Beyond base camp

In the first piece in a new series, Sorcha Ní Dhubhghaill MD reports on how the learning curve never really ends

Sorcha Ni Dhubhghaill

Posted: Saturday, February 1, 2020

At the start of our climb towards becoming a great surgeon, we face a simple choice: Learn to do this, or give up on being a surgeon altogether, let alone a great one.
So we all did it. We read the books, we watched the videos, and did whatever it took to convince ourselves that we could do this. Obviously, we couldn’t do it. We were still learning to. And each time we made a mistake, or a complication would arise, our supervisor would bail us out. That’s why we learn under their watchful eye. They are our safety net. Ready to step in when things go south.
Fast-forward a decade or two, and now you’re mid-career. An independent surgeon, working away, doing your thing. So how do you go about learning something new at this stage? Because this time the question is not as straightforward. You can learn to do this new thing, or you could not. You could just keep on doing what you know, and know to work.
It’s a question that has been on my mind a lot lately as I was thinking about how to best handle specific cataract cases. My preferred approach to cataract surgery is the divide and conquer technique. It’s reliable, and it’s what most of my surgical trainers used. In general, it leads to good results, and happy patients.
But it’s no silver bullet. For hard, brunescent lenses, a chop technique has its benefits. It reduces both the zonular stress from rotation, and the amount of phacoemulsification energy required. This reduced energy has piqued my interest recently as my clinics have been filling with endothelial dystrophies.
So I have decided that I want to start chopping again. But it is very difficult to look at a cataract and try something new, knowing full well that the patient before you would be perfectly fine with normal technique. It’s hard to step out of our comfort zone but it’s a choice we all have to make. At every point, surgeons had to deal with the same dilemma; Treat the patient in the old reliable way or take a risk and try something that might be better. I wanted to try something better so I decided to chop again.
I learned a horizontal chop approach many years ago but when I converted to using the “Bag-in-the-lens” as my primary lens I started to make 5mm anterior and posterior capsulorhexis. I was worried that the smaller size would make me more likely to tear the capsule when gliding the chopper to the periphery of the lens and i felt stressed enough learning how to place an entirely different type of lens. Now that I have mastered the lens, I decided to combine it with chopping.

Step one: Getting 
the theory down
I’ve been reading the books and watching videos online. YouTube can be useful in a pinch but EyeTube is where some of the best surgical videos can be found. David Chang ( provides lecture and resources on line and I absorbed as much as I could from them.

Step two: Practice

I have followed some wetlabs, but most wetlabs use pig eyes and these can be difficult to simulate the chop manoeuvre. Unless they are pre-treated, most porcine lenses are very soft and not the ideal practice material. Artificial models with a more wax-based lens ( can be more useful and since it’s not biological, you can bring them to the operating room to practice, unlike the pig eye.

Step three: Implement
I am currently working with the DORC EVA phaco so I called the representatives to overhaul my settings. They added a phaco chop dual linear control step. Once everything was set up, I reviewed my patient list to find the best candidates. Like a beginner surgeon, I looked for cataracts that were not too soft, too hard or had any zonular compromise. Once I had the theory, the practice, the settings and the patients it was time to get started – and that was the hardest part. But I took it slow, very slow, and things have been going very well.
Practice makes perfect. Going through another learning curve as a senior surgeon can be a real hit to the ego and self-confidence but it can also be a powerful lesson in staying humble and open for new techniques. Cataract surgery is constantly changing and improving. We have to be able to change with it, or risk not being able to give our patients the best options available. So that learning curve – your climb to the top of your craft – never really ends.

Sorcha Ní Dhubhghaill MB PhD MRCSI(Ophth) FEBO is an Anterior Segment Ophthalmic Surgeon at the Netherlands Institute for Innovative Ocular Surgery (NIIOS) and Antwerp University Hospital