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Following these 10 best-practice habits can help surgeons establish a standard of care for the countless surgeries they will perform throughout their careers.
1. Be prepared
Identify ocular comorbidities that may present intraoperative challenges and have a game plan. Conditions like small pupils, intraoperative floppy iris syndrome, loose zonules/phacodonesis, dense brunescent rock-hard cataracts, white intumescent cataracts, and posterior polar cataracts all pose potential risks, need proper approaches, and require the possible use of assistive devices intraoperatively.
2. Discuss lens options
Discuss appropriate lens options for the patient and desired target refractive outcomes. Cataract surgery is refractive. Patients may have high expectations of fast and painless surgery as well as excellent visual results, including the possibility of reduced dependence on glasses. Offer elective options of premium IOLs. It is also important to have the ability to conduct enhancements when needed.
3. Obtain reliable biometry, use appropriate lens formulas
This involves treating any pre-existing ocular surface disease (OSD), repeating axial length measurements when warranted for confirmation of differing eye lengths, and knowing which formula is suitable. Using the latest generation of multivariable formulas can enhance predictability of refractive results. Surgeons should also personalize A-constants for the most precise outcomes.
4. Utilize technology
Fine-tune machine settings for optimal fluidics and power utilization for your technique.
Work with an experienced phaco machine representative to tweak things precisely. Suboptimal settings can lead to inefficiency as well as complications. Small changes can make big differences.
5. Conduct a time-out
Perform a time-out to confirm the correct patient, correct eye, correct procedure, and correct IOL. Having several people involved in the confirmation process reduces the risk of error.
6. Adjust machinery properly
Position the head, microscope, foot pedals, and portable instrument stand properly. The surgeon should be comfortable, have unencumbered access to the eye, be readily able to receive and pass instruments without looking away from the field, and continuously establish good focus, magnification, and centration.
7. Be efficient, but safe
Less time, phaco energy, and fluid in the eye is best, but do not rush. Hand movements and positioning should be precise and effective. Minimize the number of times instruments are placed in and out of the eye. Not only does this take more time, but each entry also has the potential to introduce contamination and/or distort the wound.
8. Train staff
Assistants should be familiar with the surgeon’s technique, set up, machine settings, and instruments. Standardize the process as much as possible, as this will benefit all involved. A well-performed cataract surgery is like a carefully choreographed dance-each team member provides a supportive-but-critical role in the performance. This results in efficient and ergonomic movements that avoid omitting steps or making errors.
9. Reduce infection
Use intracameral antibiotics to reduce the incidence of postoperative infection as supported by numerous studies on large numbers of patients.
10. Practice self-evaluations
Learn from mistakes, colleagues, meetings, journals, and videos. This involves keeping up with advances in technology and trying new techniques/devices/IOLs. The field of cataract surgery (and ophthalmology, in general) is constantly advancing-thus, there is a need for continuous adaptation.
It is important to be self-critical and continuously strive to improve. At times, requesting observation by a colleague or engaging a surgical consultant/proctor may be helpful.
Elizabeth A. Davis MD, FACS
Dr. Davis is partner, Minnesota Eye Consultants, Bloomington, MD. She did not indicate any proprietary interests relevant to the subject matter.