WHEN THINGS GO WRONG IN CATARACT SURGERY

“It’s upside down,†said Dr Zijlmans. “It’s open, in the bag and upside down.†I stared through the operating microscope in horror and saw, in my peripheral field of view, Dr Zijlmans making the universally recognised circular hand motion that means: Switch places with me. You messed it up and I need to fix it. I began to sweat and my throat closed up. A wave of shame crashed over me. Was this the end of my trust-building with the cataract team? If I couldn’t properly complete the simplest step of a cataract operation, how could I be taught to crack a nucleus?

Thus began my first attempt at intraocular surgery. This was not at all the start I had imagined. We’re in training for more than two years before we learn phacoemulsification, and we’re allowed, and expected, to jump right into the action during our first week in the cataract operating room. It’s incredibly exciting. But at the same time, it’s also nerve-wracking. We mostly operate with topical anaesthesia, so a little tetracaine is the only thing standing between us and them. What if they cough? What if they sneeze? What if…?

Dr Zijlmans is a very relaxed character, a cataract specialist with 12 years of experience. A lot of the trickiest cases get referred to him, and he has helped train countless residents and fellows. This upsidedown IOL was no big deal for him to fix. Evaluate, flip, reposition – end of story. While we were scrubbing for the next operation, I joked with him. I wanted to assess the damage I had done. “I think you might have loaded the IOL upside down in the cartridge,†I said. After all, he was my “assistant†during the last case. “Sure, sure, that’s quite likely,†he quipped, a sarcastic smile barely visible in his eyes behind his operating mask. “Loading an IOL can be tricky.†T

he first time we’re present during cataract operations is during our paediatrics rotation, where we assist surgeons who operate both juvenile and senile cataracts. We get to see about 100 procedures and get familiar with the microscope, the equipment and the operation itself. Assisting phacos is not quite as exciting as the strabismus operations that we’re allowed to do ourselves. So besides watching attentively during the procedure, I’d challenge myself with the routine peri-operative tasks. Unpacking the phaco set – with all its instruments, syringes, needles, tips and sleeves – became a little ritual of precision and speed. I liked to imagine that I was a young child on Christmas morning, unpacking my new Lego set and putting it all together. How smoothly could I do it without making any mistakes? Could I finish setting everything up before the surgeon made the first incision?

But now I was doing the real thing. Intraocular surgery is weird. Fine instruments are manipulated with our hands, yet everything is controlled by our eyes. There is almost no tactile feedback, and so little resistance given by the ocular tissues to the sharp instruments. It’s the purest form of hand-eye coordination and fine motor skills. Combined with the very small margin of error, it’s enough to cause any attending surgeon to have at least a few sleepless nights. Niels, a resident with 20 full phaco procedures under his belt, had advised me on this: “Make only small, slow, controlled and predictable movements. You don’t want the supervisor to die of a heart attack.â€

My next IOL insertion went well and I, ahem, congratulated him for loading the lens correctly this time. However, during my third chance, desperate to avoid the same upside-down mistake, I spent too much mental energy making sure the lens opened as it should. Was it correct? Had it flipped? Doubt. Stress. I hesitated and stopped turning the injector screw. The leading haptic started unfolding in the anterior chamber, and before I knew it, the lens optic was stuck in the middle of the incision. Oh man, here we go again! Again the “switch seats†sign: a closed hand, moving in a circular motion with the index finger pointing straight down, as though he were stirring a big bowl of soup. Although the patients are aware that residents and fellows might perform part or all of their operation, there’s no need to alarm the patient. We silently switched seats and Dr Zijlmans continued with the operation, pulling the lens back out.

“Had you ever seen that before?†I asked while we were scrubbing for the next operation. “I’ve seen everything before, including all the mistakes you’re likely to make in the next four months,†he answered calmly. During the next few operations, it all went more smoothly. Just stay away from the posterior capsule, I kept telling myself. Pull those nucleus quadrants into the iris plane and emulsify them in the anterior chamber. After all I’d heard about the fragility of the posterior capsule and the drama associated with its rupture, I couldn’t believe my ears when Dr Zijlmans said, “Go ahead and polish the capsule.†What?! You can’t be serious, I thought. It’s four microns thick! I don’t even want to go near it. I hesitated. “Just do it,†he said.

Good teachers have the big picture in mind. That includes the big picture of patient care and favorable outcomes far beyond the eye being operated at that moment. Yes, a trainee is more likely to cause a complication than an attending. Yes, that’s unfortunate for everyone involved. However, if an ideal situation exists for a complication to occur, it’s during an operation under the supervision of an experienced surgeon within a large training hospital with access to vitreoretinal surgeons and general anaesthesia. The outcome of a complication here is likely to be better than that of the same complication in the hands of a first-year ophthalmology graduate operating in a general hospital an hour’s drive away. That is, of course, the setting in which the large majority of recent graduates end up. The net advantage lies in operating early and often, sitting next to the real pros. So, I slowly polished the posterior capsule, my confidence growing. A week or two later, I had completed my first phaco procedure from beginning to end.