Lecture: Cataract Phacoemulsification Surgery: Optimizing Trainer Supervision and Trainee Learning

During this live webinar, Dr. Gupta will cover how to approach teaching the steps of phacoemulsification cataract surgery. Instructional terminology to facilitate understanding between Trainer and Trainee is suggested. He will present video examples of how Trainers can safely and enjoyably teach beginners and those with surgical difficulty. Trainees will appreciate how to maximize learning opportunities and perform cataract surgery.

Lecturer: Dr. Rajen Gupta, The Newcastle upon Tyne Hospitals NHS Foundation Trust, England, United Kingdom


Dr. Rajen Gupta: Hello. It’s a real pleasure to be able to give this talk today. I’m just going to share my screen. As I’ve mentioned it’s a real pleasure to be here. I’m a consultant in the UK in the north of England. And for the last 11 years or so, I’ve had a real passion for teaching cataract surgery. And over the years, I’ve taught a lot of novices as well as people who have had difficulty with their surgery that they’ve come to me to try and sort out the problems. And I realized that over the years, a lot of emphasis is given on teaching the trainee. But not a lot of emphasis is given on how to teach the trainer on how to teach. And even though you can get somebody who can do an operation, it doesn’t necessarily mean they can teach it to somebody else. And I wanted to address some of those issues.

So, some of the images and text is taken from my book which Springer kindly allowed me to use. So the idea today is to try and provide it and understanding of how we learn the steps of cataract surgery. And how to maximize that learning in theater for your trainees. And provide a concept of instruction and the terms and the words that we can use during that training. And then I’ve changed my talk around a little bit just to give you an example a Phacoemul make a space. And I’ll briefly talk about feedback on how important it is.

I’ll be talking a little bit about the Phaco epiphanies those little light bulb moments that made me think ah, that’s how you teach that step. And I’ll try and give you some video examples that will get more frequent as the talk goes on. I hope afterwards you’ll be able to apply some of those concepts and promote safer and more enjoyable supervision. I remember this talk is for you. So do feel free to ask questions. And I’ll try and answer some of those at the end of the talk.

So I’m going to ask you a question first of all. I know that some of you may be trainees and learning cataract surgery. But some of you may be supervisors. So, I just wanted to get a feel. Have you received any previous training on how to supervise a training learning on how to perform cataract surgery?

So if you could just answer that question that will give me an idea of where we are. Here we go. So a lot about just under 68% of you haven’t had any teaching on how to teach. So, we’ll just close that, excellent. And the rest of you have, good. Let’s just move my next slide. My slide has just paused on me. Oh there we go. Let’s just go back.

In question two, we all perform Capsulorhexis. There’s a cartoon diagram here. And what I want to know is your terminology just as a kind of guess here. What do you call the part indicated by the short solid arrow just here pointing to this bit in the cartoon? So, again I’ll just give you about 20 or 30 seconds just to answer this question. And again this relates to the nomenclature of when we’re teaching surgery. We need a shared common language between you and the trainer so that you can communicate very, very easily in whatever language you use. Here we go. So that part of the rhexis flat I’ve called the outer edge. So there’s a variety of answers there just showing me that a lot of people have different terms for different parts of the anatomy. We’ll come back to that in a moment.

So, we know that everyone may perform and learn cataract surgery very differently. But the aim is that we all strive to have a really good looking eye, beautiful vision. And the way that we perceive things, you can look at this diagram and look at it as a duck or a rabbit and it doesn’t really matter which way you look at it. It’s okay whether you see one picture or the other and that’s the same thing for cataract surgery.

It doesn’t really matter whether you are right or left-handed. That’s okay. It doesn’t matter when you use Cystotome or a needle whether you chop or divide or chip and flip. Use a bimanual or automated topical Subtenons. Whatever block you use is fine. All are good but it just depends on how you are taught and that is the key thing. People worry about learning different techniques but they need to concentrate on the technique that they have and learn it very well. So, how do we learn things? Well, it’s important to realize where you are in your training.

There is the novice who have never done any surgery who’s keen on ophthalmology. And then there’s the beginner who start to do cataract surgery and can do various little bits of it. But they can’t do a whole operation. They need to be told what to do. And if they break the rules, complications occur. And then there’s the advanced beginner who can do a whole operation. But they have to cherry pick and choose routine cases usually. And then they continue to progress along this curve to more technically demanding cases all the way up to proficiency where you can do an operation fairly rapidly a variety of techniques or hard cataract, soft cataract, small pupil, large pupil.

And we can see that years later you eventually become an expert where you can create new techniques yourself. Talk, seemed not to even concentrate whilst you do the operation. And you can see that this appears to be a one way street. But if you suddenly start to do something new, if you suddenly say go from divide and conquer to a chopping technique, you’re no longer and advanced beginner or even proficient. You may go back to becoming a beginner. And it’s important to realize that that when you learn something new, it isn’t familiar.

We all hoped that we have this smooth progression all the way up the curve. But in reality, sometimes you’re going to get a PC rupture. It’s going to happen but we hoped it doesn’t happen very often. And often trainees want to start doing the whole case very, very early. And then they run into problems. They start doing a case. The tape case gets taken over and they [indiscernible] [00:06:39] surgery. And eventually they realized that help is needed and they need somebody to help them out and sort out their surgical difficulty.

For the beginners out there, I’ll just show you something that I’ve noticed on the video. As the PC ruptures, the pupil suddenly dilates. There we go. That is known as a pupil snap sign. And it’s one of the clinical signs that you see in a PC tear. You don’t necessarily have to see the lens fall backwards. But that’s something to watch out for.

Trainees will often tell you and they will know themselves if they are on a smooth curve or if they are on this curve that goes up and down and having difficulty. So, it’s always useful when you get a new trainee to ask them what part of the operation are they happy with and what parts they’re not happy with. And then you can focus on the areas that they’re not happy with and try and work out why they’re having problems with it. So always ask them. Sometimes the trainees may not tell you and then you have to spend several weeks trying to work it out because they’re fearful that if they don’t tell you that they’re good at something they won’t get any surgery. But we need to try and change that.

With the effect of COVID, many theaters have been closed. And often trainees will go on holiday. They will have a break for a couple of weeks and the question is this. How does that affect their surgical performance? They may come back and their non-dominant hand is just all over the place. Just in the video, you can see that the cornea gets hit. It’s no fault. It just sometimes happens when they come back from a period of leave. So, on this graph, this is the normal curve that we hope to attain. If they go on holiday, you think that they should return at this point here.

But actually what happens is that they don’t continue on this curve. But their confidence and their ability goes down. And then it takes a while for them to come back up to the same level and then continue their progress. So, as a trainer in the training, you have to realize you will have little dips in your progress and your confidence and your ability if you take a break. And this is an example of a graph. One of the questions I was asked for this talk was how many cases does it take to get to a whole case stage? Well, it depends on the individual. But here with one list week you can see that the trainee is doing modular parts, they’re a beginner.

At about four months, they do their first whole case. They are still doing small parts of the modular when it comes down to it. And they go on holiday just here. I know that they’re going to have an issue. So, what I do is I go back to modular training for a session and then they continue with the whole cases. At six month, this training changed to a new trainer. They’re continuing whole cases very, very nicely on that smooth curve. But then they go on holiday once and twice. And each time they come back, they’re given the same sort of cases or even more complex because that’s where the trainer thinks they are with no change in the training and two PC ruptures occur.

And then their confidence and everything dips and they go back to modular training. So you can see how that graph is important to change the way that we teach if somebody has a break in their training. It’s important to realize how we learn. And this is a graph. It’s known as a bimodal graph from Tim Ferris’s book [indiscernible] [00:10:19] when he talked about how you learn something. And in the video you can see that an inter ocular lens has been inserted. The first part of inserting the lens was very, very straightforward. So you can learn something very, very quickly as in the graph.

And then as you continue to learn, you’re still learning but your confidence goes down becomes a little bit more tricky, a little bit harder. And you can see here that the trainee can’t get the second haptic into the back. So there is a point where they’re still carrying on and eventually it clicks. They get to that point where you could do that part of the operation very, very nicely. And then they just accelerate all the way up to proficiency. And it’s important to think about this when you’re teaching cataract surgery because we could break down the surgery into its component parts.

Irrigation aspiration, inserting the lens, soft lens removal during the Capsulorhexis, removing the fragments, et cetera. And if you introduce too many parts but overlap each other, what happens is that you introduced the second part when your confidence and your skill is you’re still learning from going down. So you start having problems with the first part whilst you’re learning a second part. And it’s really up to the trainer to look at the trainee and determine when this start this inflection point when it clicks. That they could do it very nicely and they can then introduce a new part.

And the beauty of this is that every single step that we do can be broken down into smaller and smaller steps. And you can introduce new steps as they go along. So, let’s take an example of that. Let’s think about Phacoemulsification of the lens. If we think about all of the different steps, its one step but it’s not really. You have to check the tip. You have to insert the Phaco tip into the eye without it hitting the iris, without causing cornea stretching. You have to groove and sculpt. Then you have to rotate. Then you have to crack the lens or learn how to chop it. Then extract the fragments from the Capsulor bag, then remove the fragments.

So how can you make that easy? Well, if I’m starting off with a brand new trainee, I know that grooving and sculpting uses the most energy. So that can cause a lot of damage to the endothelium if they’re not used to the foot pedal and they’re controlled. So, I will break up the cataract into about six or seven pieces. I know that the trainee might have difficulty removing the first fragment from the bag. So, I will remove it for them. And then they just learn how to control their foot and use the phaco probe and their second instrument.

And in the picture here, a Malyugin Ring has been inserted. And again I’ve broken up the lens, extracted the first fragment. So that the trainee could just practice on an eye with the Malyugin Ring in and learn how to do Phaco to reflect on what you’re trying to learn and break it down into steps. My role as the trainer is to teach. And I have to keep reminding myself that the trainee that I’m teaching isn’t an expert. They can’t do what you do.

They may not be able to do the [indiscernible] [00:13:35] patient who suddenly realize that you have to balance on the edge of your chair, use a platform and balance on one leg. So, it’s up to the trainer to find the right balance between all of the pressures in theater that encouraged learning. And all of those negative things being too fussy, being too critical and demanding that hinder the progress of the trainee. So, the trainee needs to learn skills. In the video that I’m about to show you in number one.

It’s a routine case and the trainee is learning how to remove viscoelastic and SLM removal. But unknown to us, the person who had a history of trauma and has got zonular dehiscence. So, during the SLM removal, you can see that the zonules are starting to pull. And now you’ve got a trainee who’s a complete beginner. They have to use two hands on the irrigation aspiration probe. If they pull anymore, the hole of the Capsulor bag is going to tear and cause a problem for this patient.

Now the trainee is back kicking on the foot pedal. Once I’ve showed him them how to do it. They’re keeping their hands still but it’s still not working. There’s too much material in the port for it to be released. So now we’re stuck. The trainee can’t let go of the instrument and I’m not operating. So, it becomes tricky. What needs to happen is that I need to insert some viscoelastic into the eye and remove that trap material in the probe so it could be removed. And then I can take over and put in attention ring and finished the operation.

So I’m trying to do this with my hands around the patient’s chin. So in real life it’s difficult and quite scary when this happens because you have to sort it out. Now, I want the trainee to practice putting in viscoelastic themselves. So on a routine case in video number two, the trainee is removing the SLM.

And I’ve said before you remove the IA tip, I want you to insert viscoelastic through the sideboard. So in a safe moment they get to practice that technique just in case they ever needed in the future. In that way I can teach some of the skills in a safe environment. So, instead of critical time, it’s a calm safe time and also you can use simulations as well if you got any. In that way we practice those movements.

If you ever ask your trainees on how they feel about their training you get important and clues to the way that things are happening. And I asked a survey a few years ago and the trainees came back I was worried I would make a mistake. I didn’t know what to do but I was told off when things went wrong. Training was stressful. I couldn’t sleep well the night before. If you are a parent and you have a child and they were going to school and getting shouted at or bullied and they couldn’t sleep. And they were worried about making mistakes in their maths. You would go straight to the school and find out what the problem was. And yet we will put up with a trainer that shouted you, humiliate you or make you feel bad about when a mistake happens. And why is that we put up with this in any specialty?

It is because as adults, we will remember that we will learn a new technique eventually. So, we will put up with all of the problems and all of the shouting because we know in the long term, we’ll learn how to do an operation. The problem with that is that as well as learning phacoemulsification, you will learn that training and teaching are horrible things. You will find them events that you don’t really want to take part in. And you think that training has to be horrible and it doesn’t. We can make training fun and enjoyable. And even as a trainer, supervising was stressful and I could feel myself frustrated. So, everyone at the moment is unhappy and we need to change that.

This is the Hebbian version of the Yerkes-Dodson law. And it’s useful for thinking about performance and learning in theater. At one side, we have minimal learning going on. This is where the trainees in theater not doing anything, they just write up the notes. They looked down the microscope and they don’t really pick anything up. All the way up to at the peak where everything is fantastic. The training is great, they’re learning, each week they do something new and they think everything is brilliant.

Then at the other end, the training is terrible, it’s not effective. They make the same mistakes week in, week out. So the first question is, is how do we get the person from minimal learning all the way up to optimum? So let’s talk about that. And there is something called an activated demonstration. So you’re going to find cases where the training probably shouldn’t be operating because it may be too complex or they’re not ready for that type of case.

But what you can do is ask them to look down the microscope. And you give them a question and then you discuss the answer later on. And you have to remember that things in cataract surgery happened very, very quickly. And the trainee may not even realize what you are doing as the expert. So, I think we go in this video. What do I do to help crack the lens. So, in real life things happen very quickly. You may get water on the eye that blocks your view. And the question is did you see what I did? And I suspect that many of you are still wondering how I cracked it. And I’m going to come back to that later. The trainer’s aim therefore is to limit the major modifiable risk factor in theater that hinders your training. What is it that pushes you down to training isn’t effective? So let’s think about that.

Question number three. What is the major modifiable risk factor in theater that hinders training? Is it not enough opportunities to operate? The theater time is limited? The trainer forgot their wedding anniversary, stress from any cause or complications? So we’ll just wait for people to answer that question. And then we’ll see what the polling says. I will sip a water.

So, the answers will hopefully be coming in shortly. So, we have 28% of people saying not enough training opportunities. Theater time is limited, stress from any cause, 23% and complications. Great. So, we’ll just wait for the screen to advance. It is actually stress from any cause and all of those answers may influence the stress. And we have to work out what induces your anxieties. So let’s think about that. It could be the perception of a surgical step. How many of you are just about to operate and somebody tells you oh, the next patient is the father of somebody I know or it’s their birthday. Or they say that this person is deaf.

So even before you operate, your hands are shaking. You stop blinking. Your heart rate is going and you haven’t even touched the eye. So over the years, I’ve realized that I don’t tell the trainee that there’s anything like this that may make them nervous or stressed out. We have to stop making the perception of a surgical step difficult. Many of your colleagues will say Capsulorhexis is difficult. The sub incisional SLM removal is difficult. I never tell trainees that any part of the operation is difficult.

What I say instead is you need particular technique to do this step. And we need to learn it as we’re going along. It could be inappropriate feedback. The pieces just gone or the zonular dehiscence and the training get shouted at. Why on earth did you do that for? So the trainee feels bad and they get stressed for the next case where you as the trainer don’t give them another learning opportunity. It could be ghost surgery. And what I mean by this is that no instruction is given during the surgery. The trainer doesn’t talk, the trainee doesn’t talk and intervention only occurs and take over when a complication is just about to occur or it has occurred. And we need to avoid this.

I’ve learned over the years that when I’m teaching people who may not necessarily speak English as their first language or they’re left-handed. Whatever, I need to instruct them and patients don’t mind you instructing them during the surgery. As long as your conversation is good and you use set phrases and you’re praising the trainee all of the time, that’s an excellent rhexis. That was very good technique. So, we need to avoid not talking and it could be misinterpretation of what we do.

I mentioned about the Capsulorhexis and we had a variety of terms given. We need to have a shared language between the trainer and the trainee. So, in this diagram, we have the rhexis itself. The arrowheads is the fold. The star is the tearing point. We have the outer edge of the flap and the flat proper. Go north, what do I mean by that? Well, I don’t know. One of the trainees came up to me and said I was operating. And my trainer told me to go north inside the eye. And I had no idea which way north was? Was it towards the patient’s feet, the ceiling, to the back of the room, who knows? There was no communication, no shared nomenclature.

It could be that we’re not recognizing the clinical science. It could be time. You’re stressed, you’re clock watching. So you work out what makes you stressed and start to make change to avoid it. So, let’s look at some clinical signs and then I’ll come back to the nomenclature. So in the UK we have trainees that do seven years of training. This is somebody in their third year. They’ve done over a hundred whole cases but they’re having problems with their Phaco. It’s taking a long time to operate. So they came to me and I put in the Malyugin Ring. I divided the lens into pieces. And I said okay, let’s take out the lens. And this is the training.

And we can see here that in their very first piece, there is a little round hole in the fragment. And this is a complete beginner. This is the very, very first Phacoemulsification of the lens. Again the same thing, I’ve broken the lens up into pieces. And again that same round circle is in the fragment. So, that’s a clinical sign and it tells me something about the foot control of that trainee. And every stage of the operation is clinical signs. And we can’t assume that the trainee recognizes these signs because it may take many years to recognize them whereas the expert, the trainer knows them and can work out what’s going on.

So, we have to point out any clinical signs as we’re going along. That little hole or I call it a donut tells you that the foot pedal control isn’t good and needs to be developed. So I’m just going to pause the presentation for a second. Here we have material behind the target fragment here. So, this is the piece that the trainee wants to take. But I want you to have a look at what happens. The material behind the fragment is being removed and that’s because the hole in the fragment allows the aspiration to go through it. So, that puts that person at risk of having a PC tear or a rupture. And that’s purely because they’re too heavy-handed with their foot control. And we see this time and time again in operations. And we need to teach the trainee what they’re doing.

So, we need to change those factors that induce stress. Trouble is making change is difficult and usually it’s your own self-imposed barrier that stops you from making that change. And we need to change it so that supervising and learning cataract surgery can be fun. So, we mentioned stress and time is the enemy. There was a study in the UK that suggested how quickly people can do an operation. Consult will take just under 20 minutes. A beginner in the first three years takes just under 28 minutes and in between about 23 minutes.

And your own times may vary. And it’s important to know how long you take as a trainer or how long your trainee takes or if you’re doing part of an operation. And you need to focus on creating time. So, instead of doing the whole operation, you can focus on the task. And in this trainee, you can see their first Phaco in the one video. They still haven’t got microscope control because the video’s gone off screen. But I’ve broken up the lens and they’re just developing their control. And five weeks later, they’re still taking out fragments. But their control is so much better and they can deal with the dense lens.

As time progresses, I will then allow them to do bigger fragments and then go on to grooving and cracking. So they’re learning things as they go along. But they will have foot control and microscope control and second instrument control. Try and avoid any tasks that are inappropriate. So for a complete beginner, every time I teach them to drape, they can’t drape because they’re nervous and they’re scared. And what happens is they always get lashes in the way.

So, the trainee then has to try and operate on a case where there’s eyelashes in the way. And the trainer, me, will get frustrated and annoyed and stressed that are making the operation difficult. So now for a complete beginner, I don’t teach many draping. And I avoid that effort of being irritated at that time. So, after about six months once they could do whole cases, I then introduced draping. So by the end of six months the one thing that they say to me that they want to learn is not cataract surgery but draping. So, try and think how you can create time in theater.

Let’s go back to terminology. So, one of the big moments I had was misinterpretation and how to avoid it. And in 1945, Duncker published his puzzle known as the Candle Problem. And the task is this. You need to fix the candle to a wall and light it in such a way that the candle wax does not drip on the floor or a table below. And in addition to the candle, you have a book of matches and you have a box of pins. And there is a concept of fixed perception. And I’m sure all of you out there are trying to work out how you put the candle on the wall.

Some of you may light the wax and try and melt it. Some of you may use the pins to try and stick it on the wall but the solution is very, very simple. All you do is empty the box and put the box on the wall and pin it. The trouble is the way that the instructions are given that fixed perception is that the box belongs to the pins. So we need to change the terminology, so that you can solve the puzzle faster. And if I had said to you there is a box and pins, you would have solved the puzzle faster rather than saying a box of pins.

If I give you a hand out and I underlined the key words that make you solve the puzzle box and pins. Again you would have solved it faster. They also change this puzzle and gave two groups of people the same puzzle and said look. If you solve this puzzle faster than the other group, we will give you a prize and you would think that the people who had the prize the incentive would solve the puzzle faster but they didn’t. What happened is that they became stressed that the thought of losing the prize. And they had difficulty and it’s the same with cataract surgery.

If trainees are worried about being taken over then that’s going to influence how they operate and cause problems. So, if you say to the trainee look there are five cases on the list, you are going to scrub up and operate on at least three of them if not five of them. Even if you have to take over, they know that they’re going to operate again. And it takes that stress away. So, we can break down the surgery into all of its steps. But we have to remember that perfection is the enemy of good surgery. And the enemy of any terminology is the lack of shared terminology.

And as you start develop new techniques whether you’re going from divide and conquer to chop, et cetera, you need that terminology. So let’s look at some of that. Here, we have an irrigation aspiration metal probe. You may use by manual and that’s absolutely fine. You may use a silicone tip but it’s the principle of the terminology. So in picture one, I want the trainee to go from position A to position B, back to A and then C. So, what instruction do you give them? If you’ve never thought about this before then how do you teach irrigation aspiration? Well, I called this right lateral movement and left lateral movement.

In diagram two, the tip is held in the same position but rotated. What do you call this? It’s important because sometimes when you grasp soft lens material, you may need to rotate the instrument so that it winds around it. And then you can peel it off the capsular back. And I call this clockwise wind on a stick and anti-clockwise wind on a stick. Simple terms that I can say very quickly. And then in diagram three, we have a combination of movements. So, I call this wind on a stick to the right, wind on a stick to the left.

And all of the movements can be practiced above the intraocular lens. Before the trainee practices soft lens removal and you can get your terminology. You can tell the trainee right. Wind on a stick, sub incisional direct drag fishing whatever terminology you want. You can make them do certain movements. And once they get a hang of it, it makes your life easier. And you can use simulation if you’re so lucky to have one.

So, let’s talk about SLM. I divide the zones of an eye into zones one, two, three, four and five and the direction is the direction of the probe. So, if I say to the trainee they’ve done zone one, zone two, zone three, there’s some left zone three, zone three excellent zone five. The trainee will do what I want them to do. And I can see where they’re going. I can make sure that the movements are good. And I can give them feedback on their technique. And it’s predictable so my heart rate doesn’t go up. And the trainee knows what they’re doing. And it’s especially important because they then develop the skills to do those movements. And if the pupil comes down, they can still do the movements.

Now, remember that graph breaking down the steps. Keep practicing the technique above the lens until they get it right. And you can remove the sub incisional if you think it’s difficult. Why take over? The trainee knows how to remove viscoelastic and put in the lens. But they can’t remove SLM but they can remove it if it’s done easily for them. So remove zones one, four and five. The trainee goes in. Now I want them to do zone two.

They’re a little bit nervous, a little bit of difficulty. Now they’re in. We wait till the AC fills. Now they’re going to go to zone three. But no, I don’t want them to do that part. I want them to do what I want. I’m the trainer, so to zone three. At the beginning aspiration on, wind in a circle, holding, peeling aspiration now, peel the SLM off the bag. Drag, drag, drag foot down. Zone three aspiration on, go around in a circle, holding aspiration, peeling, removal. The trainee comes out, they put the lens in. Then a little bit more SLM is left. The next time and the next, then the next until they can remove 360 degrees and all of the zones. It then becomes very, very easy. And within a session or two sessions, they could do that very smoothly.

Capsulorhexis, we’ve gone through this diagram. But how about when they’re actually doing it? And as a trainer, I know where to grab the outer edge so that the rhexis doesn’t go out but the trainee doesn’t. So you have to direct them. But if you don’t have terminology to tell them where to grab it, how do you instruct them? So here we go. What would you call the triangle, the circle and the star?

I call this short hold, mid hold and long hold. So now I have terminology, so that the trainees knows what I want them to do. And when I do Capsulorhexis, I have an upside down clock and wherever I make the section that is always 12 o’clock, 6 o’clock and then 3 o’clock and 9. And I use these cardinals to direct what the trainee has to do.

Now this trainee is stuck because they were having difficulties with the rhexis. And if you noticed that they’ve gone far too far, past the 3 o’clock cardinal. They’ve pulled the flap so far that they now have difficulty grasping it. So, they don’t know why this happens every time they operate. So, your job as the trainer is to say hang on, hang on. Look, this is what you’re doing and this is why you’re having difficulty because in that position, you distort the cornea and you can’t grab. They flap itself.

So at this point, the trainees hands start to shake, they no longer blink. So, I tell them to come out and I just give them a quick instruction on what they’re doing. I reassure them that everything is okay. The rhexis hasn’t gone out and everything is good. They then go back in and they do what I tell them. And this is the same trainee from one week to another. And I’ve given them a handout. We’ve gone through how to perform rhexis. And at a later date, if anyone wants me to give a talk on how to do anything specific in cataract surgery I can.

So, one other things that I learned very quickly on just in this direct video you can see that the trainee had a very long flap. They don’t even know when to let go. So, everything has to be corrected. In the diagram down here, you can see that I’ve said avoid degrees of a circle. Trainees do not know where 180 degrees is or a 135. If you say go to 225 degrees, it’s going to be impossible for them. They can’t think fast enough. So, do try and make it simple.

So, it’s important to look at the real time supervision and the linguistic implications of whatever language you speak in. You know, work out your instruction. What do you call the Phaco tip? The long edge, the aperture, the sleeve. What you call the keratome? You’ve got the cutting edge, the shoulder, external ostium, internal ostium. How about the lens, leading haptic, trailing haptic, optic haptic junction, the shoulder, the optic. Everything has a term so that you and the trainee can understand each other.

Question number four, I often get asked this. Whilst a beginner, how deep is deep enough before attempting a crack? So, what do you think? Is it 2.5 times the depth of the Phaco tip? Is it until the Y suture can be seen in the lens? After performing four grooving strokes? When the trainer says it’s enough? When the pupil snap occurs or it cracks with ease? We’ll just give the polling a little bit of time and then we’ll see the answers.

Hopefully you will see that there is a theme to these answers and here we go. When it’s so 53% of you said when it’s 2.5 times the depth of the Phaco tip, 5% said four grooving strokes and 12% when the trainer says it’s deep enough. Well, the answer for a beginner is when the trainer say’s its deep enough. Remember the trainee doesn’t know. They don’t know what they’re doing until they are told and it takes a little bit of time for them to get used to it. So, how can a trainee know when it’s deep enough?

The trainer will tell you when to keep grooving but I use something called depth perception ridge. So after I make my first groove, I widen and then go for depth. Go for more grooves until the trainer says stop. Or you can tell that it’s deep enough and that comes with experience. But by making a second wider groove, you can see this ridge here and that allows a little bit of parallax too low to show you how deep you are getting with your Phaco tip.

And again it’s up to the trainer to tell you. If it doesn’t crack, it’s not because the trainee is doing anything wrong. It’s because the trainer is not telling them. So, I mentioned about the activated demonstration earlier. And what I did was, after I created the groove, I rotate the groove by about five degrees as in picture one. I then rotate my Phaco tip by about 90 degrees so that the long edge is on the right hand side because there’s more surface area that allows you to hold the wall and then crack. So, let’s just have a little look at that.

In video three up here, you can see it in slow motion five degree rotation long edge. The instrument is inserted and cracked. Now even if your groove isn’t quite deep enough as a beginner, this will help you overcome that depth and it will make it much, much easier for you to crack. So, the phrase I used for the trainees is minor rotation, long edge and crack. That’s all I say and that’s what they do.

And remember that activated demonstration. If you look at it now, you can see it happen. And even though it floods, the same technique is going on. And then you can discuss it and the trainee does it. So, how do we actually learn surgery? Well, I thought that I had made up this concept but actually it was described many years ago as Peyton’s 4-step.

The first step of anything is to demonstrate what you are doing in real time. So, in this video, we’re going underneath the lens to remove the viscoelastic. I teach this to complete beginners within the first month because it’s part of viscoelastic removal training. And it looks scary and nerve wrecking but actually if you break it down into its components which is the next step. So, we have the port in picture A in the safe zone port up, wind on a stick. So, that the port faces lens right lateral movement, then push the lens a little bit to the right and dip the tip down. And then start to come out as if you’re putting the instrument back to the primary position. All of the steps can be broken down and then the trainee will then tell you what they’re doing. So, they tell you the steps and then they would perform it.

Now, I’m not going to show you the same video of a trainee but how it can be applied. So, here’s a trainee who had done hydrodissection and they’ve created a plate. And they’re having a little bit of difficulty removing the plate because they don’t quite have that experience yet. And as they get nervous, they grabbed the iris there. And what are the options? Do I take over? Do I teach them a new technique where they come out and they fill the eye with viscoelastic to fluid up the plate? I don’t want to do that, I’m too lazy. I want them to use the techniques I’ve shown them.

So, it suddenly occurs to me that there was a gap. So, I say to them look, let’s pretend that plate is the IOL. Just go underneath it as if you are doing viscoelastic removal. Lift up the plate and put your foot down and this is what they’re doing. So, something that becomes stressful becomes very, very easy because I’ve taught them a specific technique. So, again it’s up to the trainer to teach you tricks. And then they go back to removing the SLM as normal.

So again, I mentioned about handout. So years ago I started producing a little hand out. And this is a drawings that I gave to the trainee. I found that they took too much time putting down instruments, picking them up again. So, I taught them how to palm an instrument and un-palm an instrument. So, this is the de-construction, the video is demonstration. The trainee then tells you what they’re doing and then they demonstrated. Very easy to learn and it speeds up your surgery.

So, let’s see how I can show you putting teaching into practice. There is something that I call make a space. After you split a lens up into its fragments, you can see that the pieces jigsaw together. So again, we need terminology. What do we call the pieces? Apex, the shoulder and the base around the curve. So, the first make a space technique is well which fragment should you remove? And I think all of you out there will be very easy to say well, actually look it’s got to be this fragment here because it’s the smallest fragment. But when you’re trainee, you’ll crack the lens and you’ll go straight for the fragment ahead of you.

But as a trainer I know I have to teach them to rotate the lens and take the smallest fragment, make a space. But as it’s rotated all those pieces will jigsaw together. So, the first thing that you need to do is the second technique. You have to create space. So, you hold back the fragment and then you engage the smaller fragment and pull it out. But you can improve on that technique. You can see that there is space here. So, you need to move the fragment a little bit to the left before you pull it into the center. So, I call this a seven or reverse seven. Simple phrase and it gets the trainee to do what I want.

So, they move the fragment to one side or the other before they pull it into the center. And then finally free a shoulder. As the fragment comes out, you can see that the shoulders may get stuck. So as the fragment is being removed, you rotate the Phaco probes slightly so that one shoulder comes out and then you rotate it back. So that the second shoulder comes out. I think these are basic techniques. But they don’t get taught because when you’re an expert, you can forget all of the basic techniques and you just take them for granted.

Let’s look at that. So here we have a trainee, they’re going to grab the fragment out of the bag. Look at the technique. They’re not doing a seven reverse seven. They are shaking the fragment to remove it. It works but if you had a case of pseudo exfoliation or a history of trauma with zonular dehiscence that may damage the zonules and then cause problems. So you need a slightly safer technique. It works and don’t get me wrong. If you need to get it out that way, that’s absolutely fine.

So let’s look at a making a space technique. And when I get the trainees to operate, I make them do everything slowly. So, make space number two, hold back a fragment. You’ve got the smallest fragment there. Hold it back, engage it, make a space, pull it over to the right a little bit and extracted with ease. Now, the second instrument is in the wrong position there because it’s too far but it’s fine. So that’s make a space. Now let’s have a look at another principle. The first fragment has been removed. We need to get the next fragment.

So, I call this technique reverse rotation because it happened beneath your Phaco probe. So, what’s the make a space principle here? They jigsaw the pieces as they’re rotating. So, the first thing they do is crack the lens again, that creates space and ensures that the fragment is removed. But if you look at this, can you see the fragment down here underneath the Phaco probe? You can tell that soon as this fragment is removed, it’s going to hit this fragment and hinder its extraction. So, let’s have a little look. We’ve said consider cracking. So, we crack.

We take out that piece but we know that it’s going to cause a problem. It’s not going to come out very easy. See the [indiscernible] [00:48:10]. Now, the trainee is a little bit nervous now because it didn’t work as well as they wanted. They’re trying to de-bulk it with their second instrument. Now, watch the fragment behind. So, the target fragment wasn’t removed, this one here. That one came. So, what do you think happened to this fragment? Correct. They developed a little donut hole and that allowed the other fragment to come to it. So, they were fortunate that a PC rupture didn’t occur.

Make the trainees do things slowly. Here’s a little chopped technique. It’s called easy chop and if you want to look at it, that’s something to think about. It’s very easy to do. He’s rotating that shoulder and de-bulking. So, make the trainee demonstrate the techniques so that you know that they can do them. And as they progress, they will get very, very quick at doing them and they could do them very, very safely. So, coming to feedback just before we answer some questions.

This is probably the hardest thing to do because it’s very difficult to tell trainees what they’re doing well and what they can improve on. And it’s a two-way think. And many trainees think that you will be criticizing them. So, you need to tell them I’m now going to give you feedback and tell them that phrase. So that they know that you’re not yelling at them or shouting at them. But you are giving them feedback. And this is one of the strongest things that can improve your cataract surgery. So, I showed some pictures at the beginning.

On my first slide of one of my trainees who is very, very tall. And one of the most important things to do is protect your neck and your back in cataract surgery because we are all at risk of having back and neck problems. So, the one thing I call Mark doing it was leaning very over his patients. And I got him to pump the bed up to protect his back. So, you need to focus on things that are positive and trying to avoid yelling and shouting. So what did you do well? What could you have done better? What would you consider doing next time? And this is what I would suggest.

And then the trainee at the end of the attachment with you, can do the same thing to you as a trainer. What did you do well as a trainer? What could you do next time, et cetera? At the end of every theater list, I asked the trainees what five things have you learned today? Protect your back, minor rotation, long edge and crack, comprehension, Peyton’s 4-Step, nomenclature and new skill. If you check then you will make sure that you’ve taught them something.

So, in summary, it’s important to understand how we learn, how to apply that understanding, how to think about the causes of stress and make change. Avoid that ghost surgery, keep instructing out loud, patients do not mind, try it and ask the patient. Work out the instruction for your particular techniques whatever language you like. Payton’s 4-step approach and have fun while you’re teaching. We are so lucky to be performing cataract surgery and ophthalmology is one of the best medical specialties and we should have fun doing it. So, good, better, best. Never will I the trainer rest until the trainee’s good Phaco is better and the trainee’s better Phaco becomes their best’.

Now, I think we’ve got a little bit of time for questions and I think I previously mentioned that I’m happy to go over the hour and discuss a little bit more. I do have some bonus videos if there was time to go through those if anyone wants any additional topics to talk about.

So, let’s just have a little look if there’s any other questions. We did have some from previously and I’ll talk about those if you like. So, some of the top-tips people were asking me, well, what are your top-tips for cataract surgery? Well, hopefully I’ve given you quite a lot of them there. And for hydrodissection remember to burp and express the small amount of viscoelastic before you try and do your hydrodissection. You will find that you have a much better wave and it allows the lens to ride up and the wave to go completely behind and that will help you with your SLM removal on the rotation of the lens.

People talk about, you know, Capsulorhexis and how to do it and the difficulty with it. One of the things I will save the Capsulorhexis is that what I would do is allow the trainee to do a Capsulorhexis and I’ll just look at these questions. Do Capsulorhexis and you as a trainer, do the Phaco? That way if they do a small rhexis you can deal with it because you’re experienced. And if you’re doing the Phaco component, you as the trainer do the Capsulorhexis or it’s a decent size so that it allows the trainee not to be stressed out by having it making it difficult.

There’s a couple of questions here let me answer these. The perception of the steps is true. As a resident, you get bombarded on how hard Capsulorhexis is. I completely agree. We should really avoid telling people things are difficult. Do you ask trainees to view their videos? Absolutely. If you record your surgery and then go over it with your trainer, you will learn things that you don’t realize that you’re doing. And you will speed up your learning because you can reflect on it and you can get that feedback.

One of the questions is, which method do I teach to teach? I do what’s called reverse training. So, I do viscoelastic first, I then do put in the lens and lens training with the movements on top for SLM, then SLM, then I teach Capsulorhexis and hydrodissection. Then I teach small fragment removal, large fragment removal. Then I teach cracking. In other words, I create the cross and then I get them to groove. So, by the time they groove they could just do it very easily. And then, I teach them cornea section and the very first time they do a corneal section, they do the whole case.

What are your views on bilateral cataract surgery? It’s a good question. That depends on the individual and really for trainee. It’s a question that you have to kind of make up your own answer for. There’s a lot of evidence that if you need to do it, you have to risk especially with COVID you may not have a choice.

Here we go, for rhexis, push or pull which is technique is better? Either techniques for Capsulorhexis are fine whether you use a Cystotome or whether you stab the rhexis with your keratome, or whether you stab it with your forceps. It doesn’t really matter which technique you use. The question is this, how you are taught it in the terminology that you use? I can show you a video of how I do Capsulorhexis teaching. So, let’s have a little look at that.

Somebody asked me what do you do if the Capsulorhexis is too small? I’ll just show you this quick video. So, this is a video of enlarging the Capsulorhexis. So, just to show you, you insert the scissors and make a single cut. But if you want to make it easy for yourself as I’ve mentioned, make a second cut further along so that when you are grabbing hold of the flap and tearing it, it automatically completes. And that makes it very, very easy. So, you don’t have to worry as a trainee of making two smaller rhexis because it’s up to your trainer to save the day. And this just avoids the risk of capsular phimosis or a little bit of subluxation especially in cases say where you’re teaching the trainee to do rhexis in pseudo exfoliation. So, you can see that. You can easily make the rhexis a little bit bigger. Let’s share you another video.

As you go along you can start playing. So, this is a technique that I was just in theater and everything was going very smoothly. And I just thought, okay let me just have a little bit of a play. So, minor rotation and crack the lens is a little bit soft, so I’ve done a proximal cracker as well. And I thought know, if I put my second instrument across the eye whole lens with the Phaco split it and then do a reverse rotation, it will split the lens. So, without even rotating and grooving, it’s a kind of part chop. We can see that again. So, Phaco should be fun as well for you as the trainer as well as the trainee. So, we’ve split the lens, move the instruments and crack again. Hold the fragment back with your Phaco tip and put the second instrument across, stabbed the lens slide and then just reverse, rotate it. And you can see that the lens is starting to split and then very, very easily you can make us quick crack. I’ll tell you if you do this on a soft lens, it puts a smile on your face.

People were asking me about chop and how to learn it. So, this is a quick video of learning chop. This is a easy chop. So, you have to bury the tip and the second instrument just simply stabs the lens next to the Phaco tip and then you crack it. But here the trainee is pulling the fragment and the Phaco tip is slipping out. So, you can see that the crack the chop didn’t quite work. But it doesn’t matter. If it didn’t work, you just go back to grooving and cracking in the normal fashion. So, let’s rotate the lens and try chop number two on the same lens. So, bury the tip buzz, buzz, buzz and it goes push, push, push, push, push. Now, keep your hand still, stab the lens and just crack it. Stab, but the Phaco tip is falling out because the trainee is pulling the hand back. It doesn’t matter. We can again sculpt and crack if we had to. But we’re learning the technique so we expect them not to do it perfectly. So, again they buried the tip, in goes the tip, again the tip is falling out slightly because they haven’t got that hand controlled yet they keep wanting to pull their hand back to, into the safe central area.

I’ve shown them before how to chop and demonstrating it but now this is performance. So, the trainee knows the techniques but they have to try. So, let’s try again. Attempt number three. The tip is now more steady. The second instrument goes in, crack. There we go. Their first decent chop. Chop number five, bury the tip, instrument second instrument stops, cracked. There you go. Chopped. And that’s what I call easy chop. So, you can learn these techniques but it does take several cases to do it. And you just keep going and the trainee has now chopped that lens. And this is the trainee who is probably not done the whole case because I’m teaching them how to manage fragments.

Yes, they haven’t done grooving. They haven’t done cracking yet. Oh sorry, they have been cracking but now they’re learning that chop. I’ll just see if there’s any more questions at the top. Here we go. There’s a few more questions. Let’s see. If there was a limitation of cases in the current circumstances, can we teach more than one module on a single surgery?

Absolutely. You just have to decide which bit you are teaching them and don’t have too many components near each other. For instance, you could teach them the cornea section and you could teach them eye wall insertion, or you could teach them Capsulorhexis and fragment removal if you have to. But you have to make sure that the rhexis is of a decent size.

So, cases are limited with COVID, so you have to work out as a trainer what you’re going to do. And the question here is, is there an age to start teaching Phaco? That’s a great question. I recently talked somebody who was 62 years old. It was a pediatric ophthalmologist who was – haven’t done any operating on Phaco for at least 15 years. They were left-handed and I had to teach them. Let’s just pause this video. That I had to teach them how to do Phaco from scratch. So, you can teach somebody at any stage as long as you have the nomenclature and to tell you the truth it was very good fun teaching them because they had great hand-eye coordination. And whatever I told them, they just simply did. So, it was very, very good.

I hope that really helps. I’ll just read through if there’s any other sessions. How do you crack a soft cataract if it doesn’t [indiscernible] [01:01:57] becoming a ball? That’s a great question. So, I think if you’re teaching a trainee how to tackle a soft cataract, you may want to get them to simply delineate the lens as often as you can. Four or five delineations and then hopefully they’ve got foot control to just simply aspirate out the lens. And then if you need them to flip over the ball, you need to turn and I called that a push me-pull me technique where you pull the soft lens material and you use your second instrument to push the material away from you so it folds and flips over.

Patient selection for beginners. I will teach virtual anything. One of my new trainees did their second whole case on a 94 year old because that was the best case on the theater list. So, as long as you instruct them and you have faith and instruction, it’s fine. But if you have to take over, you have to take over.

I think I’ve answered most of the questions. So, I’m going to stop there I think. And if anyone wants me to do another talk specifically on how you learn particular aspect of a surgery, I think I’d be more than happy to do that. Sorry, there’s one more question here.

Can you practice on animal eyes? Absolutely. You can practice on a tomato to do Capsulorhexis. You can – I was practicing using two tables this morning as the lens and showing a trainee how to groove between the gap in the table just to show them where to put the Phaco tip. You can use whatever you like, what makes it easier and fun. Okay. I think I’ll end there if there’s no other questions.

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Click here to watch Optimizing Trainer Supervision and Trainee Learning in Cataract Phacoemulsification Surgery Part 2

August 5, 2020

Last Updated: October 31, 2022

3 thoughts on “Lecture: Cataract Phacoemulsification Surgery: Optimizing Trainer Supervision and Trainee Learning”

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

    • 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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