‘PIPPA WANTS TO DO IT!’

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PIPPA WANTS TO DO IT!” shouted my daughter right into my ear as I reached over her to pull her ski boots on. “I CAN DO IT MYSELF!” she screamed before she collapsed in a fit of kicking, screaming, frustration and rage. “PIPPA CAN DO IT!”

Philippa is two years old and she wants to do everything to become self-sufficient, independent from the constant need to be helped. It doesn’t matter that everyone around her has to wait – she’s going to practise what she needs to do, because soon she’ll have to do it herself.

I recognise that feeling. I’m currently in the middle of my “Cataract 2” rotation, which is an incredible four-month period of nothing but cataracts. After this rotation, we’re expected to be capable of smoothly completing a standard phaco with reasonable precision. To get to that point, we spend three full days per week in the operating room, for 16 consecutive weeks. It’s surgical heaven.

The attending staff doctors are enthusiastic and motivated instructors. They each take the time to teach us this tricky procedure. However, they’re not interested in spending 40 minutes watching us struggle through an operation. The patient gets restless, the nurse gets bored and the waiting room starts to overflow. We have to be sharp and our learning curve must remain steep. To succeed, we have to fight for the right to operate, and for that, we have to be ready.

We each have our own way of preparing. Some read cataract surgery textbooks, watch surgical videos online or practise on a surgical simulator. Personally, I choose to seriously focus on observing the procedures performed by my attendings. What better way to learn how it’s done correctly than by watching a surgeon who performs more than 1,000 phacos per year?

We all talk with older residents, asking them all kinds of questions, to learn what we can expect from each of the surgical attendings. Each doctor seems to have their own expectations, teaching methods and techniques. “Dr So-and-so is particularly obsessive about the primary incision, so make sure you concentrate on that. Otherwise, he’ll take over before you even get any further.” Other doctors get very annoyed if the sterile drape isn’t perfectly placed, or if you touch the iris when inserting instruments into the anterior chamber, or if you sculpt too deep.

Some doctors perform bevel-up quadrant removal, worried about accidentally perforating the posterior capsule. Others are strictly bevel-down, in order to protect the corneal endothelium. A third group keeps the bevel parallel to the iris plane, realising that most of the quadrants’ movement are determined by the direction of irrigation flow in the eye.

After seeing the many possibilities, I opted for what I considered to be the best possibility for each step. I tried to do my first 100 solo procedures using as little variation as each particular case would allow. The goal was to master my own method from beginning to end.

I copied Dr Creten’s drape technique and emulated Dr van Rooij’s preoccupation with sterility. I tried to replicate Dr Reus’s multiplanar incision and perfectly circular capsulorhexis, followed by his reliable no-touch hydrodissection. I attempted to operate with Dr de Faber’s speed while trying to stay calm and collected, like Dr Zijlmans. Dr Lemij taught me how to perform a post-op analysis of what could have gone better. Finally, Dr Nieuwendijk was my model for how to interact with the OR staff: firm and decisive but also friendly and fair.

A crucial aspect of being allowed to operate frequently was my selection of cases. Many are simply too risky for a resident, but standard cases are always available, and it is awful to miss those opportunities. So, I make sure to arrive at the operating room very early to screen all the day’s cases to determine which are perfect for my skill level; which are way out of my league; and which I might have to fight for. I then sit down, relax, drink an extra cup of coffee and imagine a flawless phaco in my mind while waiting for the attending to arrive.

Sometimes it’s obvious: a perfect patient and a perfect eye. Other times it’s less so, like a post-vitrectomy eye, or one with pseudoexfoliation. When I’m feeling particularly confident, I really push the envelope: an eye with +6.0 D hypermetropia, a shallow anterior chamber and a relatively small pupil requiring a 27 D IOL.

Sometimes it works and sometimes it doesn’t, but just like a young child, I have to fight to do as much as possible myself, because soon enough, it’ll all be my responsibility. I will do it myself.