What I Wish I had Known for

My 50 First Phacos

Lorraine M. Provencher, MD
University of Michigan, Kellogg Eye Center
 • Review step-by-step lessons from
my early surgical experience

• Highlight useful simulation tools for

OBJECTIVES the early phaco surgeon

• Improve patient safety by bending

the surgical learning curve
Poll Question 1:
How many phaco surgeries
have you performed?
a. None
b. < 50
c. 50-200
d. 200-500
e. 500-1000
f. 1000+
Poll Question 2:
What step do you find most challenging?

a. Wound construction
b. Capsulorrhexis
c. Hydrodissection
d. Nuclear disassembly
e. Cortex removal
Lesson #1: When you are assisting, don’t
just be an assistant…
 Active • How: peek around the scope
• Why: “I wish I knew what you were thinking right now…”
• What: if you were operating, next step
Assistant

Primary Surgeon

Learning before the Case

Lesson #2: Anticipate,
anticipate, anticipate…
• Pre-op evaluation & tactful patient selection are crucial
• Anesthesia selection
• Positioning and exposure
• Dilation, red reflex
• Zonular or capsular issues
• Ocular history, prior surgeries

• When and where might something go wrong?

• Ideal balance: case complexity < surgeon skill

Poll Question 3:
What step of cataract surgery is MOST
important?
a. Wound construction
b. Capsulorrhexis
c. Hydrodissection
d. Nuclear disassembly
e. Cortex removal
 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction

Anesthesia, positioning, and exposure

Lesson #3: Every Step Matters

 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction

Anesthesia, positioning, and exposure

Every Step Matters

 Positioning
• Chin/brow
• Bed

Exposure
Lesson #4: SET • Lash drapes
• Sponge drain
yourself UP for • Retrobulbar block
success
Chin Down…
Chin Up!
Sponge Drain
Retrobulbar
Block
• Akinesia
• Anesthesia
• Mydriasis
• Decreases photosensitivity
• Proptosis

Cataract Surgery for Greenhorns

 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction - paracentesis

Anesthesia, positioning, and exposure

Every Step Matters

Lesson #5: Be particular about your paracentesis

§ Paracentesis: ~1 mm uniplanar,
radial wound
§ BSS, meds, anesthetic, viscoelastic,
hydrodissect, etc.
§ Second instrument
§ Nuclear rotation and disassembly

§ Blades, knifes, needles

Lesson #5: Be particular about your paracentesis

§ Location depends of the type of

second instrument (generally 60-90
degrees from main wound)

§ Determine where your dominant

hand wants to rest à main wound

§ Place para in relation to the main

wound
Lesson #5: Be particular about your paracentesis

§ Mistakes:
§ Too close
§ Too far
§ Too long

§ Solution: make another

 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction – main wound

Anesthesia, positioning, and exposure

Every Step Matters

Poll Question 4: What type of main
wound do you use for phaco?
a. Clear corneal < 2.4 mm
b. Clear corneal >/= 2.4 mm
c. Scleral tunnel
d. Limbal
Lesson #6: Main wound woes
• Max architectural stability:
• Width: 3.5 mm or less
• Length: 2 mm

• Must be of adequate length to

accommodate the sleeve of the phaco
probe and later the lens

• You create the wound on the way IN

and OUT
Lesson #6: Main wound woes

Too posterior: conjunctival balloon

Too long/anterior: corneal distortion, edema, poor view

Too short: leaky, iris prolapse

Tilt or slide: leak, roof issues

Too posterior: conjunctival balloon
Too long: visibility issues
Too short: leaky, iris prolapse
Tilt: leak
 Simulation
Platform: Wounds

• Human cadaver eyes

• Porcine or bovine eyes
• Model eyes

Simulated Ocular Surgery, Cataract Eye – Basic (gel lens).

http://simulatedocularsurgery.com
 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction

Anesthesia, positioning, and exposure

Every Step Matters

Lesson #7: A good CCC
can save you later…

• Centered
• Round
• Continuous
• 5-5.5 mm
Trace the path you want the rhexis to take

Phacodynamics, Barry S. Seibel

Trace the path you want the rhexis to take

Credit: Dr. Eduardo Mayorga

 o w
K n
s t
u
M
Simulation Platform: Rhexis

Eyesi by VRmagic Kitaro by FCI Ophthalmics

 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction

Anesthesia, positioning, and exposure

Every Step Matters

Lesson #8: Make Sure It Spins

• Just under anterior capsule

• Peripheral enough
• Watch for lens vault
• Blot
• Won’t spin?
• Try sub-incisional
 Lens

Cortical removal

Nuclear disassembly

Hydrodissection

Capsulorhexis

Wound construction

Anesthesia, positioning, and exposure

Every Step Matters

Poll Question 5: What type of
lens is most challenging for you?
a. Soft nucleus
b. Dense leathery brunescent
c. Chalky white
d. Intumescent white
e. None, I’m that good…
Chylack LT, Wolfe JK, Singer DM, et al. The Lens Opacities Classification System III. Arch Ophthalmol.1993;111(6):831–836.
Lesson #9: Different Lens, Different
Strategy
Soft Lens Moderate Lens Dense Lens
• Aspirate • Divide & conquer • Dispersive OVD
• Bowl & collapse • Variations of chop • Divide & conquer
• Prolapse • Variations of chop
• Soft chop • MiLoop
Lesson #9: Different Lens,
Different Strategy
Capsule compromise
• Avoid hydrodissection
• Soft lens: aspirate or bowl
out/collapse
• Hard lens: V-groove
Shallow AC
• Avoid over fill
• Slightly more anterior wound
• Hooks > ring
• Dispersive OVD to protect
endothelium
Zonular weakness
• Minimize spinning
• Avoid chamber collapse
• Chop
• Early capsular support
Post-vitrectomy
• Hyperdeep, less stable chamber
• Increased bag mobility
• Hydro delineation
• Lower IOP (bag)
• Generous OVD
Lesson #10: Know when it’s safe…
Nuclear removal Nuclear removal
• Epinuclear material • Little to no cortex/epi material
• Heminucleus remains • Poor red reflex
• Pieces in front of phaco • Last few pieces (surge)
• Flow/IOP adequate • Leaky wounds (pushing down)
• Chamber stable (good wounds)

Cortex removal Cortex removal

• When most of cortex remains • Last few bits of cortex
• OVD fill • Dense PC plaque
• Flow/IOP adequate • Second instrument insertion
 It’s usually not
the patient…
It’s usually you…
 OVD
Block
Ring
Stain
Hooks

If you think you should…you

probably should!
Suggested
Resources
Huge Thanks
• Tom Oetting, MS, MD
• Eduardo Mayorga, MD
• Manjool Shah, MD
• Hunter Cherwek, MD