EyeWorld Asia-Pacific December 2011 Issue

31 EW CATARACT/IOL December 2011 operating microscope (making sure the trainee isn’t hunched over, making sure the shoulders are relaxed, and ensuring appropriate hand position and stabilization) is essential prior to beginning a teaching case. Awkward positioning makes the surgery more arduous for the trainee and can potentiate a nervous tremor. Often the beginning resident doesn’t have enough experience to recognize awkward positioning and needs to be instructed. 3. Switch seats frequently: The attending surgeon should have a low threshold to switch seats with the trainee if he or she appears to be struggling with a particular step of surgery, visualization is poor through the side scope, or if the attending gets that sinking feeling that a step of the surgery just doesn’t look quite right. I switch frequently with trainees in any of the above situations, and once I have moved the case beyond the point at which the trainee was struggling and/or ensured there are no complications, I hand the case back over to the trainee. 4. Introduce cataract surgery in a stepwise manner: Performing an entire cataract surgery from start to finish can be overwhelming for residents early in their cataract surgery training. At the Harvard Ophthalmology Residency we introduce cataract surgery to residents in a stepwise manner. This approach to teaching surgery allows the trainee to focus on one step of surgery for a series of cases before progressing to entire cases. 5. Take time after each case to discuss every step of the surgery with the trainee in detail: Ideally surgical videos of the trainee’s cases are available for the attending and trainee to review together, but in the absence of this technology, simply talking through the steps of surgery after each case is helpful. There are often many teaching points that can be highlighted when reviewing the cases in this step-by-step manner, even when a case goes smoothly. EW Contact information Borboli: sheila_borboli-gerogiannis@ meei.harvard.edu Greenstein: Scott_greenstein@meei. harvard. edu Kloek: Carolyn_kloek@meei.harvard.edu Refractive - from page 27 –0.75 D. He outlines this in more detail at www.doctor-hill.com/iol- main/postRK.htm. Dr. Hill said hyperopic drift in RK eyes makes it hard to estimate central corneal power. “This is due to the fact that the assumptions made by many devices do not line up with what’s actually going on with the central cornea,” he said. To help remedy this problem, Dr. Hill has had the most success with the ASCRS post-refractive calculator and the Zeiss Atlas topographer. Dr. Wiley’s practice has recently started corneal crosslinking, which he believes helps to strengthen these corneas and decrease the diurnal fluctuations. “First you do the crosslinking to decrease the daily fluctuation, then you get a new prescription, and then you do cataract surgery. If you do cataract surgery first, you may have a perfect result, but crosslinking could shift the prescription in the wrong way,” Dr. Wiley said. Handling refractive surprises Preparing patients for possible refractive surprises is key, Dr. Koch said. This often involves a careful conversation with patients before surgery, pointing out that their previous refractive work makes their eyes more challenging. It also entails explaining to patients the extra costs that could be incurred from additional LASIK or PRK procedures if necessary, Dr. Koch added. When a refractive surprise occurs, the choice that surgeons make may depend on cost issues— for example, whether or not they have their own laser center or ASC, Dr. Wiley said. “There are typically three options: lens exchange, a piggyback lens, or LASIK or PRK. I typically go through those options with the patient. If there is any astigmatism and if I’ve missed the target, I think the best option is a corneal refractive procedure like PRK,” Dr. Wiley said. “With lens exchange, it’s a little more challenging. It’s easier to go back in, say we’re going to do PRK, treat astigmatism, and feel confident we’re doing it with one surgery.” If a refractive surprise occurs in an RK patient, Dr. Hill recommended following the “rule of twos”—don’t do anything until there are two stable refractions, two consecutive visits, 2 months after surgery at the same time of day. “A piggyback or any exchange would then be carried out in the same manner as any refractive surprise. I do not recommend LASIK or PRK following RK,” he said. If the refractive surprise is extreme, Dr. Koch will perform a lens exchange. If it’s something smaller, he will do LASIK or PRK. He also has another go-to approach. “I select what I think is the correct power of lens to replace the current one, and I select a piggyback lens. I go into the OR prepared for a lens exchange. If that seems ill advised, I’ll place a piggyback lens. That said, I’ve never had to do this, but I think it’s a good fall back, especially if you’re not comfortable getting the lens out of the eye,” Dr. Koch said. EW Editors’ note: Dr. Hill has financial interests with Alcon (Fort Worth, Texas, USA/Hünenberg, Switzerland), Bausch & Lomb (Rochester, NY, USA), Carl Zeiss Meditec, and other ophthalmic companies. Dr. Koch has financial interests with Abbott Medical Optics (AMO, Santa Ana, Calif., USA), Alcon, Calhoun Vision (Pasadena, Calif., USA), and other ophthalmic companies. Drs. Blecher, Huang, Wang, and Wiley have no financial interests related to their comments. Contact information Blecher: 215-339-8100, mhbmd@earthlink.net Hill: 480-981-6111, k7wx@earthlink.net Huang: 301-897-3322, h3md@comcast.net Koch: 713-798-5143, dkoch@bcm.edu Wang: 713-798-7946, liw@bcm.tmc.edu Wiley: 216-621-6132, drwiley@clevelandeyeclinic.com Index to Advertisers Abbott Medical Optics (AMO) Page: Supplement Phone: +1-866-427-8477 www.AbbottMedicalOptics.com , www.amo-inc.com , www.tecnisiol.com Carl Zeiss Meditec Page: 19 Phone: +65-6741-9600 Fax: +65-6842-7117 Moria Page: 10 Moria SA Phone: +33-(0)-1-4674-4674 Fax: +33-(0)-1-4674-4670 E-mail: moria@moria-int.com www.moria-surgical.com Moria in China Phone: +86-21-5258-5066 Fax: +86-2-5258-5067 www.moria-surgical.com.cn STAAR Surgical Page: 39 Phone: +65-64936953 E-mail: atan@staarag.ch www.staar.com, www.iclinfo.info Technolas Singapore Pte Ltd Page: 13 Phone: +65-6592-0792 Fax: +65-6250-1060 E-mail: Y.Ng@technolaspv.com , M.Soon@technolaspv.com , A.Koh@technolaspv.com www.technolaspv.com , www.intracor.net www.intracor.net