Cataract surgery continues to be our bread and butter as anterior segment surgeons. In seeking to improve our surgical skills, we often focus on phacoemulsification itself, and many of our expert peers do a wonderful job describing myriad advanced phaco techniques like phaco quick chop, phaco flip, and phaco back chop. This article reviews some other aspects of surgical preparation and techniques that are equally important to the success and efficiency of a cataract case.
Of course, this is an era of efficiency. Whether one operates in an ambulatory surgery center or a hospital-based OR, the challenge is to produce better outcomes with less time spent per case. This demands not only enhanced phaco efficiency but also greater overall case efficiency, which allows for a progressively smaller margin for error and complications. I have found that the secret to improving efficiency and delivering excellent surgical outcomes lies—like so many things—in the details.
I acquired the following pearls from my own experience, mentors, peers, and OR scrub technicians. They have enabled me to evolve into a better anterior segment cataract surgeon, while increasing the efficiency of my cases. These tips are so simple and straightforward that surgeons can implement them tomorrow morning in the OR without additional cost or time.
SEEING IS BELIEVING: IMPROVED EFFICIENCY THROUGH ENHANCED VISUALIZATION
Pearl No. 1. I begin by zeroing the microscope over the surgical field at the start of each case to allow adequate compensation for accommodation. Then, I align the focus on an iris crypt. This prevents my having to search for the optimum intraoperative focus on the intraocular field several minutes into the case.
I usually use two rooms, and the staff typically sets the OR microscope for me. I still take 5 to 10 seconds to adjust and maintain the proper alignment of the microscope to achieve the highest magnification and focusing points. With my 40th birthday behind me, I need this help more than ever!
Pearl No. 2. I apply a viscoelastic “syrup” with balanced salt solution (BSS; Alcon Laboratories, Inc., Fort Worth, TX) over the cornea to enhance my view of the dynamics of the case (Figure 1). I use Viscoat (Alcon Laboratories, Inc.) with BSS, which lasts the duration of the procedure. This strategy eliminates the OR technician’s having to squirt the cornea with BSS every few seconds.
During the past several years, I have noticed that improved preoperative care of the ocular surface (ie, treatment of blepharitis and moderate-to-severe dry eye) reduces obscurations due to meibomian secretions during the case. (See Preoperative Regimen for Optimizing the Ocular Surface for my presurgical treatment regimen.)
Pearl No. 3. I streamline the staining technique by infusing trypan blue dye in a TB syringe containing an air bubble that is in front of the dye (Figure 2). I see my fair share of complex or hypermature white cataracts that lack a red reflex (Figure 3); trypan blue has been a game changer in these instances. I like to infuse the air bubble and the stain all at once, with the air bubble’s taking the lead such that it tamponades the dye and better stains the anterior capsule. This strategy avoids my having first to inject air through one syringe and the trypan blue through another.
Pearl No. 4. I reduce direct illumination over the field and use retroillumination to better view the anterior capsule during the capsulotomy (Figure 4). This method works especially well with the newer microscopes such as the Opmi Lumera 700 (Carl Zeiss Meditec, Inc., Dublin, CA). I use this technique in cases where the cataract is hypermature and dense but not white. It saves money and time. I reserve the trypan blue for more difficult cases, including white cataracts.
STABILITY IS KEY: CREATING EFFICIENCY THROUGH GREATER CONTROL OVER THE GLOBE’S MOVEMENT AND HEMOSTASIS
Pearl No. 5. I establish the globe’s fixation with the viscoelasticcannula positioned intracamerally in my left hand (Figure 5). This step is helpful when I am creating the primary clear corneal incision, performing the capsulorhexis, and injecting the lens into the capsular bag (Figure 6).
After instilling viscoelastic into the anterior chamber, I leave the cannula positioned intracamerally to stabilize the eye while performing the previously mentioned steps. I remove the cannula upon their completion. I also avoid using any toothed forceps on the conjunctival surface, which promotes hemostasis in the eyes of patients who use anticoagulants and blood thinners. I abhor chasing bleeds or having a patient come in the next day with a subconjunctival hemorrhage or associated chemosis.
CARPE DIEM: CREATING EFFICIENCY WITH DISCIPLINED BUT OPPORTUNISTIC PHACOEMULSIFICATION
Pearl No. 6. I have adopted a disciplined, efficient, “take-it-while-I-can” approach during phaco manipulation that includes the use of two or three well-described techniques that I have mastered. I prefer stop and chop, phaco tumble, and back chop. I remove the cataract in a disciplined fashion but also in real time and as it comes. For example, if after hydrodissection, hydrodelineation, and/or spinning, the cataract catapults into the anterior chamber, instead of placing it back in the bag and stressing the zonules, I begin phacoemulsification and chopping in the anterior chamber.
BEARING UP UNDER PRESSURE: EFFICIENCY THROUGH WOUND MANAGEMENT AND IOP CONTROL
Pearl No. 7. It is important to keep the IOP steady at the end of the case. I maintain a target IOP of 20 mm Hg. I measure this in a tactile fashion or with a dry Weck-Cel sponge (Beaver-Visitec International, Inc., Waltham, MA) after injecting BSS intracamerally and performing stromal hydration until the target pressure is achieved. Stromal hydration of the paracentesis as well as of the primary corneal incision ensures corneal sealing for the first several hours. If the wound’s integrity is in doubt, I place a suture without hesitation. Wound construction and the postoperative maintenance of a seal are of the utmost importance in cataract surgery. Minimizing the number of times instruments must be passed into and out of the eye is also crucial.
Combined, the techniques I have described have shaved precious minutes off my standard cataract case while improving my surgical outcomes. I am confident that implementing these pearls tomorrow morning will likewise shorten readers’ surgical time per case and increase their overall efficiency.
Jai G. Parekh, MD, MBA, is the managing partner at Brar-Parekh Eye Associates, Woodland Park, New Jersey, and chief of cornea and external diseases/ director of research at St. Joseph’s Regional Medical Center, located in Paterson, New Jersey. Dr. Parekh is also a clinical assistant professor of ophthalmology on the Cornea Service at the New York Eye & Ear Infirmary in New York City. He is a consultant to and a speaker for Bausch + Lomb and Inspire Pharmaceuticals, Inc., and he is a member of the speakers’ bureaus for Alcon Laboratories, Inc., and Allergan, Inc. He acknowledged no financial interest in the other products or companies mentioned herein. Dr. Parekh may be reached at (973) 785-2050; firstname.lastname@example.org