Tuesday, October 20, 2015

Learning phacoemulsification cataract surgery

Performing phacoemulsification cataract surgery is nowadays the quintessential eye operation-the one that most people think about when referring to eye doctors. To recap, this operation removes the hazy natural lens of the eye, and replaces it with a new, perfectly clear lens implant.

What's doing the surgery like?
It is a bit like playing an organ (or driving a car with manual transmission), you need both hands and both legs-how so?

Left foot:
Operating microscope (focus and zoom adjustments)
Right foot:
Phacoemulsification machine pedal (activating vacuum/aspiration and ultrasound power)

Left hand:
Second instrument for manipulating cataract
Right hand:
Phacoemulsification handpiece

So, it is a bit of a ballet, with coordination between the 2 hands and  the right leg the most important part. Like learning how to drive a car, after a while (for experienced surgeons)
1. Most of the routine parts become automatic
2. We anticipate problems that may occur
3. We consciously and subconciously set safety limits on what we do
4. We tweak our technique according to the type and hardness of cataract we are facing

Phacoemulsification is also done entirely while looking through a microscope. That takes a little time to get used to. Hand-eye coordination is particularly important, because there is much less tactile feedback when dealing with tiny things. I like to think that computer gaming in my younger days helped in this regard!

Wet lab training

A 'wet lab', you say? You mean there are wet ones and dry ones?

A wet lab in the context of surgical training involves the teaching of techniques using wet material-ie animal eyes and similar such biological tissue. We did some training for phacoemulsification on pig's eyes and also stitched pig eyelids for practice in our day.

However, animal eyes are very different from human eyes. In fact, it is usually more difficult to accomplish certain techniques with such eyes than in real life, and I was never very fond of wet labs. Still, the experience of doing things while looking through the microscope was quite useful.

Milestone: first phaco

It actually didn't take me very long before I performed my first whole cataract surgery. Besides wet labs, cataract surgery was taught (and it still is quite similar today I think) by letting the training surgeon perform some steps of the procedure at the beginning. For some trainers, this might be what are considered the easier steps first, followed by the more technically demanding ones. I started out under Mr Fearnley at Northampton doing the incision, and by the end of the year, just before Christmas 1999, I had performed my first full phacoemulsification cataract operation and lens implant under Mr Baranyovits. It was a huge milestone, finally I got the feeling that I could actually cut it as an eye surgeon!

As a trainee, there is always a sinking feeling when the supervisor says-"time for me to take over...". However, although you had to stop, it was then a great opportunity to see at first hand different techniques used to rescue the particular situation at hand, whether it was a posterior capsule rupture or zonular dialysis. The best supervisors will give a debrief and perhaps go over the surgical video when everything's done and dusted. This is a bit like reviewing the black box after a crash, the difference being that great supervisors sometimes salvage situations so well that post-operatively, the patient is none the wiser.

I went through a period when I would read anything I could find on the topic. I read Barry Seibel's 'Phacodynamics' practically cover to cover. I would visualise and imagine different techniques and scenarios in my head. I would review many surgical videos, whether they were straightforward or complicated cases. And slowly, bit by bit, doing this operation became second nature to me.

Live surgery

Every year, there are 4-5 major ophthalmic conferences where live surgery takes place. A live feed is installed from an operating theatre to the conference hall, and we get to see well known surgeons performing surgery with live commentary from a panel of experts at the conference hall. Which is not so different from listening to Thierry Henry weighing in on the Arsenal team on match day...!

I often attend these sessions, where sometimes manufacturers will showcase new surgical equipment or new lens implants. Occasionally we see new surgical techniques, but often the cases are fairly standard cataracts. Occasionally we see unplanned 'highlights' (the whole conference hall becomes deathly quiet...), and while I don't think anybody wishes for these complications, sometimes we learn more when things don't go so smoothly, rather than the other way around.


Nowadays there are videos of everything on the internet, including cataract surgery videos! While I don't think I have learnt anything much personally from these videos, I could see how they might be useful to younger surgeons in an earlier phase of their training. It is always worthwhile to take a look and think of the things the other surgeon is doing well, and also on what could be improved.

I posted this video to share some tips to deal with difficult dense white cataracts (Note: graphic video of eye surgery):

To sum up

As in most things in life, the best practitioners of a procedure make it look simple. The best practitioners of a procedure also deal with all types of cataracts and potential complications of the procedure well. Even though nowadays cataract surgery can be done within 20 minutes or less for each eye, it takes a fair amount of time and training to get to a stage where we are both slick and safe at it. For me, it is a great privilege to have this opportunity to help so many people, and it's a very rewarding one at that!

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