Dr. Devgan, assistant clinical professor, Jules Stein Eye Institute, University of California, Los Angeles.

Uday Devgan, MD, FACS

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The path to learning ocular surgery is a long and challenging one, but it is enjoyable and worth the investment to bring sight to our patients. True success 

 and the passion to consistently learn from every case and evolve your technique every year.
	
	During the years of residency and fellowship training, basic surgical skills are acquired relatively quickly and the fundamental techniques and procedures are learned. Because this part of the learning curve is the steepest, there is a frustration barrier that must be overcome to get your hands to do what you need. No one is born knowing how to suture with 10-0 nylon monofilament,

 is instrumental in learning. Similarly, manual dexterity must be developed in both hands with particular attention paid to bring the non-dominant hand up to par with the dominant hand. Modern day cataract surgery is two-handed and the older, one-handed techniques are not as safe or efficient.
	
	The blue line in our graph is the young doctor who cannot find the drive to push past the frustration barrier to become an ophthalmic surgeon. As such, this doctor will drop out of training, switch to a different medical specialty, or choose to be a medical ophthalmologist who does not perform surgery.

Completing residency training will allow the ophthalmologist to acquire a reasonable surgical skill set and to become a competent surgeon, but not to become a true expert with the highest level of surgical skill and judgment.

The red line in our graph is the surgeon who is able to get past the frustration barrier and become a competent surgeon. But the passion and the drive to be better, simply is not there. This doctor will be stuck in this zone of mediocrity forever and will simply do the techniques that were learned back in residency training. We have all seen the surgeons who continue to perform older, outdated procedures because that is what they learned decades ago and that is where their comfort level lies. The critical question to ask is, “Am I doing the best for my patients and am I giving the surgery that I would want to receive?”
	Becoming a true expert requires the surgeon to have a passion for ocular surgery and then to continue to learn independently for many years to come. Much more will be learned in the years after residency and fellowship compared to during the formal training.
	
	The green line in our graph is the expert surgeon who has the drive and determination to learn from every single case and consistently evolve surgical techniques over the years. This surgeon embraces the very difficult cases and prepares diligently for them. This surgeon has the passion to be the best and will maintain that passion for decades. This is the true expert.
	
	There is an incredible amount to learn in the first few years in practice. Having senior colleagues and partners are helpful in providing mentorship both in and out of the operating room. A large portion of surgical success is pre-operative planning and discussions with patients, as well as post-operative management. Once we are able to push through this passion barrier, we will want to do more of the tough surgical cases because we will enjoy the challenge. And then finally, when we are widely considered master surgeons and true experts in the field, we will still keep up with learning from every surgery and further advancing our skills.
	
	We can all become true experts by channeling the passion for ocular surgery. We must learn from each and every surgery that we perform. We need to keep up with the latest techniques and technologies through continuing medical education and collaboration with colleagues. We understand that our field keeps evolving and the way that we operate today may not be the preferred technique in the future.
	
	When it comes time for me to have surgery on my body, be it cataract surgery, orthopedic surgery, or cardiac surgery, I want a true expert who has the passion to be the best. I’m sure you feel the same.

For the video and discussion for this article, please visit the link 

Dr. Devgan is in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills. He is clinical professor of ophthalmology at the Jules Stein Eye Institute at the UCLA School of Medicine and Chief of Ophthalmology at Olive View-UCLA Medical Center. Dr. Devgan owns and runs CataractCoach.com, a free teaching website where a new article/video is posted every day.

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We can all become true experts by channeling the passion for ocular surgery, according to Uday Devgan, MD, FACS.

Understanding the surgical learning curve

Think of the phaco incision, capsulorhexis, and IOL centration as your “signature” on every cataract surgery that you perform.

Many ophthalmologists will perform tens of thousands of 

 during their careers, and each of these procedures can improve the vision and enjoyment of life for a patient. We take pride in our work and we want to deliver the best for our patients. We also leave our unique signature on every eye.

One year or even one decade after your cataract surgery, anyone who examines the patient with a slit-lamp microscope will notice these three things:

Take time to master each of these steps to produce the best visual results for the patients, and also to perfect your surgical signature. Everything else in the surgery including the nucleo-fractis technique, the ultrasound energy, the fluidic volume used, the viscoelastics, and even the postoperative 

, is transient and will not be seen years later.

1. Measure the capsulorhexis to ensure the correct size and placement

The capsulorhexis is important for successful cataract surgery because it gives the capsular opening strength during cataract removal and allows for stable, long-term positioning of the IOL.

We can create the capsulorhexis using forceps or a bent-needle (cystotome) and we aim to make it round, well-centered, and about 5 to 5.5 mm in diameter for most cases. For these manual techniques, it is helpful to measure first to get an idea of the appropriate size prior to starting the capsulorhexis.

We can also use automated devices such as a femtosecond laser or units which uses a electrical discharge, to create a consistent capsulotomy.

Most of the time, I use forceps, which have been marked at 2.5 mm and 5.0 mm from the tip, to guide me. At the beginning, prior to starting the capsulorhexis, I measure the anticipated position and diameter. Then I start the tearing of the anterior lens capsule and then stop and re-measure just to be sure.

Then after completion of the capsulorhexis, a final measurement is done to confirm the correct diameter (Figure 1A and 1B). We use the forceps to estimate the ideal position and size of the capsulorhexis, then during this step, we can use the marks on the forceps tips to ensure the correct radius and diameter of our opening.

Many surgeons use the iris or pupil size as a guide for capsulorhexis creation - but you should not. Do not fall into this trap.

Look at the picture in Figure 2 - Do not use the iris to guide the capsulorhexis size because dilation and anterior segment size will vary between patients. The large myopic eye (left) has a bigger capsular bag and dilation compared to the average emmetropic eye (right).

Both eyes have the same model lens with a diameter of 6.0 mm and both have a capsulorhexis which is about 5 mm in diameter, giving and excellent overlap of the optic. But the eyes are very different - the anterior segment size, the white-to-white measurement, and the pupil dilation are all markedly different. In the large myopic eye, using the iris as a guide would have resulted in an overly large capsulorhexis which would not have held the IOL optic securely.

This is the reason why I use marks on my forceps.

Measure the capsulorhexis for best results

What's the secret to a perfect capsulorhexis?

Please, do not use the iris to guide rhexis size

2. Craft the phaco incision so it has balanced architecture -- it will seal better and induce less astigmatism

The phaco incision is critical to the success of the cataract surgery. It gives us controlled access to the cataract, assists in maintaining fluidic balance, induces minimal astigmatic changes, and seals securely. A well-constructed incision makes the surgery safer and the recovery quicker.

A good incision will have excellent balance between the roof and the floor and an appropriate architecture. It will seal well and securely with minimal astigmatic effect.

If the incision has too long of a tunnel length, it starts out very shallow with a thin roof and then the surgeon abruptly changes angle to enter the anterior chamber. The result is a bad incision with too thin of a roof and too thick of a floor which does not seal well. (Figure 3)

The angle of approach of the keratome will determine the tunnel length of our phaco incision. If the angle is very flat and the blade is right against the ocular surface, the tunnel length will be long. If the angle is greater and the blade is now more parallel to the iris plane, the tunnel length will be shorter. We can vary this angle as we make the incision to tailor the technique to the anatomy so that every eye has a great incision.

This angle tends to be about 30 degrees (Figure 4) but it can vary based on the patient’s anatomy. The corneal curvature plays a role as does the corneal thickness. There are variations in human anatomy so the surgeon must be able to make adjustments to provide the ideal result for each individual eye.

If your incisions tend to be too short, then using a smaller angle with the tip of the keratome angled more toward the corneal apex is appropriate. If your incisions tend to be too long, then using a larger angle will allow the tip of the keratome to enter the anterior chamber sooner, resulting in a shorter tunnel length.
	 

The ideal angle of approach for the phaco incision

Good versus bad corneal phaco incisions with OCT

Phaco incision OCT and live video analysis

3. Center the IOL, particularly if there is an optic with diffractive rings, and dial in the correct toric axis

With new technology IOLs, we have the ability to address corneal astigmatism as well as provide a wide range of vision without glasses. The toric correction on the IOL must be aligned with the steep corneal axis and the diffractive rings of the multi-focal, tri-focal, or extended-depth-of-field optic must be centered appropriately.

The technique that I prefer is to first align the toric marks of the IOL with the steep axis of the cornea, and then center the diffractive rings using the Purkinje images (Figure 5). This ensures the best visual outcomes for the patient.
	 

We must align and center a toric diffractive IOL

We enjoy performing cataract surgery as much as our patients enjoy the visual results, and we take pride in every case that we do.

These are the three most obvious signs of the prior cataract surgery and they are a reflection of the surgeon’s meticulous attention to detail.

We want to strive to make a beautiful incision with balanced architecture and a round and appropriately-sized capsulorhexis. Then, the well-centered IOL will perform at its best and produce the best vision for our patients.

Dr. Devgan is in private practice at Devgan Eye Surgery in Los Angeles and Beverly Hills. He is clinical professor of ophthalmology at the Jules Stein Eye Institute at the UCLA School of Medicine and Chief of Ophthalmology at Olive View-UCLA Medical Center. Dr. Devgan owns and runs 

, a free teaching website where a new article/video is posted every day.

Uday Devgan, MD, FACS

Articles

Understanding the surgical learning curve

These 3 things are part of a cataract surgeon's signature