Having problems with phaco ??

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johnbl

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Very busy experienced phaco surgeon happy to help ophthalmologists with high complication
rates, problems with different parts of the procedure, desiring to take their phaco to the next level or whatever. This is for real. Contact me through SDN.

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Just curious to know what exactly is considered a high complication rate? Maybe different acceptable rates 1st year out versus 5th year out from training?

I can't say I have ever heard from someone say personally what their rate is, but I have heard an acceptable range is 1%-4%. Any thoughts?
 
Just curious to know what exactly is considered a high complication rate? Maybe different acceptable rates 1st year out versus 5th year out from training?

I can't say I have ever heard from someone say personally what their rate is, but I have heard an acceptable range is 1%-4%. Any thoughts?


I think an "acceptable" range for PC rent and vit loss is 1/200 cases.

...for dropped nucleus: 1/500 (really no reason you should lose nucleus even if you break bag)

...for endophthalmitis: 1/1000 (can't really do much to control this)

Again, this depends on your patient clientele. If you are getting referred all PXF, 4+ monster cataracts, then the accepted rate will obviously be higher. But for most run-of-the-mill 20/50-20/100 cataracts, the complication rate should be on the order of 0.5% or less for most experienced surgeons.

For me, I think "experienced' is >1000 cataract surgeries.
 
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For an experienced phaco surgeon, a PC breakage of 0.5%or < , dropped crystalline lens< .2%.. Endophthalmitis rates will be less if you are using intracameral antibiotics, but there is a trade-off with improperly prepared compounding pharmacy or OR staff reconstitution of antibiotics. I work in a large corporate owned ASC where I can no longer use intracameral Vigamox because of the Anti-label status of that drug for intracameral use. (thanks ALCON)
 
i am at about 26,000 cumulative phaco procedures and can tell you I am a better phaco surgeon now than I was at 10k or 20k cases. I have more "situational awareness" and enough experience to have a sixth sense of where the case will potentially go if I use different techniques. The technique and approach may vary depending on what I see and how the case proceeds. Small pupils, PXF, brown lenses, non-english speaking pts no longer keep me up the night before as in the past.
 
One pearl I can give newbie phaco surgeons when they are having a difficult case is to stop and analyze why the case is tough. Sounds elementary, but in the OR under stress it often isnt that obvious. Is the pt moving around?? If under topical, is the pt not cooperating and moving the eye as you want? Or is the pt cooperative and just the circumstances of the anatomy (shallow ac, small pupil, rock hard lens, etc etc) the issue. My experience is the cases that often go "south" and lead to complications often have all the above. If the pt isnt cooperating, dont hesitate to have anethesia put the pt asleep (with LMA or intubation with general anesthesia).. They may be reluctant to do this...but tell them you need control over the pt which is now lacking.
 
Did anyone find it difficult first starting out? I'm a few months into private practice and I don't know if its getting use to the new asc (I'm using a new machine) or what, but I'm just not comfortable. I had one broken capsule in my residency training, and I've already had two since I started. Please tell me this gets better. Any tips on how to get over this hump would be appreciated.
 
Bump. I've also had more trouble than I imagined with phaco. It's almost always related to a shallow ac or small pupil. Would be interested to hear input.
 
Very busy experienced phaco surgeon happy to help ophthalmologists with high complication
rates, problems with different parts of the procedure, desiring to take their phaco to the next level or whatever. This is for real. Contact me through SDN.

Hi. I would like to know more about what you are offering. I actually went to India for some training to try to lower my complication rate but I don't think it helped because the equipment was so different and the guy was very seldom in the room. I have done over 500 Phacos but have pc rupture rate as high as 5 percent and I am frustrated. Fortunately most of these patients have done well but I lose sleep every time this happens. Please let me know how best to contact you. Thanks.
 
Did anyone find it difficult first starting out? I'm a few months into private practice and I don't know if its getting use to the new asc (I'm using a new machine) or what, but I'm just not comfortable. I had one broken capsule in my residency training, and I've already had two since I started. Please tell me this gets better. Any tips on how to get over this hump would be appreciated.

always more stressful when you are out on your own, that goes for the OR and in clinic. This is because you've loss your safety net. For the OR, you want to start with easier cases and build your skill set. To do this however, you have to know what is easy and what would present challenges. Identifying your limits is not an easy thing sometimes.

As one of the above post mentions, common challenges for the beginning surgeon are 4+brunescent NSC, white fluffy diabetic cataracts prone to the argentinian flat sign, high hyperopes with shallow AC, high myopes with hyperdeep AC and reverse pupillary block, floppy iris, pseudoexfolation syndrome, post vitrectomy eyes where they can have thick leathery posterior plate, posterior polar cataracts, mostly psc cataract with otherwise soft lens....etc.

How well you deal with these challenging cases will improve with experience. Watching videos on youtube, eyetube and the complications sessions at aao/ascrs are helpful to learn from others.

if you have a helpful colleague/mentor, it is helpful to analyze and debrief with them on challenging cases. Talking it through with someone can help you identify what critical steps you may be missing. it could be as simple as patient positioning, adequate anesthesia, not hydrodissecting as much as possible, phaco settings that are too fast for you.

If you are comfortable, you can discuss the details of your challenging cases here and get some pearls on managment.
maybe get your partner to shadow you in the OR one day.
record all your surgery and go through them.
have the rep for the phaco machine come out and optimize your settings.
 
Bump. I've also had more trouble than I imagined with phaco. It's almost always related to a shallow ac or small pupil. Would be interested to hear input.

shallow ACs are going to be tough just because their is less room. I find the most challenging part of these cases to be the capsulorhexis. remember to use the wound as a fulcrum so not to lose too much viscoelastic. fill the ac with additional viscoelastic midway through the rhexis to keep the surface of the lens flat. you are more prone to have your rhexis run out when the ac shallows and the tear goes down hill. the case should be easier once you start phaco and make more room. for these cases, try not to be too fancy on your nuclear disassembly. divide and conquer is just fine.

small pupil - use a malyugin ring. there is 6.0mm and 7.0mm. i always use the 7.0mm
 
Also for very shallow ac, might consider iv mannitol to decompress the vitreous. Consider having retina do a ppv.

Havent had to resort to these 2 options yet.
 
I know it sounds really simple, but one thing that really helped me in my first year out was to sit down the night before and envision the case and make plans about how I would do each and every step and visualize the cases in my head. Also, I would talk to myself in my head through the cases as I would go through the case and try to stay very calm and execute each and every step (from positioning the patient on the table, setting up the microscope, all the way to finishing up and hydrating the wound) as perfectly as possible. When you first start out on your own, do not worry about going fast. Try to look for clues when things are not behaving as they should. For instance, if you notice there is some posterior pressure, immediately find out from anesthesia what the BP is, make sure the patient is not straining under the drapes, if they are heavy make sure they are not positioned in such a way on the table (Trendelenberg) to be causing this, etc. It will keep getting easier and easier.
 
I agree with all of the advice given above but wanted to add my two cents as well as share my experiences as well. I've been out of training now for 5 years and it does it get better. I definitely had my struggles at the beginning but overcame them and currently fell like I've become a pretty darn good cataract surgeon. I still remember (very well) my first surgery day at an outpatient hospital at my first job out of fellowship. I had four cataract surgeries, one of which was a a brunescent cataract which happened to be the first case. The microscope was an older generation Zeiss and let's just say the view was far worse than what I was used to during my residency and fellowship. Despite using the trypan blue the rhexis proved quite difficult and ran outward. Long story short, during the phaco the area where the rhexis ran out extended to the posterior capsule and that rock hard nucleus sank immediately. I was devastated. To make it even more embarassing the phaco rep from Alcon was there to help with settings and watched the whole thing! The next two cases went well but then on the last case I had a PC tear with vitreous loss. I was devastated to say the least. I had done over a 100 cases in my cornea fellowship with only one PC tear. And then this happened. I don't remember exactly but I think I ended up having around 10 PC tears in my first 100 cases. Which really is not good at all. But as I gained experience and became used to the equipment things became much much better. I'm with a different practice now and operate at different places but now I'm doing sub 10 minute phacos on routine basis and have had 1 PC tear in my last 800 cases ( and in that one case the patient moved causing the tear). So yes things can get better! Here are some pointers I'd like to share based on my experience.
1. Definitely agree with doing easier cases at first. In retrospect I was way overconfident based on my fellowship experience. It is a whole new ballgame when you don't have an attending watching every move you make and telling you when you are doing something stupid. Or saving the day when you do end up doing something stupid.
2. When starting out do blocks (retrobulbar, peribulbar, or sub-tenon's). It allows you to have more control over the surgery than topical.
3. Don't hesitate to use general anesthesia. Some patients will just not be able to cooperate even when blocked. Make life easier on yourself.
4. If at all possible use the equipment you used during training. I know some surgery centers and hospitals try hard not to buy things and try to push new docs to use existing equipment. (Been there) Getting a new phaco machine or microscope is difficult but obtaining a chopper, etc. you used should not be negotiable. It should be about the best patient outcome. Not $.
5. When you are debating whether you should use trypan blue because the red reflex is less than ideal just go ahead and use it. Better safe than sorry.
6. When you are debating whether you should use an iris expansion device because of a small pupil just go ahead and use it. Better safe than sorry.
7. If doing topical anesthesia (which most of my cases are now) not every patient is a good topical candidate. If it is difficult in clinic to place drops or check pressure due to patient squeezing topical could prove quite challenging.
8. When starting out have the phaco reps from Alcon or whichever phaco system come in the OR with you to adjust settings. They are very knowledgeable.
9. Know how to load IOL's. Not all nurses do and one day you might find yourself stuck with one.
10. Know how to trouble shoot problems with the phaco machine. Again not all nurses know how.
11. When complications happen learn from them. Don't kick yourself to hard. Complications happen to every surgeon. If they don't they are lying.
12. Know how to handle complications. Read up and watch videos on managing them. In my experience even if complications happen if they are managed properly patients will almost always end up with good outcomes.
13. Place a second instrument under the final nuclear fragment during phaco to prevent the capsule from entering the tip of the phaco.
14. Don't use power in the periphery. An attending in my fellowship always said this. Only use power to bury the tip in a nuclear fragment then bring it out of the bag to emulsify it. This prevents the phaco tip from rupturing the peripheral capsular bag.
15. Try to avoid letting patients drift in and out of sleep. When they wake up in the middle of the surgery they don't realize where they are and can suddenly move.
16. Finally someone above mentioned discussing problems with you a colleague. I think this had more to do with the doctors in my first practice than anything but I did not find it helpful at all. I was usually told something like "oh stuff like that happens" or "I don't know what to tell you". To make it worse several of the docs I worked with acted like were perfect and never had any problems (although I learned to find out otherwise). At least in the private practice world so far I've found other ophthalmologists are very reluctant to discuss complications.

I'll try to think of some more tips and keep posting them.
 
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