1. Dr Gupta this was an excellent talk both for trainees and trainers. Any tips for converting an excellent MSICs surgeon to phaco?

    1. Great question.
      I would tackle this from several aspects:
      a) Surgeons who can perform MSIC have a fantastic amount of surgical skills which can be transferred into learning phaco, these skills need to be build upon and utilised rather than thinking you are learning a completely new skill from scratch. Hand eye coordination, instrument handling and respect for ocular tissues will be present.

      b) It is likely that phaco operation skills can be learnt quickly but the MSIC surgeon will feel they are taking too much time to learn. This is bound to cause frustration and one of the hardest things to learn in phaco is patience and actually slowing down movements. This allows time for grasping technique and allows supervisor to watch and analyse what is being done so feedback can be given. Video is idea for this and review will enforce good technique and highlight areas where change is needed. Phaco surgeons are very self critical and strive for perfection, remember this is the enemy of good phaco surgery.

      c) the case mix and patient selection will be important as I suspect many patients will have dense, or white cataracts. during learning phase it may be wise to select which patients are more suitable for phaco, but remember if removal is not possible one can covert to ECCE or one has supervisor that can help out.

      d) if possible set your self a goal of which part of the operation will be learnt from patient to patient or indeed at each session. it is possible to cover more than one part but I suspect it is very tiring and then technique may suffer as there is too much to grasp.

      e) try to find a supervisor that can teach in a basic format, experts often can deal with complex challenging cases with ease but forget that beginners do not have the same ability. As technique improves your basics alter to more refined techniques. more instance moving from divide and conquer to chopping.

      Hopefully the supervisor can prep the case to allow for “easy surgery” in steps regardless of the case as suggested in the talk. the beginner should feel as if the surgery is straightforward rather and want to do more immediately after. If the trainer or the beginner feels too tired after the surgery then something is not right and they are being given a module not suitable. break down the steps as much as possible to build confidence.

      f) ensure the terminology is set before hand, so that the surgeon understands what to do: they are the hands and the supervisor is the thinker who plans ahead. eventually the amount of instruction can reduce as skills are learnt. Avoid ghost surgery.

      g) use Peytons 4 step approach ( I thought I had created this teaching method then discovered it was already a well published method for surgery training !) and use the time whilst scrubbing to discuss the steps of the new stage to be performed or practiced.

      h) Feedback. this is critical for confidence. ensure you follow a positive feedback for each case and highlight good points learnt at the end of a session. don’t focus on the negative.

      i) try and listen to the sounds of the machine. at first it is tricky for a beginner to remember to switch settings age phaco 1 to phaco 2 to IA cortex and then OVD removal. The sounds are useful for informing you of the amount of aspiration or phaco being used. for my beginners I often ask for the settings to be changed.

      j) set a realistic time span for doing whole cases, with one list a week it may take about 4 months to do a whole case smoothly but then things will speed up.

      k) if used to using a simco then this could be used instead of automated IA. use what feels comfortable.

      if left handed then some other rules apply… happy to discuss if needed.

      I hope this helps to convert to a stress free phaco surgeon. As briefly mentioned in the talk, the details of basics for surgery are in my book with videos.

      I will try and set up additional talks as requested from other Drs covering how to do rhexis.

      All the best and have fun learning.
      Dr Rajen Gupta

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