Tuesday, May 26, 2009

I asked Bob, if he would make a few comments concerning his technique, and operating on a fellow ophthalmologists. Some of his comments are technical and I have explained them, following each item that a lay person may not be familiar; with (..................).

Tim, Yes! I would be happy to lend my two cents worth.

As for the basics, I always say that the softest cataracts can become the hardest and the most experienced surgeon still has to be compulsive about a thorough hydrodissection and in only the softer cases will I also hydrodelineate. (Loosening the cataract with fluid) Before all that comes the proper incision and with premium IOLs, a 2.2mm incision with torsional on the INFINITI can't be beaten. (The machine we use to remove the cataract) I really find it helpful to mark the steep axis if I wish to make the incision on axis. (To reduce astigmatism) I routinely mark toric (astigmatism) patients as well in the preoperative holding room for the "next patient" ready to be brought back. Having a slit lamp in that room has greatly enhanced my ability to make toric IOLs more accurate and to reduce pre-existing astigmatism for other patients as well. As you know, I rotate the slit beam to the axis for the incision-in the case of premium IOLs, or to the axis for the final position for the toric IOLs and there I place a sterile ink mark on both sides of the limbus. (edge of the eye) In addition to being more accurate and faster it eliminates all the goofy and none too well designed axis marking devices! (Boy, do I really agree with that!) I bet the cost of a portable slit lamp fixed to a table on wheels is less than the cost of the numerous making instuments some docs have in their ORs.
I start and end my rhexis with the Utrata forceps and really try for an overlap on the IOL, meaning a 5.5mm rhexis. (a 'rhexis' is creating a hole in the thin, transparent membrane covering the capsule)

As for operating on a fellow eye surgeon, I suggest treating the doctor as the patient and doing all your own measurements and calculations. I suppose if it was a first time then a beta-blocker might be a good idea to control the tremor!!! (Some surgeons get very nervous, and have a tremor. A beta-Blocker medication reduces tremors) Tim, it is much the same as doing live demonstration surgery or operating on a loved one/family member. You always want every patient to have the very best outcome possible.....just in those close and personal patients, it is even more foremost in the surgeon's mind. (I agree, in is all psychological when operating on a relative, or friend)

One final comment on my own situation is to point out that the Zeiss Lumera operating microscopes have really changed my operating day. I truly do move thru. procedures with greater ease due to the enhanced red reflex compared to my former Leica scopes. (I also agree with that.....I previously had the old Zeiss scope, and the new Lumera is a technological leap, not just a small step.) I am confident that I would not have had a capsular complication during my ASCRS surgery case from Tijuana a couple years ago if I had been able to use the Lumera (which was not even available them).

Please keep me posted as to your progress,

Bob

Thanks for the excellent comments, Bob. The small things Bob, and any excellent surgeon does, makes the difference, and produces accuracy. The smaller incisions, good hydrodissection, marking the axis of astigmatism, a 5.5 mm rhexis, the Lumera microscope, just to name a few, are additive. Leave one out and it will decrease reproducibility, and accuracy. On the topic of operating on surgeons, friends and relatives. There is one other situation that many surgeons shy away from. Operating on a one-eyed patient. Think about that one! No surgeons wants a complication, and in any patient it is difficult to swallow, but a one eye patient would be even worse. It is completely psychological. You have heard the term, "psyching yourself out." That is exactly what can happen in any of those types of patients, if you allow it. I treat everyone exactly the same, and in the one eyed patients, I often forget who they are. They are in the mix with the rest of my schedule, and it is generally after the case when I tell them everything went fine, that they bring it up. I had the privilige of operating on two active physicians, and a close family friend last Wed. I treated them just as Bob treated me.....no different that the next person, and everything went perfectly.

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