Phacoemulsification, like any other surgery, comes with its learning curve. Here are some pearls, from my experience, to help you ‘shorten’ and ‘Flatten the curve’.
1. Believe in yourself:
The first step to successfully doing anything in life is to believe in yourself. Believe you can and you are half way there.
2. Observe, Observe, Observe & Learn
I am a firm believer of this quote by Marilyn vos Savant, “To acquire knowledge, one must study; but to acquire wisdom, one must observe.” Each skill in life can be improved by observing others. It is the same case for surgeries too. The more you observe a particular type of surgery, the better you get at it. Observe your seniors. Observe their hand movements, observe how they complete a straight-forward case and observe how they tackle complications. Try and observe as many people surgeons as you can, as each and every phacoemulsification procedure teaches you something new.
Residents in today’s era are blessed with easy availability of the internet, and the bombardment of webinars. All types of surgeries, in complex situations, by world-renowned surgeons are available to view at the tap of a finger. Make the most of it. Take your time and do it right.
If possible record your surgery and try to watch later on. Observe every step in slow motion. This way you can understand where you went wrong and need improvement.
Pay special attention to your complications. Identify the precise instant when your chopper or sinsky tore the capsule. Watch the incision construction in slow motion to see why your incision was leaky. Watch capsulorhexis over and over until you can identify when and how an extension to the periphery happened. So, observe and try to learn from your own mistakes
3. Choose the right case & know your patient well
This, in my experience, is the most critical pearl. Trainees must be handed cases that somewhat match their experience and surgical skill. The small pupils, pseudoexfoliation syndromes, and subluxations must be tackled by seniors. It is often the Mature and the very early cataracts that may pose a challenge for the young surgeon. Hence, a grade 2-3 cataract, with a well-dilating pupil is the ideal phacoemulsification case. Each surgery performed well, boosts confidence, and ultimately one wants to challenge oneself by choosing more challenging cases. On the other hand, a beginner, given a complex case tends to land up in a complication, dents his confidence, and taking him/her back ten steps.
Know in-depth, the details of your patient’s clinical/medical history and complete pre-operative examination. Recheck and confirm the IOL power, and keep as back-up one more PCIOL and 3-piece IOL or an Iris Claw IOL.
4. Know your Phaco Machine & Microscope
In the operation theatre, your phacoemulsification machine is your best friend and your worst enemy. Know it well, and it will see you through the most complex of cases. A resident must know how to set up the machine, as well as how to troubleshoot. One must have complete knowledge of the foot-pedal, the control panel, the tubings, the phacoemulsification console, and most importantly, the handpiece. There should be perfect harmony between your right hand (handpiece), left hand (Second instrument), and your foot pedal.
Get acquainted with your microscope, and its controls. The foot-controls of the microscope are as important as that of the phaco foot-pedal. Visualization is of paramount importance. Make sure you have the best possible view through the microscope, right position of eyepieces, the right ergonomic position of your hands and feet. If it doesn't feel comfortable, then re-arrange your position until it does. Don't proceed with surgery until you are in a comfortable position and have access to all footswitches.
5. Know the Phacodynamics
Phacodynamics encompasses the ultrasonic power and the fluidics. Conservative use of phaco power is of paramount importance. Excess ultrasound power is absorbed by the endothelium and is translated as post-operative stromal edema, both being directly proportional. Hence, thorough knowledge of the different modes of phaco power dissipation, and when to use them, is emphatic for optimizing surgical outcome. Phaco-fluidics includes the influx and efflux of fluid from the eye. A harmonious balance between the two is also of paramount importance because an imbalance can lead to surge, resulting in unwanted consequences.
6. Perfect your incisions
Perfect incisions are an underrated component of successful phacoemulsification. A tri-planar incision is self-sealing and seems to be most acceptable. A leaky wound can not only result in a flat chamber but can also act as a gateway for pathogenic organisms, resulting in disastrous sequelae. Hence, wound architecture should be perfect.
As a rule of thumb, always suture when in doubt. This can save an extra trip to the operation theatre, and occasionally much more serious sequelae.
7. Eyes don’t see what the mind doesn’t know (Know the Complications)
There are a plethora of complications that could occur before, during, and after phacoemulsification, like any other surgery. The key lies in identifying these complications at the right time and hence managing them appropriately. But, one can only know of these complications, if one knows how to identify them. There is no denying the fact that these are picked up much easier with experience, however, beginners must read about all complications in detail, no matter how trivial they seem.
“The definition of a good surgeon is not the one who never gets complications, but the one who can get out of his complications well.”
8. Don’t hesitate to ask for help
Confidence makes you grow, but overconfidence could lead to a fall. If, at any stage of the surgery, you have difficulty in completing a step, no matter how trivial, always look towards your seniors for assistance. True courage is asking for help, so never hesitate.
You will walk with your head held high, knowing you did good towards the patient, which is after all, the purpose of medicine.
Talk to your patient. Hearing the reassuring voice of your surgeon reduces anxiety, aids relaxation and makes everything go more smoothly.
9. Convert if needed, Don’t balm your ego
Again, I must emphasize, the wellbeing of the patient is the purpose of our rigorous training. If you feel incisions are leaking after hydration no harm in applying a suture.So, during surgery, if push comes to shove, don’t think twice before extending your corneal incision and converting to ECCE/SICS.
10. Keep Track of Your Outcomes
Patients deserve the best we have to offer. In order to help our patients develop reasonable expectations of surgery, we can provide them with our own data on outcomes from our own experience. Note down your visual and refractive results, calculate your surgically induced Astigmatism (SIA). Use the results to modify your surgery and optimise surgical results.
"If you really look closely, most overnight successes took a long time." -- Steve Jobs