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Cover Focus | Nov/Dec '21

Cases 1 to 1,000

Advice for avoiding common pitfalls in the early days of surgical practice.

We’ve all heard it before: “I had my first day in the OR, and everything went very well!” Was that really the case, though—especially for those who have transitioned to a new geographic location or have taken over an existing practice? Newly minted surgeons should expect and mentally prepare for a challenging first 6 months when transitioning to being in the OR without attending supervision.

Having hit 1,000 cases in my first year out of training, I can personally attest to the steep learning curve that young surgeons must climb in the early days of surgical practice. With this experience behind me, I feel a duty to share some insights that may help other surgeons to avoid common pitfalls as they navigate full surgical autonomy.


Two years ago, I published an article on my first cataract surgery in residency. The nervousness, expectations, and thrills were tangible, but an attending was present for the entire case. When I stepped back into the OR 8 months after graduating amid the pandemic, my skills were there, but my attending was not. Moving into a rural yet high-volume environment, I didn’t realize the deep water I was swimming in at the time. My operative days quickly became full of pseudoexfoliation, dense lenses, and mature white cataracts. Some days I felt like a god, and others, like a devil. If you are transitioning out of training and away from a big city or academic center, then you may, too.

In speaking with friends and colleagues in their first 5 years of practice, I crowdsourced ideas of some of the obstacles a new surgeon should be ready to encounter. First, it will feel like starting out all over again. Although you know all the steps and have performed them hundreds of times, be prepared to get humbled. The room will be new, the patient positioning will seem off, and the drapes will likely be dissimilar from what you are accustomed to. Expect different equipment that is potentially outdated or older than what you used in training. Don’t expect the Ferrari microscope you trained on for your opening day. New surgeons should come prepared to deal with fuzzier optics and dimmer reflexes.

Keep in mind that you may not have access to a phaco machine with modern fluidics; even if you do and you import your settings, the platform may still behave differently, especially at higher altitudes. Intraoperatively, it is important to ensure that your main wound is well constructed and to plan for the wrong instruments. Companies and brands change, products are made differently, and the staff may not know the nuances of the various choppers and speculums. The night before my first operative day, I learned that none of my instruments had arrived in the mail. I was forced to use my partner’s chopper, forceps, and keratomes. Additionally, the scrub tech and staff will be used to a certain rhythm, and it won’t be yours. Be prepared for “Dr. Y. doesn’t do it that way” or “We’ve never heard that before.” It is perfectly acceptable to stand your ground and express your preferences, but do so in a polite and friendly manner.

A good surgeon adapts on the fly, but a better one anticipates problems before they occur. It is wise to regularly check the surgery center’s inventory to ensure that crucial items are always in stock. I had to learn to open the anterior capsule with Utrata forceps after the scrub tech informed me that we were out of cystotomes and didn’t have time to bend 20 needles. While discussing capsulorhexis creation, I’ll put it plainly: You will hit vitreous in your first year, most likely on your first day. The most common reasons are run-out capsules and accidental chopping of the bag. I suggest taping a handheld card with the steps for vitrectomy onto the phaco machine to reference when this occurs.


Certain steps can be taken to ensure a better first day and first year, starting with your tools. Obtain a list of the instruments used in your training program and give a copy to your new surgery center manager on your first day. Follow up regularly to ensure that your instruments have been ordered and will arrive on time. Transfer the settings on the phaco platform you used in training to your new machine via USB drive and have the device representative present on day 1 to fine-tune the system as you go.

On your first day, the anesthesia staff will be prone to deep sedation; consider if this is a wise option. Many surgeons, myself included, have experienced difficulty with fixation and with subsequent steps of surgery due to patients’ prominent Bell’s reflex. I’d recommend meeting with the anesthesia team in advance to discuss the plan for your first day. It may also be wise to perform retrobulbar blocks or peribulbar blocks on your first few cases. This eliminates fixation issues and allows you to get used to the other variables in a more controlled environment.

Review each case the night before surgery and make a list of any special considerations. Note conditions such as small pupils, pseudoexfoliation, and nucleus density. Have a plan for how to approach nucleus dissection in each case, as this will vary widely. When things do go wrong (and they will), have a first-aid kit ready. Ensure that your scrub tech is well versed in anterior vitrectomy, three-piece IOL implantation and cartridge sizes, and the difference between cut I/A and I/A cut. Place emergency items on or near the phaco machine, including trypan blue dye, a pupil expansion ring, a capsular tension ring, 10-0 nylon, and extra OVD. You will be surprised how long it takes to find these items when you need them.

A cold scope is a foggy one. Microscopes tend to fog with temperature variation between the ambience and surgeon. If it is excessively cold in the OR and you run warmer, be prepared for fogging. I use an adhesive nasal bridge mask and turn the scope on 30 minutes before cut time to allow it to warm up. The importance of proper positioning and microscope ergonomics cannot be overstated. Tape the head of every patient supine, with a 5° roll toward the operative side. Increase the magnification of the scope and manually focus on the conjunctival vessels, then back off on the magnification to a comfortable working space. Remember to reset your microscope after every case.

In your first few cases, make the capsulorhexis larger than normal (>5.5 mm) and revert to simple nucleus removal. Resist the urge to try new chopping techniques. A simple divide and conquer or stop and chop will help you navigate the confidence curve faster and eventually progress comfortably to combo chops or vertical chops.


The new ophthalmic surgeon has much to think about during their first few days or months. Skills develop gradually over time, and each OR day is an opportunity to learn and grow. Remember to be patient with yourself and recognize that no surgeon achieves excellence without running the gauntlet of complications, heavy days, and variations in surgical pathology. By the time you hit case 1,000, you will look back fondly on your first day, even if it didn’t go as perfectly as planned.

David Felsted, DO
  • Cataract, refractive, and microinvasive glaucoma surgeon, Barnet Dulaney Perkins Eye Center, Flagstaff, Arizona
  • Member, MillennialEYE Editorial Advisory Board
  • dfelsted@gmail.com
  • Financial disclosure: None