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Young Ophthalmologists
Transitioning from Supervised Cataract Surgery to Independent Cataract Surgeon: 12 Clinical Pearls

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  1. Do not underestimate the transition. In your final year of training, surgery often becomes less challenging as your comfort level rises. Surgeons often assume the same comfort level will follow them to the real world. The reality is that operating on your own in a new environment can generate significant anxiety, and you suddenly miss having an attending surgeon by your side. Do not underestimate this transition and make every effort to prepare for it.
  2. Replicate your residency operating room experience as much as possible. The fewer changes you make to your operating environment the better. Try to find an operating room (OR) that is equipped with the same phaco machine, microscope, viscoelastics, etc. Before graduating from your training program, make a list of every instrument you use, along with its brand and catalog number. Be sure to include the specific phaco tubing, handpiece and tips.

    Ask the equipment rep for your phaco machine to transfer all your settings to the machine in your new OR. Before operating without an attending physician, make sure the new OR has all the same instruments. Something as seemingly trivial as the surgical drape, lid speculum or the focal length of the objective lens on the microscope can have a significant impact on your comfort level and, therefore, the success of your surgery.
  3. Know more about your equipment than everyone in the room. You are ultimately responsible for the outcome of your surgical procedures. Therefore, the burden is on you to know how to operate all the equipment, especially in the event of an unforeseen complication or malfunction. Read the manual for the phaco machine and microscope in your OR and ask the equipment reps to provide educational sessions for you and the OR staff. If you do not know the specific equipment settings you have been using as a resident, now is the time to learn them and learn why your attending(s) chose them for you.
  4. Work out of one surgery center at a time. The practice you join after training may use several surgery centers. It is wise to establish yourself at one center and become comfortable with surgery and outcomes there before adding services at a second or third center. Again, the fewer variables you can change at once, the more comfortable you will be.
  5. Focus on difficult cases at the end of residency. Never again will you have the access to skilled teachers that you have during training. Now is the time to learn advanced techniques such as iris retractors, pupil-expansion rings, capsular tension rings, sutured IOLs, etc. Gain as much exposure to such techniques as you can during residency, as it is much more difficult to learn them on your own.
  6. Do not focus on speed. If, in the back of your mind, you are considering adding an extra step to a surgical case, such as a pupil-expansion ring or a retrobulbar block, then by all means do it. When you are starting your practice, your surgical volume will be low and time will not be of the essence. Just because every other surgeon at your surgery center performs cataract surgery under topical anesthesia does not mean that you must. So, if using retrobulbar anesthesia for the first few months alleviates your anxiety, then do so. Always focus on achieving the best possible outcome with the least amount of anxiety, regardless of how many minutes are added to the procedure.
  7. Schedule less-complicated cases early, difficult cases later. A count-fingers cataract in an eye with pseudoexfoliation and a 4mm pupil is an example of a case best avoided during your first few months of practice. Choose cases with the least potential for complications initially, then add cases with increased difficulty as time goes on.
  8. Ask for help. Every surgeon had to make the same transition you are making, so we all understand. Ask for help when you need it, and do not be afraid to refer a patient to a colleague for a second opinion.
  9. Change one variable at a time. Your surgical technique will evolve with time as your comfort level improves and new technology is introduced to the field. When changing your technique, change only one variable at a time. For example, avoid changing both the type of viscoelastic you use and the phaco machine you are using at the same time. Change one of these variables first, then when you are comfortable, change the second.
  10. Practice complication management. Complications happen in the hands of even the very best surgeons. Complications are less likely to result in a poor visual outcome if you are prepared to handle them in advance. Stage complication drills with your OR surgical staff so that everyone knows what is expected, where the supplies and equipment are located and what equipment settings are required to manage the problem. The staff will appreciate the effort, and you will be able to manage complications more efficiently and successfully when they inevitably occur.
  11. Add premium services later. Industry will bombard you with enticing technology, such as multifocal and astigmatism-correcting IOLs. This technology is exciting and is the future of ophthalmology, but approach it with caution. Patient expectations are very high when they are asked to pay for these services, so your surgical outcomes must meet these expectations to avoid unhappy patients. Look at your outcomes retrospectively and establish your own A-constants and surgeon factors. Track your complication rate and ensure that it is within accepted norms. Once you are providing excellent, consistent outcomes, you can then consider adding premium services.
  12. Be humble. You are graduating from an excellent training program with excellent surgical skills. Enter the world of ophthalmology with confidence, but maintain humility. The learning curve for the practice of ophthalmology is very steep in the first few years of practice, so do not lose perspective of where you are in your career and do not become discouraged by the steep climb.

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About the author : Lance J. Kugler, MD, is a cataract and refractive surgeon in Omaha, Neb., a member of the YO Info editorial board, and a graduate of the Academy’s Leadership Development Program X, class of 2008.