Pearls for the young cataract surgeon
Challenging cases presented and discussed at symposium
The Symposium organised by the Young Ophthalmologists Committee at the 23rd Winter Meeting of the ESCRS in Athens, Greece – Pearls for the Young Cataract Surgeon – featured words of wisdom from a variety of experienced doctors.
First to speak was Basak Bostanci Ceran, from Turkey, who discussed her first rhexis and hydrodissection attempts. In the words of her mentors, if you don’t have a perfect rhexis, “you will be doomed in the following steps”. Dr Ceran showed a video of an early rhexis, with poor visibility, poor centration and little control. In subsequent cases she learned about the many variables at play in each patient. These included pupil size, globe exposure, red reflex and capsular texture and eye movements, which are almost impossible to replicate in a simulation environment. One of her key points of advice was that good visualisation is a must: “Before doing anything, learn how to use your microscope.”
The ideal rhexis is something that Thomas Neuhann, Germany, is still striving for. It is not a technique that requires certain movements; rather it is a principle that must be understood, he believes. “Once you understand it, then you make it work for you.” Quoting his co-inventor of the capsulorhexis Howard Gimbel, he asserted that “it’s not about circularity, it’s about continuity”, reminding the audience that a perfect circle is not essential.
Vincent Qin, Belgium, showed a series of video cases where complications occurred and how they were overcome. These included posterior capsular rupture, dropped nucleus and rhexis running out. His advice was to plan ahead and in case of complication stay calm, add some viscoelastic and then think.
Richard Packard, the UK, described the dream phaco – many factors must align for this to take place, from patient selection, draping and microscope preparation, to perfect incisions, minimal ultrasound use and so on. Machine settings must be optimal, the patient must be calm and the surgeon must be comfortable.
Recalling his own mistakes, Vasilios Diakonis, Greece, described the difference between conscious incompetence and unconscious incompetence in young surgeons, warning against the danger of the latter condition. If a young ophthalmologist understands their limitations, they should step back and allow their mentor to take on more challenging cases. When searching for such a mentor, it’s important to find one with conscious competence, as the unconsciously competent cannot explain how they do what they do. Ultimately, he advised doctors to learn from their mistakes and not to repeat them.
Closing the session, Boris Malyugin, Russia, showed his mastery of challenging cases with videos of his more difficult procedures. Most intriguing was “FLACS upside down”, where the main incision and paracentesis incisions were made at the wrong sides as the technician had put the right eye settings on the left eye. After asking his expert colleagues what they would do in this situation – Dr Packard said he would make an incision with a knife and “get on with it” – Dr Malyugin, “not looking for the easy way”, decided to opt for a temporal approach. The situation got worse when a posterior capsular rupture occurred. Key here is converting the flap into a posterior capsulorhexis. He also showed a difficult case with an extremely floppy iris, and how it was dealt with including use of the Malyugin pupil expansion ring.
His take-home message was the importance of knowledge of the basics, mastery of cases, attendance at meetings such as the ESCRS Meetings and most important of all, experience. “The definition of a good surgeon is not the one who never gets complications, but the one who can get out of his complications without any complications,” he concluded.