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Residents & Fellows Corner | Jan/Feb '16

It’s All About the Fundamentals: A Resident’s Perspective

In cataract surgery, every step builds upon the previous steps. For this reason, success for beginning surgeons is often obtained by starting at the end. At my institution, Weill Cornell, we use the backing in technique to teach new surgeons; this technique was first developed by Mark Wolken, MD, and is now widely used among training programs.

In my OR, the first step new surgeons perform in cataract surgery is removing the viscoelastic from the eye once the IOL has been placed. The next step they learn is loading and inserting the IOL. From there, I continue teaching steps in a backward progression until a resident has performed all steps of the procedure. I have found success and good results with this method of teaching.

The excerpt below describes one resident’s experience learning cataract surgery.

– Jessica Ciralsky, MD

Throughout residency training, residents are exposed to numerous cataract surgeons. We typically learn from both highly experienced surgeons as well as those right out of training. Residency is a roller-coaster ride. Every attending has a different opinion on the correct way to perform cataract surgery. However, there are some common themes that I have learned and feel obligated to pass along to my fellow residents in an effort to make this audacious task easier.

First Things First: Start at the Finish Line

As Stephen Covey so plainly put it in Habit 2 of The 7 Habits of Highly Effective People, “Begin with the end in mind.” Early on, residents are sometimes put in positions to fail in cataract surgery rather than to succeed, in part because they begin by performing difficult steps such as the capsulorhexis or phaco chop. Instead, residents should start by mastering the easy steps that take place at the end of the surgery. Learn how to load an IOL—or, not just load the lens in the cartridge, but actually insert the IOL into the eye. Although I have been on the unfortunate side of tearing a capsule from inserting an IOL, it is much less frequent than learning to chop a lens. Hydrating wounds seems easy, but having watched numerous residents perform this, it is a step that can’t be overlooked. After breaking a bag by having my cannula leave the syringe like a rocket, I now know to keep a hand on the cannula.

Once a resident has mastered the final steps of cataract surgery, then he or she can work backward, approaching the starting line. In my experience, learning multiple ways to make a paracentesis is advantageous for a resident. Learn to make a paracentesis using 0.12 forceps for stabilization or using cotton tip applicators, Wek cell sponges, or even no stabilization at all. After you have proven proficient in this step, you can move to basic wound construction with a keratome. The architectural design of the wound can make or break a case. If you don’t like the wound you created, stop, close the wound, and make another one.

After the resident has mastered the beginning and the end of surgery, it is time to move to the heart (or nucleus) of the matter. Again, nothing is more painstaking and humiliating than jumping ahead in the learning process. Surgical mentors should encourage residents to pace themselves with the learning process. My father has always told me that if it takes you 5 minutes to do a rhexis, take the full 5 minutes; do not rush this part. I could not agree more.

My recommendation is that residents learn the basics with a cystotome and a pair of casulorhexis forceps. Other advanced devices can be learned at a later date, but beginners should keep it simple. After you have conquered the capsulorhexis, move to nuclear disassembly. Start with the tried-and-true method of divide and conquer. The early part of training is not the time to learn phaco chop, stop and chop, phaco flip, etc. There is no reason for the resident or the attending to get discouraged because the resident makes mistakes using advanced maneuvers when he or she never mastered the basics. After all, you have to learn to walk before you run, right?


To quote one of my mentors, “Cataract surgery is fun.” The pressure to learn everything in a day should not be allowed to get to a new resident. This is a process, like everything else in life. Take cataract surgery one step at a time, and remember to always begin with the end in mind.

Michael Patterson, DO
Michael Patterson, DO
  • Chief Resident, Department of Ophthalmology, Palmetto Health/University of South Carolina School of Medicine
  • Captain, South Carolina Army National Guard, Columbia, South Carolina
  • mdpatte@gmail.com; (931) 260-8069
  • Financial disclosure: None