Recollections of my first intraocular surgery

In our locality, one of the first operations for trainees to learn is the extracapsular cataract extraction (ECCE). Needless to say, all but a few have restless nights before operating, I was no exception. To prepare, I sat diligently next to my laptop, cruising through the Youtube videos of the steps of ECCE, hoping for some passive diffusion of wisdom.

This was followed by a diet of my most admired supervisors’ demonstration CDs of how they perform a flawless cataract operation. The night will then be filled with dreams of ECCE, snapshots of iris prolapse, expulsive haemorrhage, and the nucleus falling ever away into the abyss. The worst was when my session was cancelled, and I was back in the windowless clinic, seeing my sixtieth patient in the daily mill of the clinic. It was not my first ECCE, but I was hoping that this time, I would get to complete it, as well as writing the words “uneventful” in the discharge summary. My supervisor had not arrived yet. I scrubbed up. In my mind, replaying the steps over and over again, noting the previous mishaps, and making sure not to repeat the same mistakes.

I meticulously cleaned the eye; the lashes one by one (lest one tiny stubborn microbe stayed hanging on the lash causing endophthalmitis and the demise of the patient). I was quiet all along, trying to stay focused, geared like a race car driver before the Grand Prix. I secured myself firmly in the seat of control, making sure I had my pedals exactly where I wanted and my back in a slight but comfortable lordosis. I needed to act professionally, in front of the nurses, I wanted to have an aura of, “I know what I’m doing”, when in fact, I have only done this a handful of times. I needed to portray a sense of calmness, for all eyes were on me to perform. The phone rang which startled me while I was in a trance.

My supervisor was running late, but won’t I start first as I’ve done this before, right? I mustered the courage and quickly muttered, “Yes, of course”. (The chance of flying solo was too good to pass). I was both excited at the challenge, and anxious – what have I got myself into? I feel my heart thumping away at 150 beats. I asked for the 0.12 forceps and a pair of Westcott, (at the same time, I offered a prayer, “please let me help this patient, do no harm, please be my guide, above all, PLEASE keep my hands still!”). After considering the location of the pannus and the limbus, I decisively cut into the pristine white conjunctiva, “This is it, the point of no return” I thought. For I was reminded by my mentor’s words, “each step defines the level of difficulty of the next, and in turn affects the overall outcome of the surgery”. Later comes the part where I find great difficulty in, holding the beaver blade in my tremulous hands, having to curve, slide across and cut to a precise depth in microns seemed all too much for me to handle. I rehearsed by waving the sharp blade in the air over an arc configuration, like a golfer practising his swing before he hits the ball, except, I do not have the luxury of multiple strokes for the glory of getting a “birdie”.

I took a deep breath in and for the next few seconds I held my breath nervously, hoping that would help control any hand tremors; while placing the blade onto the edge of the cornea, sliding along curving gently, all the time imagining the blade of an elegant figure-skater, forming a perfect arc of a groove on the snowy-white, untouched ice. On completion of the wound, I breathed a sigh of relief and euphoria, still a little giddy from the breath-holding and to have managed so far. Later, came the next big hurdle, luckily my supervisor arrived just in time for the delivery. I felt an instant calmness wash over me, that she was by my side and directing me through the manoeuvre which I was still trying to master.

“Push”, “go on, push harder”, “you can do it”, “open up”, “it’s not coming...I think its stuck!”, I replied apologetically and gingerly, my voice in a muffled shrill, trying to hold back any signs of lost of control in case she takes over MY first case. Finally, I made the extra cut, and all ends well with a bulky, solid, ruby-brown pearl which nonchalantly popped into the water-bag, quite unaware of the trouble it had caused its owner, the patient; and by now, me, catching my breath with beads of sweat percolating over my forehead.

Next, the mad rush of getting the sutures in place, closing the wound before the risk of a catastrophic suprachoroidal haemorrhage. Predictably, the sutures were replaced multiple times; I bent the needle inadvertently, until finally, the cornea became a little frayed at the edges from my repeated attacks. During irrigation-aspiration, the cornea collapsed down completely at times, there were star-folds on the capsule, and in case my supervisor was not entertained, I yanked at the anterior capsule unintentionally.

Miraculously, the intra-ocular lens was inserted in the bag, and I painstakingly fiddled with the final closing sutures, to that end, it resembled the wounds of Frankenstein. At last, I stared proudly at the intraocular lens sitting securely inside the bag. Throughout my years of training, I am most grateful for those who have sat patiently next to me, with the poorly focused, nauseating side-tube view. Despite my clumsiness and dangerous feats, they have heroically sat glued to their seats, knowingly and unknowingly allowed me to make mistakes (without much compromise to patients’ outcomes), so that I may grow and gain my own operative experience. I hope that one day, I would grow up to be just as good as them, both as a cataract surgeon and a teacher.