Learning phacoemulsification is fun but challenging! It is crucial to discuss the growing pains of the early surgical experience so that we can learn from each other, bend the surgical learning curve, and provide better care for our patients. In this webinar, we proceed step-by-step to review practical lessons that I have learned as a young phacoemulsification surgeon.

Lecturer: Lorraine M. Provencher, MD, glaucoma fellow and clinical lecturer at the University of Michigan Kellogg Eye Center, USA.

Transcript

DR PROVENCHER: Okay. Okay. Hello, everyone! Welcome. My name is Lorraine Provencher. I’m at the University of Michigan. And the title of this morning’s webinar is: What I wish I had known for my 50 first phacos. And if I had a chance to really revise this title, I would change it to what I wish I really understood for my 50 first phacos. I think a lot of the things I’m gonna go over today are relatively basic, and they’re things I knew, I had read about, but really understanding them and grasping their importance is something that came much later. So I’m gonna go step by step through lessons from my early surgical experience. We’re gonna start at the beginning of cataract surgery and go through time course, and I’ll highlight things I learned and I wish I had known a little earlier. Along the way, I will try and highlight useful simulation tools for the early phaco surgeon. And then also the ultimate goal here is to improve patient safety by bending the early surgical learning curve. So just to get to know you all and who all is out there, we’re gonna start with an early poll question. I would like to know how many surgeries you have performed. Have you performed none, less than 50, 50 to 200, 200 to 500, 500 to 1,000, or more than 1,000? Great. So it looks like the majority have performed either less than 50, maybe 50 to 200, or none at all. So this is great. Some of you are very experienced, however, and have done over 1,000. So we’ll do another question here real quick. What step do you find most challenging? Is it wound construction, capsulorrhexis, hydrodissection, nuclear disassembly, or cortex removal? And it looks like the vast majority of you find nuclear disassembly challenging, about 60%, and then about a quarter say capsulorrhexis. So we’ll go over some of that today. Again, what I wish I had understood for my 50 first phacos. And I think lesson one starts well before you even set foot or really sit down in the primary surgeon chair. I think learning can really start before you are even operating. So when you are assisting, don’t just be an assistant. And this took a while for me to really appreciate. This is a photo of me from residency, where it looks like I’m spacing out a little bit and staring at my attendings’s hair cap, instead of really being engaged. So I would encourage you all to be very active assistants. And what I mean by that is: You have a chance to turn down the brain input to your fingers and to your toes when you’re not operating, and instead increase your learning by just being a good assistant. One advantage assisting has over watching surgical videos is you have the opportunity to see what the surgeon’s hands are doing. So I would encourage you to ask how they are doing what they’re doing. To actually peek around the microscope, see how they’re holding their hands, because when you’re first starting out, things can feel really awkward, and you don’t even know what you’re doing wrong, to feel so awkward. So take a look at your attending’s hands. One great piece of advice I got is: Ask your primary surgeon you’re assisting to tell you what they’re thinking. A lot of times we don’t know what we don’t know. So to know what your attending is thinking in the moment is really crucial. Say: I wish I knew what you were thinking right now. Ask why. And then what: Think if you were operating, what you would be doing, what would be your next step. So staying constantly engaged as an assistant can set you up well when you’re the primary surgeon. Lesson two would be: Anticipate, anticipate, anticipate. So this is something we were really, really taught well in residency. And that’s when you sit down to sign a patient up for surgery, pre-op evaluation and patient selection are so crucial, especially when you’re very junior and very early in your phaco training. What I like to envision is, as you bring the patient in the room, how the case is gonna go from the beginning to the end. So what sort of anesthesia are they gonna need? Are they gonna be somebody that needs general anesthesia? Or are they somebody that’s good for topical, or maybe somewhere in between, a retrobulbar block? Think about how you’re gonna position this patient. Look at their body habitus, ask if they can lie flat, and also look at their orbit. Look at their dilation, their red reflex, how is your view gonna be, and then also make sure you’re asking about zonular or capsular issues. Have they had surgeries? Have they had trauma? Is their lens moving more than it should? And of course, you need to know their ocular history and prior surgeries. The main goal of all of this — and no one really ever explicitly said this to me, but the goal is to figure out when and where something might go wrong. Usually if you can anticipate it, you can avoid it. It’s really when you’re not anticipating something that you get surprised and things can go wrong. And the ultimate goal and ideal balance is to choose cases where the complexity is less than the surgeon’s skill level. You want a better surgeon doing the case. It’s better for patients. And when you’re first starting, you need to set yourself up for success. So we’ll do one more poll question here, real quick. What step of cataract surgery, in your opinion, is most important? Is it wound construction, capsulorrhexis, hydrodissection, nuclear disassembly, or cortex removal? And it looks like the vast majority of you said capsulorrhexis, followed by wound construction. I would disagree with everyone here. But I kind of agree with everyone, the majority of you, at the same time. So my argument is that every single step matters, but the majority of you selected steps that are earlier in the case, which makes sense to me as well. So I like to think of cataract surgery as building a house, or building a pyramid. Every step matters, and you’ve got to get the steps early on in the case right for a successful surgery. So we’re gonna go through the rest of this talk, in sort of a stepwise fashion, as we move up the pyramid, and talk about things along the way, on how you can build throughout the case and get everything right early on, to set yourself up for success. We’ll start with anesthesia, positioning, and exposure at the bottom of the pyramid. Positioning is something that I realized later on, because early on, I had great mentors and teachers that were doing all of this for me, and I didn’t realize it. There are things you can modify, when it comes to positioning. You can modify their chin position. You can’t modify their brow, but there are ways to work around it. And then also don’t forget that bed positioning can be really crucial. If you have a good modified or a dynamic bed, you can really use that to your advantage, by putting the patient either in reverse Trendelenburg, or Trendelenburg, to reduce pressure. Exposure is really crucial, and I’ll go over examples of that, but the last thing you need to be worried about are lashes in the way, distracting you, maybe an accumulation of BSS distorting your view, and you want to think about other things, like retrobulbar block. So this is a picture taken of a patient who is really draped really beautifully, great lash drapes, they’ve got the lid speculum in, with the eye nice and wide open. But what you’ll notice is, if you zoom in, the superior limbus, there’s hardly any access to the superior limbus. When you’re doing phaco, you’re often working with two hands, and you really need to be able to get your second instrument in there, superiorly, where there’s no view. It’s hard to tell with the patient all draped, but this patient is actually a little chin-down. So when they’re told to look straight ahead or to look up, they actually look like they’re superducting a little bit. So if you tell the patient just to raise their chin, it makes a world of difference, and I think I tell patients multiple times a day during an OR day to bring their chin up. It’s a really easy trick just to raise their chin, and when they’re looking straight ahead, you have better access to the superior globe, and I use this all the time, and often multiple times throughout a case. So here’s the same patient with their chin raised just a little bit, and the exposure is far better. By the same fashion, you can tilt the bed backwards a little bit, to expose the superior globe, and to get the brow out of your way a little bit. This is something I didn’t learn until fellowship, and I thought it was just so genius. But you get that pool of BSS during phaco, and it can really distort your view. And so if you have an instrument like — you can cut just a little strip off the side and stick it in the fornix, and even in topical cases, patients don’t mind this at all, and it wecks the fluid away throughout the case, and can really help with your view. And this patient probably needs to bring their chin up a little bit too, but this is a really great trick. And then finally for talking about exposure issues, I think you should always keep in mind the use and the utility of a retrobulbar block. Not only does it provide great akinesia and anesthesia for when you’re first starting out, but if you get the block in the right spot, you can get really nice proptosis and better exposure. So we used this a lot when we were first training. Every now and then we’ll pull it out to use it on a case where exposure is just not great. I’ll move a little further up the pyramid here. A paracentesis. So be very particular about your paracentesis. Just to review, it’s a 1 millimeter uniplanar radial wound, and you’re gonna be using it for injecting a lot of things like BSS, your medications, and your second instrument is gonna be going in and out of this wound a lot. So you need it to be proper. You can use blades, knives, or even a 25 gauge needle to make your paracentesis, and you’ll see here this is just a routine video of a routine para. Location is really important, and it depends on the type of second instrument you’re gonna be using, but generally the second instrument should be positioned about 60 to 90 degrees away from the main wound. So here’s an arrow showing 90 degrees. You can see that my para, in relation to my main wound here, is about 60 degrees, and what I do is: At the start of the case, I kind of rest my hand where my main wound is going to go. And then I decide — I kind of back-calculate, and put my para in relation to that. Because I will sometimes adjust where my main wound goes, based on the patient’s orbit, my exposure, and also if they have some astigmatism in that axis I want to address. So if your para is too close or too far from your main wound, you can run into a lot of funny issues. You’ll see in this video here that I’m getting some corneal distortion, as I’m trying to crack the lens. I’m also having a lot of trouble rotating the lens, more than usual. And I’m probably stressing the zonules more than necessary, because of my poor para placement. And you’ll see here again I’m getting corneal distortion. And I finally just get fed up, and realize what’s going on. So I take my second instrument out. It takes, like, two seconds. Make another para. You can barely see it there on the bottom of the screen, but it makes a world of difference. You can see how much easier it is for me to spin the lens here, and I circled for you here that I really only moved the para about 1 millimeter, and it made a huge, huge difference. So if your para is too close or too far or even too long, and you’re feeling kind of oar-locked in your wound, the solution is simple: You just make another paracentesis. So we’ll do one more poll question here real quick. What type of main wound do you use for your phacoemulsification? Do you use a clear corneal wound, a scleral tunnel, or a limbal wound? It looks like the majority of you are using a clear corneal wound, so this is really relevant here. We’re gonna talk about clear corneal wounds. So I learned early on, there are a lot of ways to make mistakes, when it comes to wound construction. But the ideal goal is to have a wound that’s 3.5 millimeters or less, and 2 millimeters in length. It has to be the right size for your phaco sleeve, though. So you need to understand that. And whatever phaco needle you’re using, make sure you’re using the right sized wound. One concept that’s really important to remember is: You actually are creating the wound on the way in, but you can potentially create the wound on the way out as well. So you need to be paying attention, as you remove the blade, because there’s an opportunity there, if your hand slips or tilts, to really mess up your wound. If your wound is too posterior, you can end up with a conjunctival doughnut. If it’s too long or anterior, you can get corneal distortion, edema, and cloud your view. If it’s too short… Lawrence, I think my headphones died. Can you still hear me?

>> Yep, we got you.

DR PROVENCHER: Thank you, sorry. If your wound is too short, you can get leaking at the end of the case and iris prolapse, or if there’s a tilt of your hand or a slide to the side on the way out, as I mentioned earlier, you can get leak or fissures. So we’ll go over some of this. Here we see this conjunctival doughnut, or some call it a balloon. The BSS is building up here, over the cornea. And you’re getting distortion of view. And so thankfully in this situation I have a really awesome assistant that is recognizing what’s happening, and wecking away the BSS to improve my view, because we’re at the very end of the case. And here you’ll see when the fluid is wecked away, really how different the view is. And so if this is happening during nuclear disassembly, it can be really harmful. So the solution to this is quite simple. You just do a little paracentesis at the main wound, and that way fluid is not directed subconjunctivally anymore. Here’s a video that Dr. Tom Oetting was allowing me to use, and this is a nice example of what happens when your wound is too long. So you see here they’re entering a little anterior. And then as they go forward, the tunnel is a little too long. And they end up with this rather long wound that is paracentral cornea, when it ends. And as they’re doing nuclear disassembly and cortex removal, you see how much hydration of the cornea you get, and it really affects your view, especially when it comes to removing subincisional cortex. So if this happens to a degree, you either need to recognize it early and be quick with your case, or go ahead and make a new wound altogether. This is a quick video of a short wound. You’ll see here that I am going in, and I’m really entering already, right there, toe down, just a little bit, to enter. It looks okay. We get through the case. No big deal. But as I’m closing up here at the end, probably hydrating more than I need to, because I know the wound is on the short side, the iris prolapses out. And this is not that big of a deal, but it is annoying, and the patient is probably gonna have some transillumination defects right there. We were able to get the iris back in, no big deal. And then here’s a common problem. And I really learned how to avoid this when I was assisting and watching other people doing wounds. But you’ll see that the surgeon’s hand is tilted just enough, so that the wound is asymmetric here. You can see it’s sort of a diagonal. A line up on the keratome, and they’re tilting. So a right-handed surgeon is naturally gonna supinate and tilt to the right. Opposite for a left-handed surgeon. But this is gonna cause the wound to be asymmetric. It can tear and leak at the end of the case. So here you see this wound is leaking, and this wound is probably gonna need a stitch. There are several simulation platforms you can use, when it comes to practicing wounds. Obviously human cadaver eyes are the best, if you have access to those. Porcine or bovine eyes can be really great, and model eyes are out there. This is a model eye in the background here, from Simulated Ocular Surgery. This is their cataract basic eye, and I’ve used this and found the cornea to be very true, especially when it comes to wounds or even suturing wounds. So we’ll go next to capsulorrhexis tips. I learned really early that if I’m going into a case and I’m worried about it being complex, or I’m worried about something going wrong, I really want to focus in and get a good capsulorrhexis, because it can save you later. The goal is to have a centered, round, continuous rhexis. And about 5 to 5.5 millimeters in size, generally. I learned that in order to get the rhexis you want, you want to trace the path you want it to take. So I’ll show you a little video here, what I mean by that. I’m setting the length of the rhexis with the cystotome here. And then I’m going back in, and as the flap is folded over, I’m actually focusing at the tip of my Utrata, more than I am at the area of the tear. So I’m not looking so much here. I’m actually watching where this is going. Because I’m tracing the path that I want the rhexis to take. And this works really well, if you have a stable chamber, and the flap is folded over properly. I’ll show you that again. In this case, I normally go counterclockwise, but I was trying to learn to go clockwise, so this is the second time I’ve ever gone clockwise, and it still worked really well, and was easy for me, because I’m following the same technique I usually do. And so I’m just using my Utrata tips to trace the path I want the rhexis to take. And you’ll see that the tear follows where my Utratas have gone. It’s really easy, I think, to get focus right at the crotch of the tear, and then you lose sight of where your Utratas are going, and later on, when the tear catches up to the Utratas, your rhexis has gone somewhere you don’t want it to go. This is another example that was — that I borrowed from Eduardo Mayorga, and this is a nice view with trypan blue. You can see the yellow circle here. You can see the Utrata tips are tracing the path you want the rhexis to take, and the rhexis follows nicely. Under a normal circumstance, this works very well. And can be applied in pretty much any situation where you have a stable, nice chamber that’s filled with OVD. The rhexis should follow this path. The other tip for capsulorrhexis that I have is: Understanding and knowing the Little technique to rescue a radial tear. We won’t go into this in depth. There’s a lot out there on it, but it’s something that you need to know when you do linear capsulorrhexis. Once you understand this technique, you understand how a rhexis in an anterior capsule behaves, so there’s more to it than getting you out of a sticky situation. Simulation platforms — there’s lots of these. The Eyesi Surgical Simulator is great, and also Kitaro can be great for practicing capsulorrhexis. The Kitaro eyes are wonderful as well, because it’s relatively reusable. This pink material — you can just do rhexis after rhexis after rhexis, and you can really practice a lot in a short time. So we’ll continue to move up our pyramid here. Hydrodissection. This is something I’ve always found to be challenging. I always thought it would be a simple step I could breeze right past, but hydrodissection is really crucial, and you should avoid with all you can to go on to the next step until the lens is really spinning well. Tips for this: I would say make sure you’re just under the capsulorrhexis edge. So when you go out with your BSS cannula, make sure you’re lifting up just a little bit, to make sure you’re just under the edge, and you get true cortical cleaving. You want to be peripheral enough so that the BSS is directed towards the equator, and doesn’t just egress right back out under the rhexis edge. Watch for lens vault. So if the lens is vaulting forward, that means that BSS is stuck behind the cataract, and if you keep pushing BSS, you’re risking blowing out the posterior capsule. After you inject, blot down a little bit, to keep your cataract back. And if it won’t spin, try subincisional hydrodissection. What I mean by that is — here, I’ll show you some graphics. You’ve got your nice perfect rhexis here. You’re gonna go in with your BSS cannula. I always go to the left first. Hydrodissect. You get your color change. Then I go to the right. And then sometimes you still have this subincisional attachment, and you really can’t spin the lens. And so what I’ve learned — and I wish I had known this a long time ago — is to just go in through the paracentesis, and do a little subincisional hydrodissection. And that completes your cleavage, and generally the lens spins really well. I’ll show you a video of that. This is just from this week in the OR. So I’m doing my first wave here. I’m just under the rhexis edge, blotting down. Going over here, doing the other half. Didn’t get quite as good of a wave. I’m trying to spin a little bit. Well, I might as well do a little hydrodelineation while I’m in there. I try and go back over here again, and the lens really isn’t spinning great. So I go in through my paracentesis, and all it takes is just a little bit of subincisional dissection. And now the lens is spinning really well. So this is a super nice trick to get those lenses to spin. Again, avoid the temptation to go ahead and start nuclear disassembly, until you’ve got a nice spinning lens. We’ll do one more poll question, before we go on to nuclear disassembly. What type of lens is most challenging for you? Is it a soft nucleus, a dense leathery brunescent lens, a chalky white lens, intumescent lens, or is no lens challenging for you? You’re just that good? Okay. So we’ve got about 31% that say a soft lens is challenging. 31% saying a dense leathery brunescent lens is challenging. And then 28% say intumescent white cataracts are challenging. 3% of you don’t think anything is challenging. So as you all know, every patient has a different type of cataract. We do our best in the pre-op evaluation in clinic to predict which type of cataract they’re gonna have, how it’s gonna behave intraop, but you can’t always do that. One would think that the harder a lens is, the harder the case is, but obviously from the poll and what we know, it’s not the case. Soft lenses can be really challenging to divide. So I like to have an approach for different lenses, and a different strategy for different lenses. This is something it took me a while to learn, but now that I’ve got it, I think I kind of go and approach each type of lens with a certain strategy. For soft lenses, you can always aspirate the lens, if it’s soft enough. You can bowl the lens out and collapse it in. So bowl it out centrally, and then I use viscoelastic to collapse the bowl in. And then you have a nice shell of viscoelastic, between the nuclear material and the posterior capsule. And it’s very safe. You can also prolapse the lens. If you have a large enough rhexis, and a good hydrodissection, the lens can pop up into the iris plane or the anterior chamber, and you can emulsify it there, sometimes doing sort of a soft chop in the iris plane. And along those lines, I will often do soft chop. So it requires very little phaco energy, and it’s more just mechanical breaking of the lens, and there are lots of great videos out there on this. But I would say, of all of these, soft chop is generally what I use. Because the lenses are often not soft enough to aspirate. They still do need some phacoemulsification. Moderate lenses, we see a lot of these. You can pretty much divide and conquer, or any variation of chop that you’re used to. I tend to either stop and chop or direct chop lenses. And then for dense lenses, you definitely should consider using a dispersive viscoelastic. Assuming you’re gonna use more phaco energy, this will help protect and coat the corneal endothelium. And divide and conquer works well. You are probably gonna use a little more energy for this, but surgeons that are really good at divide and conquer can get away with less phaco energy on a denser setting. And various versions of chop are really great for dense lenses. But if you have a really dense brunescent cataract with a leathery posterior plate, I think using miLoop can be very useful. MiLoop, for those that aren’t familiar — it’s a handheld tube with a loop that has flexible shape memory, and the loop is deployed, looped around the cataract, and used to snare, and centripetal forces are used to snare the lens and essentially cut it. It is disposable, and it is intended to be used once. And you’re using a little lever to deploy the loop. It’s on the barrel of the device. And it has a really friendly learning curve. This is early in my surgical training, and we’re using the miLoop here to get this really dense lens into several pieces, so that I can emulsify them safely. We’re spinning the miLoop here, just past the midline. You’ll see that gold flash. That’s the back part of the loop. And then I’m gonna pull the snare in here. Using a second instrument to keep the cataract in the bag, and there is a fair amount of bag movement, but thankfully I think the ring is moving more than the bag. It just looks like we’re stressing the zonules. And we might have been, but thankfully, this patient did okay. And now we’ve got the lens in the four quadrants. And they can be pulled out of the bag, and emulsified, and as you can see, this is a really dense lens, with a really leathery plate. And so this would have been really challenging for me to divide and conquer or to chop. So it’s a nice way to kind of stepwise approach those lenses. Some of you submitted questions about different strategies for different situations. So not just learning how to approach various densities of lenses, but learning how to approach certain challenges. So we’ll just go over these quickly. Each of these could be a lecture by itself. But for capsule compromise, when you’re worried about this, for example, a posterior polar — a patient who’s had intravitreal injection, and now they’ve had a rapid cataract or a vitrectomy and rapid cataract, the main concept is to avoid hydrodissection. If there’s any compromise, hydrodissection can blow out the posterior capsule and you can drop the lens. But by avoiding hydrodissection, you’re not gonna be able to spin your lens, so you have to have another way of approaching the cataract, without relying on spinning. For soft lenses, again, you can aspirate out the lens, or bowl the lens out, and collapse it, just like we’ve talked about. Again, you have that nice shell of viscoelastic behind the lens at this point, that protects the posterior capsule, and if there is a rent in the capsule, it’s already sealed off with dispersive viscoelastic. If you have a hard lens, it’s a little more challenging. But you can do something called a V-groove, where you basically make a V-shaped groove in the cataract, and then crack it that way, fill your cracks with dispersive viscoelastic as you go, so as soon as there’s access to a posterior capsule rent, it’s already sealed off, and hopefully you can keep vitreous back. There’s a lot of great videos out there on V-groove, or some people call it victory groove. But these lenses, once you have a certain set of skills to approach them, I think these cases can be really fun. For eyes that have been vitrectomized, you need to anticipate that the chamber can be hyperdeep. You don’t have that vitreous there to stabilize the eye, like you once did. The chamber is gonna be less stable. The bag is probably gonna be more mobile. So in these eyes, I like to do hydrodelineation, because then you have a nice epinuclear shell there, to keep the bag back and stable, and in its more natural configuration. You want to be ready to adjust your IOP, so when you’re doing cortical removal, you might want a little higher IOP, to keep the bag back. And you want to consider adjusting your IOP ramp, so that you’re not getting these wide fluctuations in the chamber. During these cases, I would advise you to be generous with your viscoelastic. So you might need to add viscoelastic during nuclear removal. You might need to add more viscoelastic during cortical removal. Cases where there’s zonular weakness — and again, these are all just broad points, but you want to minimize spinning the lens. Every time you spin the lens, you risk stressing zonules. You want to avoid chamber collapse. If there’s a fair amount of zonular loss, every time the chamber shallows and you get that trampolining, you risk breaking zonules or having vitreous come around the zonules. Chopping can be really great in these cases if you’re good at it. I would say if you’re not good at chopping, using your standard technique and being very careful to avoid stressing the zonules would be better than trying to chop, if you’re not good at chopping. And then considering early capsular support, whether it’s hooks or rings or segments. These things can be used early on, and you won’t regret doing it later in the case. And then patients with shallow anterior chambers — I see a lot of this, as a glaucoma surgeon. I would avoid overfilling these patients. The iris is just gonna pop right out, and then you’re dealing with the iris in the wound. Sometimes I will make my wound just slightly more anterior, to avoid iris prolapse, but again, you don’t want to make it too long or too anterior, like we talked about before, because then you’ll compromise your view. If you do need help with pupillary dilation in these cases, I would preference a hook over rings. Hooks tend to take up less space, and are easier to place in these smaller eyes. And then you also want to consider dispersive viscoelastic, to protect the corneal endothelium. And then this is my last formal point here. But it’s something that I often struggled with, early on. Is knowing — I didn’t know what I didn’t know. And I didn’t know when I was safe. And so when I was removing nuclear material, and this is one of those situations where you wish you knew what your mentors were thinking — but eventually I figured out that there are situations where the bag is more safe and where you can be more comfortable. And there are situations where you need to be more on edge. So during nuclear removal, if there’s a lot of epinuclear material, you’re safer. The bag is pushed back, and it’s out of the way of the phaco needle. Similarly, when there’s a heminucleus still in the bag, the bag is kept back well, generally, or when there are nuclear pieces in front of your phaco tip, that usually protects the bag from coming up to the phaco needle. Also, if you have a stable chamber, you’re gonna be safer. So if you have good wound construction, you’re not pushing down on your second wound and losing a lot of fluid through your paracentesis. Everything is gonna be much safer and much more stable in those situations. The converse to that is: You’re less safe, and the bag is more at risk, when there’s little or no cortical or epinuclear material. So your dense lenses, or when maybe you had a lot of great hydrodissection, and a lot of the cortex came out early on in the nuclear disassembly. You need to be more careful in those situations, because the bag is not as protected. If you have a poor red reflex, you’re not gonna know how deep you are, and so you need to be more vigilant there as well. I used to think that surge didn’t exist, but I learned the hard way that it still does. Even with excellent phaco technology that we have now. So when you have the last few pieces you’re taking out of the nucleus, especially if they’re very dense, and you’re getting a lot of occlusion bells, you need to be very careful for surge. You’ll never regret pausing, adding some viscoelastic behind those last few pieces, to push the bag back, and then taking your nuclear pieces out. It takes far less time than an anterior vitrectomy. If you have leaky wounds, and you’re noticing that, so you have BSS or irrigation fluid flying out of your paracentesis, or coming around your phaco needle, maybe your wound was a little too wide for your phaco sleeve, that’s a less stable chamber, so you need to keep that in mind throughout the entire case. During cortex removal, I think it’s easy to tend to feel a little safer during cortex removal in general, but a lot of complications can come during this step. So when a lot of the cortex is still there, the bag is relatively kept back and protected. And you can be a little — you can feel a little safer. When you have a good OVD fill, so sometimes you can remove cortex under viscoelastic, and that’s a very safe, controlled way of removing cortex. And then when you have good flow. So when the bag is staying back, you’re irrigating, your phaco sleeve is all the way in, and your irrigation is good, and your flow is good, that’s a more safe situation. When you have less cortex left, you need to be more vigilant, as the bag can waft up and get in the way, and snag by your IA. Or if you have a dense posterior capsular plaque. That is an unpredictable situation, in my mind, especially if the patient’s had vitreous surgery or has silicon oil. Those plaques — you don’t really know what the capsule is like there. The integrity of the capsule. So every now and then, I’ll just leave the capsule alone. Won’t polish it. You can always explain to the patient that they might need a capsulotomy down the road, but it’s better for the patient, I think, to leave that plaque there, then to try and go and remove it if you don’t feel comfortable. And then another thing to consider is, when you’re removing — or going in and out with the second instrument, maybe to polish or add viscoelastic, you need to be mindful that that bag is there, completely unprotected, and you can pop through it. And so just to finish up, and I think this is a theme throughout today’s talk, is: If you think about doing something, you probably should do it. So if a retrobulbar block pops in your mind, or if you’re thinking: Add more OVD, you probably should add more OVD. If you’re thinking… Should I stain the anterior capsule? We didn’t really talk about this, but if you think about staining the capsule, you probably should. You’ll never regret it. Or if you’re wondering if the pupillary dilation is gonna hold out through the whole case, and whether or not you should put in rings or hooks, I think especially when you’re early on, just take the extra time and do it, and you’ll never regret that. I wanted to show you all some of the resources I used for this talk, and that I used when I was learning early on. Dr. Oetting has a great PDF you can find online, called cataract surgery for greenhorns. Phacodynamics by Barry Seibel is a great book. You can probably read it in any language, because it’s so graphic-heavy. This is a page that’s excellent and cover many of the things that I mentioned, and then Essentials of Cataract Surgery, I think it’s a wonderful book when you’re first learning phaco. Huge thanks to Dr. Oetting, who essentially taught me cataract surgery. These are many of his concepts that I reviewed today. I wouldn’t know what I know without him and other great teachers at the University of Iowa. Dr. Eduardo Mayorga lent me some of his videos and concepts, so I really appreciate that. Manjool Shah is one of my mentors at the University of Michigan, an excellent cataract surgeon, who has taught me a lot, and Hunter Cherwick, who encouraged me to do this webinar. So I will take questions at this time.

>> Thank you! We didn’t get any live questions yet. So do you mind if I share my screen with those questions asked at the time of registration? Just since we have some time?

DR PROVENCHER: Okay.

>> And you can choose which one you want to go through. You got my screen? Great.

DR PROVENCHER: Okay. So some of these things we went over. But I can go a little more into depth. One of the questions I received was: Do you have any tips for very shallow anterior chambers? And I do. I think I’ve learned a lot about small eyes and shallow chambers in glaucoma fellowship. Obviously patients with small eyes get a lot of glaucoma. I think, again, approaching the case stepwise, starting at the bottom of the pyramid, and doing the right wound — so making sure your wound is a little more anterior, so that you’re not posterior and back there, where the iris is gonna pop out of the wound every single time you inject something into the eye, is the first step. Making sure you have good exposure, of course. If there is a small pupil or any sort of synechiae, oftentimes they’ll have posterior synechiae, I would err on the side of using hooks over a ring. My threshold is usually a 21-millimeter eye or smaller, I will opt to use hooks instead of a ring, because you just get so much crowding, and the ring is a little less predictable. Hooks are often more posterior and out of your way. And then just during nuclear disassembly, or before I start nuclear disassembly on these cases, I will reject dispersive viscoelastic, so right before you really start your phacoemulsification, reject dispersive viscoelastic to protect the corneal endothelium. And just taking it slower, and being more mindful — a lot of times their chamber is shallow, because they have zonular weakness, so the lens is vaulted forward a little bit more, so being mindful of that, looking for any signs of zonular weakness, is really important. Okay, let’s see. So advice for doing a continuous capsulorrhexis in anterior capsular fibrosis. I’ve had a few of these situations. I will often stain the capsule, so you might as well improve your view. So if you get kind of confused as to whether it’s fibrosis you’re pulling on our capsule, having trypan or Vision Blue to stain the capsule so you can see it better is the first step. If you can go around it with your capsulorrhexis, that’s what I would try to do, even if you have to make the capsulorrhexis less round or a little larger. Sometimes you can actually just try and ignore it, and just right through it, just going slow, adding OVD to keep the capsule flat, so you don’t risk radializing anything. And then I think if you want to use capsulorrhexis scissors to cut through that part, or to initiate the capsulorrhexis in the opposite direction, and kind of split the difference, that’s a nice approach for capsular fibrosis. And it looks like we have another question here. Sometimes leaking occurs from a paracentesis. 20 MVR. What causes that? So I’ve had some leaking from my paras as well. Oftentimes, I’m not posterior enough to the limbus. And so I think having it — really make sure — it should be uniplanar and posterior, and I think going right in and right out, trying not to tilt or slide to the side, when you’re going in and out, and making sure you’re posterior enough, close enough to the limbus, can be helpful. But sometimes they just leak. Oftentimes it’s probably because you’re manipulating the wound more than you realize, with your second instrument. At least, that’s what I’ve found for me. So being mindful not to distort the wound too much, and then hydrating well at the end, and if you have to glue or suture, you’ve just got to do it. And then question number five… Let’s see here. How do I irrigate and aspirate when I get posterior capsule rupture? I generally don’t use the IA tip when I have a PC tear. What I try and do is manual IA. So fill well with viscoelastic, preferably dispersive, to tamponade back vitreous. You can either do a little anterior vitrectomy, clear out any obvious vitreous, and then when you’re ready to try and remove the residual cortical material, you can do what we call dry IA, with a BSS cannula, and just dry aspirate out the cortex. It takes a long time. And a lot of patience. But it’s very safe and controlled. And then also you can use the anterior vitrector. So you would go in and aspirate, pull centrally, and then cut, to pull the cortical material in. Both techniques take a long time, but the main goal is not to pull on any more vitreous or lose any more vitreous. Question eight. How to get rid of anxiety-induced hand tremors during phaco? This is a really good question, a tough question. I don’t know if I have a lot of great tips for it. What I would do, when I was first starting out, is I tried to stick to the same routine every day. And that way, I enter the OR as normal as possible. So if you’re somebody that drinks a lot of caffeine, I would just say: Do your normal caffeine level. Don’t try and cut back or do more, certainly. When I was scrubbing in, I would always take that moment to kind of Zen, and go through the steps in my head, and that way you’re not also thinking about what’s next, what’s next, and you can focus on what’s at hand. I think it’s really interesting. Some people are better at zoning out distractions. But I would just try and focus on the fact that it’s you and the eye, and that’s all that matters. And try and just zone in, and put off other distractions, and hand tremors are hard. I don’t have a lot of great tips on that, other than… Just try and go into the OR in your normal state, well fed, you know, normal level of caffeine. Do you recommend investing time in learning extracap, in these modern phaco times? Absolutely. It’s something I don’t know well, extracap, but especially there are situations and complications where it’s important to know how to do extracap, and sometimes if you don’t have access to miLoop, it might ultimately be what’s best for the patient. I definitely think it’s an important skill, and it’s probably something I could learn better from much of the world that doesn’t do as much phaco. So currently, I was trained on a Seibel chopper, and that’s my second instrument of choice. It’s nice, because it’s easy to spin the lens with that. I found it ergonomically nice. And it’s also great for sort of a modified vertical or horizontal chop. I really do think that any second instrument, if you’re used to it, is a good second instrument. But it’s also nice to be flexible. So whatever you kind of grew up on, as a second instrument, that’s what I would stick with, if you can, and if you have the option. I don’t think there’s really any one better second instrument than others. Along those lines, like I said, being flexible is nice, because if you are in a situation where you don’t have your normal second instrument, you don’t want to be paralyzed by that. So during fellowship, I’ve used everything from a Connor Wand to a spatula. So you want to be flexible, but when you have your preferred instrument, it’s available, use it, and I think that’s what’s safest for the patient. I should also mention a Drysdale is a nice instrument I like, because it’s really safe. So if I have a soft lens and I just want to spin it, and it’s not spinning well, a Drysdale is a nice spoon-like instrument that can safely manipulate nuclear material. Okay. We have a question… Can vigorous IA be the cause of postop corneal edema? I think that’s a really great question. I think we’ve focused a lot on phaco energy, and the CDE, and how that might affect corneal edema. I don’t know if there’s data about this. I will have to look that up. But I think more and more people are talking about vigorous IA, and time in the eye, and irrigation times that can affect corneal edema. I don’t have a great clinical correlation with that yet. But I am trying to be more efficient with my IA, as well as reducing my CDE. And then we have one other question. Does phaco machine type make any difference for the beginner? I don’t think so. I don’t know for sure. I’m not an expert on phaco machines, and obviously I’m young and I haven’t been around very long to go through many generations of phaco machines. But I think knowing the phaco machine, understanding the settings, understanding how it works, having somebody go over it with you — I think if you know the machine well, and you train on a certain machine, it probably doesn’t make a difference. It’s just becoming used to something, and becoming familiar with it, and learning to operate with that certain machine.

>> All right. Thank you, Dr. Provencher. That looks like all the questions. This might be a good place to stop.

DR PROVENCHER: Thank you for joining.

>> You too. Bye-bye.

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November 10, 2018

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