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Irri­ga­tion and Aspiration

The nucleus is out, we’ve removed the phaco nee­dle from the eye and it’s time to relax. Easy from here on out, I’m afraid not. More cap­sules are bro­ken in this part of the surgery than any other. I’ll dis­cuss safe removal of the remain­ing cor­tex and pol­ish­ing of the cap­su­lar bag, all while pro­tect­ing the pos­te­rior cap­sule from dam­age.

Whit­man Shep­herd Dou­ble –Ended Cap­sule polisher

You can watch an HD ver­sion at YouTube Phaco Skills or Vimeo Phaco Skills Channel

Theme song Run­away by Adam Woodall cour­tesy of Mevio’s Music Alley

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Phacoemulsification

Every­thing we’ve done to this point is in prepa­ra­tion for emul­si­fy­ing the nucleus.  We have a good inci­sion to main­tain proper flu­idics.  We have the corneal endothe­lium pro­tected with our OVD.  The cap­sule has a prop­erly sized open­ing and the lens is com­pletely loose and freely mobile in the cap­su­lar bag.  We are now ready to man­age the nucleus.

Here are my phaco set­tings for our cur­rent Infiniti Ozil IP:

45° Kel­man Mini-flared tip with salmon col­ored sleeve

2.4 mm or 2.2 mm incision

Sculpt­ing for divide and conquer

Bot­tle height = 95
Ozil Con­tin­u­ous
Phaco power = 0
Tor­sional = 80% (lin­ear) — the bar in the box is diag­o­nal
Vac­uum = 50 (fixed) — the bar in the box is hor­i­zon­tal
Aspi­ra­tion = 30 (fixed)

Quad­rant Removal
Bot­tle height = 110
Ozil Con­tin­u­ous
Phaco power = 0
Tor­sional = 80% (lin­ear with lower limit start at 20)
Dynamic rise = 0
Vac­uum = 280 — 320 (fixed)
Aspi­ra­tion = 38–42 (lin­ear with lower limit start at 20)

Epin­u­cleus Removal
Bot­tle height = 110
Ozil Con­tin­u­ous
Phaco power = 0
Tor­sional = 40% (lin­ear with lower limit start at 0)
Vac­uum = 330 (lin­ear)
Aspi­ra­tion = 30 (lin­ear with lower limit start at 0)

Cor­tex removal

Sil­i­cone Tip
Bot­tle height = 110
Vac­uum = 550 (lin­ear with lower limit at 0)
Aspi­ra­tion = 35 (lin­ear with lower limit at 0)

Dr. Mackool’s viscodissection

You can watch an HD ver­sion at YouTube Phaco Skills or Vimeo Phaco Skills Channel

Theme song Run­away by Adam Woodall cour­tesy of Mevio’s Music Alley

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Inci­sions and Viscoelastics

In this episode I’m finally going to get to the micro­scope view. I’ll dis­cuss the impor­tance of a prop­erly con­structed inci­sion and the use of vis­coelas­tics.
Here is the for­mula for epi-Shugarcaine. This was devel­oped by the late Joel Shugar, M.D. of Perry, Florida. You can sub­sti­tute plain BSS for BSS Plus.

PLAIN SHUGARCAINE
Com­bine 3cc’s of BSS Plus with 1cc of PF Lido­caine to make 4cc’s of (plain) Shugar­caine.
We make enough plain Shugar­caine for the entire day depend­ing on the num­ber of cases.
Ex. 15cc BSS plus with 5cc 4% PF Lido­caine to equal a total of 20cc’s of a PF Lido­caine 1% solu­tion. Dr. Shugar uses 2.0 – 2.5cc’s per case.
This mix­ture is mixed in a 50cc ster­ile vial and then stored in the refrig­er­a­tor. It is taken out of the refrig­er­a­tor at the begin­ning of each case for the techs to draw up, and then replaced back. Using a ster­ile vial from an allergy lab makes it very easy and time effi­cient when trans­fer­ring the solu­tion to the ster­ile field.

EPI SHUGARCAINE
Using the plain Shugar­caine “recipe” above, take 3cc’s of that (plain Shugar­caine) and add 1cc of Epi­neph­rine PF 1:1000. This will give you a total of 4cc’s of Epi-Shugarcaine.
Again, this mix­ture is mixed and stored in empty ster­ile vials from an allergy lab.

Both Shugar­caine and Epi-Shugarcaine are mixed the morn­ing of surgery and dis­carded after pro­ce­dures are com­plete. We remix all mix­tures with each sur­gi­cal day. Gen­er­ally we are done with surgery in less than 4 hours and then the mix­tures are discarded.

We have found that if Epi-Shugarcaine is not pro­tected from light it will begin to turn a soft rose color after 4 hours and con­tinue to get darker. There­fore, to pro­tect it from light we place the mix­ture in a dark bag (and as stated above the mix­ture is placed in the refrig­er­a­tor imme­di­ately after mix­ing and returned after with­draw­ing for a case) and the solu­tion will stay clear for up to 7 – 8 hours.

pH test­ing results 6/06:

Phar­ma­ceu­ti­cal pH
Epi­neph­rine PF (Sul­fite Free) NDC 0517–1071-25 3.11
Epi­neph­rine reg­u­lar 2.77

Lido­caine PF 4% (label states “only for top­i­cal use and retrob­ul­bar injec­tion”) NDC 0409–4283-01 6.44

BSS Plus 7.35
BSS plain 6.98

* Shugar­caine (using BSS plus with 4% lido) 6.97
Shugar­caine Plain (using plain BSS with 4% lido) 6.72

* Epi-shugarcaine using BSS Plus 6.9
Epi-shugarcaine using BSS Plain 6.67

BSS Plain w/ Epi PF 1:1000 (3:1) No Lido­caine 6.75

You can watch an HD ver­sion at YouTube Phaco Skills or Vimeo Phaco Skills Channel

Theme song Run­away by Adam Woodall cour­tesy of Mevio’s Music Alley

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Why a Video Series about Rou­tine Cataract Surgery?

Hi, my name is Dr. Vince Keszei (pro­nounced KAY’S eye). I’ve been an oph­thal­mol­o­gist and cataract sur­geon for 25 years.  Learn­ing a new skill, such as cataract surgery requires that you tran­scend four dif­fer­ent stages. These are:

Four stages of skill acquisition

1. Uncon­sciously Incom­pe­tent
   • Not know­ing what you are doing and not even know­ing what you are sup­posed to do
2. Con­sciously Incom­pe­tent –
   • Know­ing what to do but not yet pro­fi­cient in the skills required
3. Con­sciously Com­pe­tent –
   • Per­form­ing skill­fully, but hav­ing to think about every step
4. Uncon­sciously Com­pe­tent –
   • ROCKIN’ ON AUTOPILOT

A very well-known eye sur­geon once told me, if you don’t oper­ate for one week, you can tell the dif­fer­ence when you start oper­at­ing again. If you miss two weeks, the sur­gi­cal staff can tell the dif­fer­ence. If you miss three weeks, the patient can tell the dif­fer­ence. I recently had my hip replaced and missed four months of surgery. When I started back, I had to take a step back­wards and con­sciously think about all the lit­tle skills and nuances that I took for granted.  I believe this presents a unique oppor­tu­nity to really exam­ine the skills required for cataract surgery. That’s what I’d like to share with you in this series. So please join me and maybe we can have some fun and learn some­thing from each other. Even if you are not an eye sur­geon, feel free to watch along and com­ment. Hav­ing a fresh per­spec­tive can some­times lead to a sur­pris­ingly insight­ful contribution.

Enjoy.

For more basic tuto­ri­als directed at begin­ning res­i­dents, I rec­om­mend the fine work by Dr. Thomas Oet­ting at the Uni­ver­sity of Iowa (I can’t believe I’m rec­om­mend­ing any­thing from Iowa. I wres­tled in col­lege and hated Iowa. Got my ass kicked) You can find these at

Cataract Surgery for Green­horns Also http://www.facebook.com/cataract.surgery and EyeRounds.org Video Atlas Another excel­lent site is Dr. Uday Devgan’s YouTube chan­nel and ceiol.com I would rec­om­mend Eye­Tube as an excel­lent source for see­ing how to deal with dif­fi­cult cases.

You can view an HD ver­sion at YouTube Phaco Skills or Vimeo Phaco Skills Channel

Theme song Run­away by Adam Woodall Band cour­tesy of Mevio’s Music Alley