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Young Ophthalmologists
10 Pearls for Your First 10 Phaco Cases after Residency

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Pearl #1: Know Your Team
You are the new kid on the block, and yet you are — and must be — the boss. Communicate your needs and expectations to your staff, but remember that a calm and confident demeanor is necessary to avoid ruffling feathers during your first surgical days. How you shoulder this burden demonstrates your character. Remember that arrogance is often the mask of insecurity. If something is not going the way you want, look within yourself to find the fault. That's probably where it is.

Pearl #2: Know Your Equipment
Knowing how to set the phaco machine is critical to your success. Vacuum, power and flow — as well as other secondary settings such as duty cycle, rise time and occlusion mode — represent essential tools in your surgical technique. They are just as important as incision size and capsulorhexis diameter.  

Do you know your phaco tip size in terms of gauge or diameter, bevel angle and design? Do you know what type of tubing you use? Can you translate all of this information to a new machine from a different manufacturer? Do you know your phaco parameters? And we don't mean "phaco one" and "phaco two."

Pearl #3: Take Your Time
Speed kills. The old warning about methamphetamine abuse is true. Rapid, deft and efficient surgery is not achieved by trying to go faster; it is achieved by concentrating on perfecting technique. Trying to go faster only leads to sloppiness and complications. Take your time and do it right. That's where the intrinsic (and extrinsic) rewards remain.   

Pearl #4: Be Honest
Answer honestly when asked, "How many of these have you done?" In fact, your first patient may be excited about being your first. As we have gone through medical school, internship and residency we have lost all perspective. Patients assume we are well-trained, competent and expert in surgery. They may prefer a young doctor who knows all the latest information. In truth, patients fundamentally want a doctor they trust. Honesty inspires trust. Deceit does the opposite.

Pearl #5: Have a Back-Up Plan
You should always know what to do next because you have already thought it through. Rarely is the operating room the place to think. It is the place to act. Have a plan to deal with common and well recognized complications. Here are a few tips:

  • Leaking incisions are hydrated, then, if necessary, sutured.
  • A capsulorhexis that tears out is managed with Brian Little's capsulorhexis rescue technique.[1] 
  • Unstable capsular bags receive capsular tension rings.
  • Posterior capsular breaks are managed with maintenance of irrigation, dispersive viscoelastic and anterior vitrectomy, followed by kenalog instillation.

Pearl #6: Talk to Your Patients
Hearing the reassuring voice of your surgeon reduces anxiety, aids relaxation and makes everything go more smoothly. Mark says things like, "Hi, it's Dr. Packer, how are you doing under there?" and "Everything's going great" and "You may get a bit of a light show now as I loosen up your cataract" and "The cataract is all out, we're just getting ready to put in your implant. Are you doing okay?"

We always have the patient's name posted in the OR so we know how he or she wants to be addressed.

Pearl #7: Record and Watch Your Surgery
Mark was watching a video recording of his surgery, and he could see an instrument just sitting there in the eye, and nothing happening. Why not? What on earth was he doing? He can't remember.

As you watch, don't attempt to criticize or second guess. Just absorb. Learning often occurs subliminally. Pay special attention to your complications. Identify the precise instant when the capsule got sucked into the phaco tip and tore. Watch the incision construction in slow motion until you see exactly when you entered Descemet's too soon and got a leaky wound. Play the capsulorhexis over and over until you can identify the motion of the forceps that produced an extension to the periphery. Once you see how thing go wrong, ask yourself how to make them go right.  

Pearl #8: Focus
When you are operating, you should be completely focused on what you are doing. Don't listen to music or chat about politics. Take your responsibility seriously. Use your internal monologue to tell yourself what to do next. Make sure you have the best possible view through the microscope, the right angle of approach, the right ergonomic position of your hands and feet. If it doesn't feel comfortable, then re-arrange your position until it does. Don't proceed with surgery until you have made everything the best possible.

Pearl #9: Keep Track of Your Outcomes
Patients deserve the best we have to offer. In order to help our patients develop reasonable expectations of surgery, we can provide them with our own data on outcomes from our own experience.

What percentage of post-op refractions is within 0.5 D of the target? How many patients see 20/30 or better without correction? Knowing these results will allow you the confidence you need to offer refractive solutions.

In the near future, Medicare and other payers may also want to know this information through PQRI. It is the surgeon's ultimate responsibility to know his or her results. Make sure you do.

Pearl #10: Never Stop Learning
The first time Mark operated after his residency, he put in his first foldable IOL (it was 1995). He implanted his first multifocal IOL in 1997. He made the transition to clear corneal incisions and topical anesthesia in 2000, the same year he implanted his first accommodative IOL. He began doing bimanual micro incision surgery in 2003.

Since 1995, there is a long list of exciting and useful technology that has emerged, including capsular staining; the capsular tension ring and its modifications; new multifocal, toric and accommodative IOLs; limbal relaxing incisions; LASIK enhancements in pseudophakia; piggyback IOLs; and phakic refractive lenses.

[1] Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg 2006; 32:1420-1422.

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About the authors: Mark Packer, M.D., is the chairman of the cataract section of the Academy's Annual Meeting program committee. He is a partner at Drs. Fine, Hoffman, and Packer ophthalmology practice in Eugene, Ore., and associate professor of Clinical Ophthalmology at Oregon Health Sciences University in Portland, Ore.

Jennifer H. Smith, M.D., is the chair of the Academy's Young Ophthalmologist Committee. She is assistant professor of Ophthalmology at Northwestern University Feinberg School of Medicine.