Pearls for the young cataract surgeon

A panel of experienced surgeons offered words of wisdom at ‘Pearls for the Young Cataract Surgeon’, a symposium organised by the Young Ophthalmologists Committee during the 23rd Winter Meeting of the ESCRS in Athens, Greece.

First to speak was Basak Bostanci Ceran MD, Okan University Hospital, Istanbul, Turkey, who discussed her first rhexis and hydrodissection attempts. In the words of her mentors, if you don’t have a perfect rhexis, “you will be doomed in the following steps”. Dr Bostanci Ceran showed a video of one of her earliest rhexis attempts, with poor visibility, poor centration and little control.

In subsequent cases she learned about the many variables at play in each patient. These included pupil size, globe exposure, red reflex and capsular texture and eye movements, which are almost impossible to replicate in a simulation environment. One of her key points of advice was that good visualisation is a must:

“Before doing anything, learn how to use your microscope.”

The ideal rhexis is something that ophthalmic pioneer Professor Thomas Neuhann, Germany, is still striving for. It is not a technique that requires certain movements; rather it is a principle that must be understood, he believes.

“Once you understand it, then you make it work for your hand.”

The ideal rhexis should be able to do three things: reliably encase or support an IOL implant; contribute to maintaining the diaphragm function between the anterior and posterior segments; and it should be maximally resistant to mechanical stress or distension intraoperatively.

To achieve these things, it must be continuous. Quoting his co-inventor of the capsulorhexis Howard Gimbel MD, he asserted that “it’s not about circularity, it’s about continuity”, reminding the audience that a perfect circle is not essential – as long as it covers the IOL margin 360°. It should also be centred. Not on the pupil or the limbus, but on the IOL, although he acknowledged that this is easier said than done.

Vincent Qin MD, CHU UCL Namur, Belgium, showed a series of video cases where complications occurred and how they were overcome. These included posterior capsular rupture, dropped nucleus and rhexis running out. His advice was to plan ahead, taking time even the day before surgery to anticipate the various complications that may occur. In case they do present themselves, stay calm, add some viscoelastic and then think about what you’re going to do.

Richard Packard MD, FRCS, FRCOphth, Director, Arnott Eye Associates, London, UK, described the dream phaco – many factors must align for this to take place, from patient selection, draping and microscope preparation, to perfect incisions, minimal ultrasound use and so forth. Machine settings must be optimal, the patient must be calm and the surgeon must be comfortable: “At the end of the day you won’t have a sore back, because you’ve got a long career ahead of you.”

Speaking to EuroTimes after the event, Dr Packard added: “It is important to have a clear plan of action for each of the successive steps in the surgery so that they are repeatable and consistent. By this means the dream phaco will encompass more complex cases.”

Conscious incompetence
Recalling his own mistakes, Vasilios Diakonis MD, PhD, The Eye Institute of West Florida, USA, advised that surgeons avoid challenging cases until after they had performed at least 50 surgeries. It's important to be comfortable with everything in the operating room, from pedal to tip. Like Dr Qin, he also suggested that “you cannot save on viscoelastics” – use as much as is necessary.

He then described the difference between conscious incompetence and unconscious incompetence in young surgeons, warning against the danger of the latter condition. If a young ophthalmologist understands their limitations, they should step back and allow their mentor to take on more challenging cases.

When searching for such a mentor, it’s important to find one with conscious competence, as the unconsciously competent cannot explain how they do what they do. Ultimately, he advised doctors to learn from their mistakes and not to repeat them.

Closing the session, Boris Malyugin MD, Fyodorov Eye Microsurgery Federal State Institution, Russia, showed his mastery of challenging cases with videos of his more difficult procedures. Most intriguing was “FLACS upside down”, where the main incision and paracentesis incisions were made at the wrong sides as the technician had put the right eye settings on the left eye.

After asking his expert colleagues what they would do in this situation – Dr Packard said he would make 
some incisions with a knife and “get on with it” – Dr Malyugin, “not looking for the easy way”, decided to use the main incision created by the laser on the inferior-nasal meridian.

The situation got worse when a posterior capsular rupture occurred. The key here was in converting the capsular flap into a round posterior capsulorhexis.

Dr Malyugin also showed a difficult case with an extremely floppy iris, and how it was dealt with including use of the Malyugin pupil expansion ring.

His take-home message was the importance of knowledge of the basics, tips and tricks in surgery, mastery of cases, attendance at meetings such as the ESCRS Meetings and most important of all, building up of experience. Ultimately, one must be prepared for complications. How the surgeon deals with them is what is most important.

“The definition of a good surgeon is not the one who never gets complications, but the one who can get out of his complications without any complications,” he concluded.