back to the trainee. And I think that’s what I found helpful and useful. Because we don’t want to take it over, we want to help them progress to the next level. But again, we’ve all said it again and again, we want them to succeed and not have complications if we can help it.

[Jeff] Brilliant, brilliant and thank you. Couldn’t have said it better myself, certainly. We’re in our final 10 minutes, panelists keep an eye on the Q&A, on the off chance that we are unable to answer verbally, that we can make sure that we address these.

I do want to acknowledge a few individuals, first of all, Orbis/Cybersight. This has become really the premiere tool, in my opinion, for connecting ophthalmologists around the world, particularly with a focus on education. Hunter Cherwick, I’d love to say this was my idea, this is certainly my passion. There’s more to come in terms of teaching teachers. Just so you know, for those of you who may not be familiar with the English language, “petty” actually means insignificant and unimportant. So I do carry that with me my entire life. So these are important pearls, they’re my pearls, not unimportant, Pettey Pearls.

Complications are inevitable, compounding the problem is not. I repeat that over and over, particularly when you take over. We talked about amygdala hijack, how important that is. I’m going to introduce a couple of concepts, a fire drill. I want to introduce a really nice phrase: “Help me understand what you are thinking?” Perhaps we ask this in different ways, but if termed the right way, it’s certainly something helpful.

And then one thing just to leave you with, when you want to know what they’re thinking, ask them. Tell me what you’re going to do in your next three steps, typically if you’re at a point of complication.

All right, fire drill, what’s a fire drill? Most of us, when we’re in school, they’ll practice fire drills. An alarm will go off, everyone leaves, we get in line, we leave the school. That way, when there is a real fire, we know what to do. And I can’t, again, stress this enough.

So this is the case, you can tell it’s a resident operating because the eye is completely buried across, not centered. And right here we see there’s a shallowing. Is there a broken capsule? Is there not a broken capsule? Well, it almost doesn’t matter. If we even think there might be, that’s the perfect time to say let’s go ahead and do our fire drill. Let’s take our viscoelastic, put it through the paracentesis. Now you tell me, how would you proceed if there was a posterior capsule tear? Let them articulate that. That will help calm them down. And then allow them to do that. And it very well may be that there isn’t, there very well may be that there is. But either way you’re really covered and you’ve giving them an opportunity to practice.

In this case, I said, “The capsule’s perfectly fine, let’s calm down, tell me what you would do next? They articulated it. Then I told them, “Okay you did break capsule, there’s a big hold. Now let’s do what you just said and move on.”

Help me understand what you are thinking? Especially as we become more experienced, I think we tend to take for granted that we, perhaps, know what they’re thinking and this again can really open you up to how to teach this person individually. I’m going to come here. I’m going to fast forward a little bit up to this point, we’re putting in a lens. The case has gone, there’s definitely posterior pressure here, despite all of our attempts at mitigating that. And the lens goes in, and the lens keeps going in, and yep that’s kind of deep, you know. And I recognize what happened.

In this particular case there’s posterior pressure, put the lens right through and I’m just watching and waiting. In this case, he’s going in and he’s actually trying to adjust to move the lens a little bit. And I’m still just watching, waiting. Watching, waiting. He still hasn’t quite recognized what’s happened here. Actually, eventually he goes in with the IA, and at this point this is where I finally say, “All right, take a moment, tell me what you see.” And he says, “Well it looks a little funny.” I said, “What does that mean funny? Help me understand what you’re thinking.” He said, “It seems like the lens is deep.” All right, well if the lens is deep what should we do, what should we not do?

And indeed, the lens was deep, too deep. As we show you here, it was quite deep because we had put it through. And he articulated the next three steps, this with someone who was experienced, comfortable. He actually ended up completing the vitrectomy at that point. Help me understand what you’re thinking?

I can’t thank the panelists enough. I can’t thank you all enough for joining us. I do strongly, strongly ask that you share this with anyone who is a surgical teacher either new, old, or otherwise. Again, I do want to thank Cybersight for helping make this happen and I will stop sharing and allow our panelists to go ahead and make some comments.

Dr. Ramanathan, why don’t kick it off?

[Saras] I love the Idea changing the tone in the OR, especially when things become difficult. I often will say, “Take the hands out of the eye, tell me what’s going on, what’s happening, what’s uncomfortable, what’s difficult?” It just takes you out of that situation and allows a little mental and physical reset. So I love that you brought up the “what are your next three steps?” Because that’s a lovely segue into doing that and what are you thinking, what’s going on? I think it’s super smart. It really helps the learner just take a breath and reset.

[Jeff] Thank you for that. We are down to our last three minutes so I’m going to give each of our panelists 30 seconds. If you could tell everyone in the world teaching surgery something, perhaps it’s already been mentioned, you just want to reinforce a concept. If it’s all right, we’ll start with Sherleen, then Tom, and then finish off with Saras.

[Sherleen] Maybe I’ll just follow up on your comment. I thought it was so smart to ask what the resident’s thinking. Because as teachers and as experienced surgeons, we already can intuit, like Tom was saying, when something might be going bad, we can kind of see things early. And novice surgeons don’t have that experience yet. What we can transmit to them and share with our experience, is that do you see what I’m seeing? And take them through the thought process, because surgery is not just mechanical it’s also the thought process going through it. So if we can transmit that experience, then we really have taken them to another level as well and that’s how we help them to grow.

[Jeff] Brilliant. Tom?

[Tom] I appreciate the opportunity to talk about this and to be with everyone from all across the United States here in the panel and all over the world. I think the problem with cataract surgery is it’s two hands and two feet and that’s too much at first. You’ve got to bring it in slowly and using things like you all talked about to bring people up to speed in a structured way, in a safe way, is what it’s all about. And it’s really fun to do and there’s a learning curve, thank God there’s a learning curve, for teachers. Because otherwise I would have been replaced a long time ago. So it’s a great thing to know that there’s some skill to this and that the cataract teaching job is not just for the most junior person. And there’s some experience that makes you better and better.

I think it’s a great thing, at least from my point of view, and I encourage everyone that’s interested to develop skills in these areas, to read the stuff that you all have written about this, there’s a lot that you all, in particular, have written about. And just make it your career. It’s a great, great career to be a cataract teacher. Until we invent a pill for cataract, I think it’s a good job. Thank you.

[Jeff] Over to Saras.

[Saras] I agree with everything that’s been said. I think you can never stop learning even when you are a teacher. I learned some little nugget from every master teacher that I listen to. I learned from all of you today. And I just want to leave, I always tell my residents, our job, meaning mine and there’s, is to always put the patient first. So what is safe for the patient always has to come first, and then their education is right behind that, it’s a very close second. So whenever I’m thinking of do I step in? Do I not step in? I think about what does the patient need me to do right now? And like Sherleen said, I agree, I like to let them go as long as I can still comfortably fix it. And it helps me keep things in order in my own head as I’m teaching.

Thank you so much for putting this together, what a terrific group and what a perfect opportunity for teacher-learners.

[Jeff] I do want to also thank everyone, both panelists and all of you for joining us. And really thank you to those educators in the world. Ophthalmology progresses because of us, the future is actually dependent on us, and we know all the challenges that go along with it. You don’t get paid for being slower, you don’t get paid for complications, but I can say that this has brought me so much value and enriched my life and ways that’s worth a whole lot. So thank you everyone, we are signing off. Again, I want to acknowledge Orbis and the team for making this happen. Thank you.

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June 11, 2021

Last Updated: September 12, 2022

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