Performing your first cataract surgery

Everything you ever wanted to know about your first cataract surgery

Soosan Jacob

Posted: Friday, July 6, 2018

Being seated ergonomically is important; Not having the cornea perpendicular to the microscope light results in a poor red glow and inability to have the entire field in focus; With the chin lifted and face parallel to the ground, a good red glow and focus is obtained

Every resident’s first ever cataract surgery is almost always simultaneously a dream and a dread! It generally follows hours of didactic sessions, watching and assisting consultants and seniors operate, watching videos, reading up extensively on the internet, going through books as well as practising on simulator eyes. Nevertheless, on the day of surgery, the phaco machine, with all its fluidics and dynamics, can appear as a daunting and stern sentinel standing on guard in the OR waiting to mete out punishment at the first opportunity.

Approaching your first case with the right mix of caution and confidence should, however, get you a pleasant outcome and experience. Adequate preparation and backstage efforts are important to make this first journey easy.

So, how do you prepare for your first cataract surgery?

This is key. It is important to spend time understanding the phaco machine that you will be using. Foot pedal practice with the test chamber gives an idea about various foot positions. Locating the reflux switch is crucial, as is recognising the various tones and pitches heard during phacoemulsification and irrigation-aspiration. Phaco power modulation is important to comprehend, though often for the first case, the mentor may control these settings from the panel, and it is more important for the trainee to concentrate on the surgical manoeuvres required.

Picking the right case is important, and a mental checklist should be gone through for patient selection. It is important not to choose an apprehensive patient or one who is unlikely to lie still without complaining, as it is very likely that the trainee will take more time than an experienced surgeon.

It is also probably better to take the first eye of a patient, rather than choose the second eye of a patient for whom the professor finished an ultra-fast and painless five-minute cataract surgery. Patients often compare and in the middle of valiant efforts at removing the cataract, it can be exasperating to hear the patient ask as to why the second procedure is not going as fast as the first did!

Avoid deep-seated eyes, prominent brows, excessively large or small anterior segments, non-dilating pupils, phacodonesis or other similar challenging situations.

The type of cataract chosen would often depend on the residency programme. Many programmes start by teaching trenching and nucleofractis by divide and conquer, and a choppable cataract with moderate nuclear sclerosis would be preferable here. Some programmes start by teaching hydroprolapse and supracapsular emulsification, and a soft cataract is better in this case.

Avoid tough cataracts such as posterior polars, which can be taxing even in experienced hands; hard brown cataracts, which may end up utilising excessive phaco energy; white cataracts, which have thin, friable capsules and absent red glow; eyes with pseudoexfoliation etc.

Once the right case is chosen, prepare the eye well with a combination of topical mydriatics and NSAIDs. A good and long-acting peri-bulbar block with absent ocular and lid movements can be obtained using a mixture of 2% lignocaine (with adrenaline – in the absence of contraindications) and 0.5% bupivacaine admixed with hyaluronidase. Pinkie ball or Honan balloon should be applied.

A trolley of height suitable for one’s own seated height should be used, as there is nothing more uncomfortable than having either to crane one’s neck forward or sit hunched over. Microscope oculars should be adjusted for height and spherical dioptre adjustment should be kept at zero.

If using prescription glasses, they should preferably be worn during surgery so that everything outside of the microscope view is also clear. Phaco and microscope footpedals should be on either side and within easy reach.

Sitting superiorly allows the hands to rest on the patient’s forehead and may be preferable over a temporal approach for the first case. It is important to have as a guide a mentor with whom you connect well and are comfortable with. An assistant nurse who is patient and has spent time with in-training residents is also preferable.

Checklists are as important to ophthalmic surgeons as to airline pilots. Make sure that all equipment is in good working order and that everything you want is available. The patient should lie with head at the edge of the trolley so that the eye is easily reachable without having to lean over.

Chin should be lifted up to get a good red reflex as well as for ease of access and good, even focus.

Microscope foot controls should be practised beforehand and should be at neutral position with a free range for X, Y and Z axes movements. The cornea should be kept moist. Capsular staining with Trypan blue enhances visualisation.

A 45-degree phaco tip allows sculpting while zero-degree tips are preferable for chopping. Prolonged surgery may result in epithelial oedema and corneal clouding. Epithelial debridement may be required to increase visibility again.

At my centre (Dr Agarwal’s Group of Eye Hospitals), we use pressurised infusion with the air pump in all cases to increase safety and speed of surgery.

It is useful to mentally rehearse and picture oneself doing each step and to know how to identify and prevent major complications. Knee-jerk reactions such as bringing the probe out suddenly if the posterior capsule ruptures should be avoided, and the mentor’s advice should be sought for actively during all steps. It is also important not to take shortcuts, even though you may see more experienced surgeons doing so.

In the initial cases, there should be no race for time. Going step by step mentally as well as surgically helps build good surgical habits that will stand in good stead later.
Finally, remember to respect the eye and do not hesitate in asking for help or in handing over the case to your mentor when required.

Dr Soosan Jacob is Director and Chief of Dr Agarwal’s Refractive and Cornea Foundation at Dr Agarwal’s Eye Hospital, Chennai, India and can be reached at

For more information on surgical steps, the reader is referred to previous articles by the author in her “Everything you ever wanted to know about…” EuroTimes column as well as to videos on her YouTube channel