I’ve enjoyed participating in the Wills Eye Hospital resident teaching courses on cataract surgery pearls & techniques. With the 2-day course coming up this week — one on suturing and the second on basic phacoemulsification techniques — I wanted to share pearls and online resources. This post is ideal for ophthalmology residents in training and colleagues engaged in lifelong learning.
I offer the following pearls for ophthalmology residents as they start the journey of cataract surgery:
- Watch videos. When I was a resident, I’d watch VHS tapes & DVDs of top ophthalmologists performing cataract surgery. I enjoyed the calmness of watching world-renowned surgeons share their pearls on difficult cases (Howard Gimbel MD chief among them). I visit CataractCoach.com daily and friend Uday Devgan, MD has created a cutting edge channel for cataract surgery pearls.
- Watch surgeons in the operating room through the microscope AND from 5-10 feet away. Learn to appreciate hand movements from a distance. Focus on patient head positioning, surgeon posture and where senior colleagues rest their hands.
- Make a list of every item you need for surgery. Glove size, Microscope PD, routine and complicated cataract cases all use various instruments, etc. Take photos of the cataract surgery phaco settings for sculpting, quadrant removal, etc. You may operate in different facilities and will want to give the OR team your preferred items. Make a list of special items you want on-hand for difficult cases.
- Also issues to make you as comfortable as possible. Do you like lights on or off during surgery? Music in background? Is the surgeon chair comfortable and appropriate? Ergonomics is critical and especially during the early days of microscopic surgery.
- Record all of your cases and watch back in real-time. No fast forwarding allowed! During my 3rd year of residency and early years in practice, I watched every case in real-time and often with my brother, Sonny Goel MD, a cataract & refractive surgeon. I still remember the pearls of an independent observer as he reviewed my cases with me. Be able to explain and minimize all time delays between steps and during the procedure.
- Every second counts in the operating room. If an OR team member needs to leave the room to get a special instrument, have the instrument on-hand for future cases. I will not enter a room unless a Malyugin Ring, Vision Blue, and other special devices are in the room before I operate.
- Start performing functions with your non-dominant hand. Cataract surgery is a bi-manual technique and you’ll want to be able to use both hands easily during surgery. I would try writing, shaving, etc. with my non-dominant hand as a resident.
- Make copies of dictations from various cataract surgeons. Surgeons have numerous techniques, and you’ll find surgery note dictations helpful as your style evolves. Develop special templates for complicated cases.
- Calculate your own intraocular lens powers. I use 7 formulas to optimize & select the intraocular lens power. This includes older generation formulas (SRK/T, Holladay 1, Holladay 2, Hoffer Q) and newer generation formulas (Barrett Universal II, Ladas, and Kane, currently free online). I also calculate lens powers for in-the-bag, sulcus, and ACIOL before surgeries. I use special colored sheets (red for right eye (OD) and light blue for left eye (OS)) as an added patient safety measure.
Here are some blog posts and videos on suturing and cataract surgery techniques. I may add more links in the weeks ahead. I hope this is a helpful start.
1. Uday Devgan, MD Basic Principles of Ophthalmic Suturing
2. Uday Devgan, MD Review: Basic Principles of Suturing with 10-0 Nylon
4. Christopher Teng, MD How to Suture Efficiently in Ophthalmology (no sound, but less than 2 minute video with text and great pearls)
Cataract Surgery Pearls:
1. Howard Gimbel MD – When I was a resident, an ophthalmology device company sent all residents a VHS tape of Dr. Gimbel performing 5-6 cataract surgeries, telecast live to an ophthalmology conference. I watched Dr. Gimbel’s videos hundreds of times (for many years, every week and on the night before I operated!). Here’s a recent video from on Effective Fracturing in Cataract Surgery.
2. Richard J. Mackool, MD – I visited Dr. Mackool at his Astoria, NY practice & surgery center twice early in my career. The first time was in 2002 and the second in 2006. Dr. Mackool is a brilliant ophthalmologist and cutting edge cataract surgeon. His columns and surgical pearls have guided me for two decades. His 2019 Mackool Online Fundamentals: Episode 1, Phaco Fundamentals is an ideal starting point for the busy resident and lifelong learner. And in 3-D online!
4. My guest submission on CataractCoach.com “Bleeding from a Pupil Expander! Now What?” is here.
5. Lisa Brothers Arbisser, MD Routine Cataract Surgery (2012) here.
6. Dr. Takayuki Akahoshi performs 10,000 cataract surgeries a year. Here is a case he performed on a grade V cataract using ICG (indocyanine green) and a pre-chopping technique. This case had a Cumulative Dissipated Energy (CDE) = 9.86. (Keep a personal log of your aspiration time, CDE, and fluid exchange throughout residency!)
7. This is an example of my cataract surgery technique video in which I describe each step of surgery in a patient-friendly manner (you’ll never look at an M&M candy the same again).
8. I also include a white cataract in which I used Vision blue here.
PS. A most successful suturing & phaco course! The Wills Eye Hospital Measey Ophthalmic Surgery Training (MOST) Lab is a game changer in ophthalmology microsurgery training. Congrats to colleagues and leaders for helping the next generation in the journey of
#ProtectingSight & #EmpoweringLives. #BelievingIsSeeing
Ravi D. Goel M.D. is a cataract surgeon & comprehensive ophthalmologist at Regional Eye Associates in Cherry Hill, NJ. He is also an instructor at Wills Eye Hospital. #ProtectingSight #EmpoweringLives #BelievingIsSeeing