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Cover Focus | Mar/Apr '19

Surviving Your First Phaco

In residency, we all hear those golden stories of residents providing 20/15 postoperative vision on their first day performing phacoemulsification as primary surgeon. But, just like TV, we know that’s fake news.

Personally, I had worked hard to reach my first day as primary surgeon, but oddly, the morning of, I was afraid I didn’t want it. Or, at least, maybe not until next year, when my skills would be better honed. But there I was, early into my second year of residency, sitting frontside at the scope, ready for a ride.

We all get used to being in the assistant safety net. We scrub, rinse, gown, glove, sit, adjust our pupil distance, position a bottle of balanced salt solution in hand, ensure the scope lights stay sharp, and scrub out after those precious 6 minutes and 39 seconds. Easy, right?

I’ve observed more than 1,000 ophthalmic surgeries, from my first year in medical school until this day, when I found myself sitting temporally with a paracentesis blade. I had to hold my own silent timeout. Name: David Felsted. Surgeon: me. Wait—yes, me. Surgery: cataract extraction of the left eye with IOL placement. No allergies, no IV antibiotics necessary, and lens is in the room. Let’s get started.

Below are some of the key lessons I learned from my first day of phacoemulsification.

1. Failure is a possibility and an opportunity

Every residency program is remarkably different. Some residents don’t touch the inside of an eye until their third year, whereas others are thrown into things within months of year 1. Some get started on the last step, wound hydration, and others, at the paracentesis. In my situation, I had made a paracentesis, and that’s about it. When it came time to sit as primary surgeon, I couldn’t believe I was finally stepping into the world of intraocular surgery. It’s incredibly humbling, but it is important to hang in there and remember that every OR day is another chance to improve and to become more consistent. It’s a chance to keep growing and a chance to fail—yes, fail—because that’s how we improve for next time. It’s hard to swallow at times, but look at the best surgeons: They’re proud of where they’ve come from and the mistakes it took to get there.

2. You’re better than you think you are

No, really—you will amaze yourself. You’ve watched phacoemulsification so many times that it truly does become second nature. On my first day, I performed both clear corneal and scleral tunnel incisions, and I was surprised by what my hands did without the micromanagement of my attending. Thinking and acting in a 3-D microsurgical environment isn’t second nature, but the skills picked up by merely watching and examining patients in the clinic certainly help. I found the capsulorhexis creation to be much more manageable than I had mentally built it up to be. It was not femtosecond-perfect, but it didn’t run or rent, so I celebrated. Realize that your early successes will look different to an experienced surgeon, and that means you’re on the right path to improvement, with slow and steady progress.

3. The shakes lessen with each case; control what you can

I’m not ashamed to say that I was shaky during my first primary phacoemulsification. Most residents are. But the tremors do subside with each case. Just be aware, and don’t get caught up in it. Let it be, and you’ll let it go; focus on it, and it stays. More importantly, don’t forget to completely drop your shoulders and work from the wrist, and don’t be afraid to ask your attending about ergonomics and proper instrument handling. Find out what works well for you, but be open to corrective feedback. If small tremors are a problem, speak to your primary care doctor about options to control them, such as beta blockers. You may also consider placing an artificial tear 20 minutes before your case. I found my concentration was so intense on those first couple of cases that I forgot to blink and my eyes dried out and became uncomfortable. Little hacks like this go a long way. Also, don’t forget to get a good night’s rest and eat properly (we’ve all survived boards). Above all else, make sure you are comfortable before the case starts.

4. There are things they won’t tell you

You will probably hit the lens at least once (best just to get over it) when learning to make a paracentesis. The incisions are hard to find and even harder to insert through. These steps seem so effortless, but you will be surprised. Ask to mark your paracentesis blade with ink to make visualization easier. You will lose your view of the capsule, so I recommend staining with trypan blue on your first several cases. No one will judge you for this. Perform under a retrobulbar block. Nucleus disassembly is the absolute hardest step for me, but a different step may be most challenging for others.

When the lens is gone and it is time to fill the bag with OVD, remember that the posterior capsule is prolapsing forward. Inject a little OVD ahead of your cannula as you insert it; otherwise, the posterior capsule will rupture. Remember that little white ghost on Super Mario who followed you around when Mario wasn’t looking? That’s how your second instrument will behave. Always keep an eye on it; otherwise, it starts to wander, press down on the capsule, or swipe the iris. With time, you will learn dual control, but get in the practice now of keeping an all-seeing eye on the eye (sorry, had to). Don’t get caught up comparing your surgical weaknesses to others’ strengths. We are all learning, and we are all good at different things. Respect that, and you’ll improve more quickly.

5. You can start preparing now

Many surgeons in training have been told to shave or brush their teeth with their nondominant hand in order to become more ambidextrous. One trick that helped me practice basic surgical skills was using my smartphone camera to get used to an alternative viewing source. Using my iPhone, I would open the camera app in video mode and place the phone face down on a platform about 6 inches above my desk, with the camera lens hanging over the edge. Using a simple instrument set (needle driver and 0.12 forceps, 8-0 vicryl), I began to familiarize myself with what it felt like to operate.

Obviously, this was not the real deal but a basic way to see what microsurgery is like. It’s actually very applicable for learning suturing, which residents in my program are tested on heavily at the end of our first year. We have several microscopes and an Eyesi Surgical Simulator (VRmagic) that are freely available for residents to practice on, but sometimes a quick suture session is a better use of time, and it really is more about muscle memory than anything else. Although the Eyesi is a great platform to start learning on, some of its parts are more realistic and useful than others.


Now, back to me in front of the scope. Fifty minutes and two bags later, I had successfully implanted an IOL and hydrated the wounds on my first case. I am proud to say that my patient has excellent vision and achieved a great outcome, but it wasn’t on postoperative day 1, and I celebrate that.

David Felsted, DO
  • PGY-3 Ophthalmology Resident, Medical College of Georgia at Augusta University, Augusta, Georgia
  • dfelsted@augusta.edu; Instagram @felmology
  • Financial disclosure: None