EyeWorld Asia-Pacific September 2013 Issue

38 EWAP CATARACT/IOL September 2013 Donna Siracuse-Lee, MD Assistant professor, Department of Ophthalmology, Boston University School of Medicine VA Boston Healthcare System Boston Medical Center As always, good communication and preparation are key teaching tools in the operating room. 1. Before surgery, I will proactively ask the resident what he/she would like to focus on that day. I then begin with the basic principles below, giving specific examples. 1.) Maintain anterior chamber stability. a. Focus on wound construction. b. Eliminate extraneous instrument passes. c. Reduce downward pressure and stress on wounds. d. Adjust bottle height as needed, down when PC tear is suspected or detected. 2.) Aspiration brings things to the tip, therefore flow rate controls the speed of the surgery. a. Slow down early on in training, during difficult case or with a floppy iris. b. Decrease when a PC tear is suspecte d or detected. c. Increase with experience and if flow/ speed is not ade quate. 3.) Vacuum holds material at the tip during phaco. a. Upward adjustments help while chopping or maneuvering pieces. b. Moderate for softer material. 4.) Phaco works when the tip is occluded. a. Phaco only when you have nucleus at the tip. b. Short taps with the pedal will redirect the piece. c. Listen to the machine. Clear the tip when occlusion occurs. 5.) Stay central. a. Avoid unnecessary movements. Allow the machine to do the work. b. Focus on coordination of hands and feet. 2. Before starting, I make sure the microscope is focused and centered and that the resident’s hands and feet are positioned comfortably for proper coordination. 3. I avoid criticisms that lack instruction. “You are moving around too much,” is not as useful as, “Stay central, rotate the tip toward your piece, and control the pedal to guide the piece in. Let the pieces come to you.” 4. I teach them to adjust density settings for harder cataracts and assure them that total phaco power will go down as efficiency goes up. 5. I explain what I am doing and why. Supervisors should adjust the settings intraoperatively, but explain how to do this independently. Intraoperatively, I will say, “I am slowing you down now by lowering the aspiration flow rate”; “I am allowing you to grasp this soft lens better by switching to epinuclear settings,” and review after the case. 6. I remind them that phaco efficiency is like parallel parking. Surgical finesse comes from small adjustments and will become second nature. 7. Postoperatively, I review each surgery step by step. This post- surgical discussion encourages a sense of self-improvement and fosters an understanding of phacodynamics and fluidics over time. EWAP Contact information Avery: bavery@salud.unm.edu Devgan: devgan@gmail.com Siracuse-Lee: donna.siracuse-lee@va.gov Go - from page 32 LASIK Surgery MORIA S.A. 15, rue Georges Besse 92160 Antony FRANCE Phone: +33 (0) 1 46 74 46 74 - Fax: +33 (0) 1 46 74 46 70 moria@moria-int.com - www.moria-surgical.com • Thin, 100-micron, planar flaps • Accuracy and predictability equivalent to Femto-SBK • Smoother stromal bed • No femto-complications • … At a fraction of the cost Think Thin SBK without femto-furrow James Lewis, MD (Elkins Park, PA, USA) 1. Lewis JS. Unanticipated stromal tissue loss following femtosecond flap creation. 28 th annual meeting of the ESCRS; Sept 4-8 2010; Paris, France. 2. Lewis JS. Skepticism about LASIK flap dogma. Ophthalmology Management . 2010; 14(9):40-45. Dr. Lewis has no financial interest and is not a paid consultant for Moria. IntraLase ® is a product and registered trademark of Abbott Medical Optics, Inc (Irvine, CA, USA). « We wanted to see the geometry, the anatomy of the flap edge. […] I was expecting the FS angle to be well defined, as these arguments have been made that it’s so much better and so much more stable. In actuality, I found discontinuity, a total absence of stroma and possibly stromal tissue loss. A week later you don’t see the gap in the OCT. What you see is an epithelial plug filling the furrow with a slightly different tissue density. We do not see the well-defined edges that are theorized to make enhancement safer and epithelial ingrowth a thing of the past. In fact, what we see may be the first sign that the femtosecond laser is not a panacea. […] Nothing suggestive of tissue loss was found in the Moria SBK cases. » 2 OCT pictures immediately after SBK flap creation 1 : Left: IntraLase ® 150kHz // Right: Moria SBK