Phaco Tips and Tricks Vikas Mahatme
INDEX
×
Chapter Notes

Save Clear


1Step by Step Phaco Tips and Tricks: (Highlighting Woodcutter's Nucleus Cracking Technique)
2Step by Step Phaco Tips and Tricks: (Highlighting Woodcutter's Nucleus Cracking Technique)
Dr Vikas Mahatme Ophthalmologist Founder Medical Director Mahatme Eye Bank and Eye Hospital Recognised Institute for Post Graduation Nagpur and Mumbai, India
3Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672
Fax: +91-11-23276490, +91-11-23245683
Visit our website: www.jaypeebrothers.com
Branches
Step by Step Phaco Tips and Tricks
© 2005, Vikas Mahatme
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2005
9788180614026
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, A-14, Sector 60, Noida4
to
My Parents.….
My Father
who inspired me
to dream of an Eye Institute
to serve the mankind
and
My Mother
who taught me to love my patients and use my
hands for manual works which helped me in
grooming my surgical skill.
My Patients.….
who complained about their postoperative
problems and taught me to improve my surgical
results continuously.5
My Best Friend since the time I started Phaco! (Author Dr Vikas Mahatme with Galaxy Appasamy Indian made Phaco Machine)
6
FACES THAT GAVE A FACELIFT TO THE OPHTHALMOLOGY IN INDIA. I SALUTE THEM
Dr Pran Nagpal
Dr GN Rao
Dr G Vankataswamy
Dr Namperumal
Dr HS Dua
Dr Keiki R Mehta
7
Dr Ravi Thomas
Dr Abhay Vasavada
Dr Amar Agarwal
Dr Mahipal Sachdev
Dr Ishwarchandra
Dr Sudha Sutaria
…And there are many more ophthalmologists who have equally contributed for upliftment of ophthalmology in India. We regret our inability to provide their photographs, although they will always remain in our hearts forever.
8Preface
Friends,
Way back in my residency, one of my patients had vitreous haemorrhage. I advised him Crooke's collosol iodine. He came to me after 15 days with a smile on his face. He was happy to have an improved vision. I was feeling proud about myself as I was convinced that his vision improved because of my treatment. Then I asked him, “how many times did you take that mixture?” Surprisingly, he said, “I didn't take it. I followed the instructions on the bottle. It said—“keep the bottle tightly closed!”
Then I realized that most of the times nature takes the care and surgeon catalyses the process so as to get good results. This is the reason, Phaco cataract surgery appears to me as most natural, since it does not disturb the nature gifted anatomy of eye to a great extent.
Over the years, Phacoemulsification is no longer the latest technology but undoubtedly the excellent, time-tested way of cataract surgery. Unfortunately, many new surgeons don't allow this technology to enter their minds. The most possible reason being fear and apprehension of learning new technique and a scare of causing harm to the patients while learning. But friends, I too wasn't an exception to this fear. I have passed through every stage of it, realising later, how unjustified my thoughts were prior to learning phaco. I am also aware of the feelings of a phaco learner—his problems and his worries. This is the reason I thought of bringing out this handy book dealing with very practical and vital aspects of phacoemulsification. 9This book has been written with the aim of giving practical tips for developing surgical skill. It does not contain the facts that are well established beyond doubts and are given in details in several text books. The theme of the book revolves round the concept “we have to learn how to learn”. This is especially true for surgical techniques where we want to learn but without compromising the vision of patient. This has been stressed all through this book. After phaco many new techniques may arrive but this book will be like a Bible that will take away your fear of learning and adapting the new technique because now you know the proper path of mastering any new procedure. I have elaborated about actions to be taken when we do not get desired results at any surgical step.
As my experience grew, one of my patients said, “doctor you have good skill and I bless you that your skill helps all the patients.” First I thought, he is talking something that is impossible. On a second thought, I realised that this can be made at least partly possible, if I am able to transfer my skills through this book.
I shall like to acknowledge the persistence of my wife Dr. Sunita. Like any wife she was nagging me but this time for a good constructive cause of getting this book completed by me. My goals are her goals. If I say I want to write a book, she will create environment to write the book. Although professionally she is a gynecologist, by heart she is an ophthalmologist. She has helped me in many ways and by all means to improve the quality of this book.
There are many more whose names I might not have written here they are like foundation of a building which remains invisible; they have directly or indirectly helped 10me in completing this book. Also last but not the least, the residents and fellows who came here to learn phaco, also shared their problems with me, which they came across while learning phaco. This has added to my experience.
Friends, once I asked my son Chinmay, “what is your dream?” He said, “I want to live in a developed country”. I was shocked! I asked him further, “in which country?” He said “DEVELOPED INDIA”! Friends, let us equip ourselves against blindness with new weapons like phacoemulsification. Let us make our contributions to convert developing India into developed India. Let us help in making the dreams of upcoming generation become true and make them live happily with good vision in a developed India.
Thanks.
Vikas Mahatme
11Why Should I Read This Book?
Friends,
In 1993 I was attending American Academy's meeting at Chicago, when the phacoemulsification had just made its way and someone asked me if I would like to go in for Phaco. Being an established private practitioner, doing lot of work with small incision extracapsular cataract extraction, my answer was a strong ‘No’. A couple of years later I found myself converted into a Phaco surgeon. Today the situation is such that cataract surgery is almost synonymous with phaco. I am not exaggerating, but almost every day a new book on phacoemulsification is coming up. Then why read this book?
The aim behind publishing this book is to share my journey towards Phaco, my views, my experiences, and the problems I faced in the subject. I am sure, they will be beneficial for all those who are still in dilemma of whether to go in for Phaco or not, for those who want to learn how to start and also for those who are already doing Phaco. You will find in this book, concepts converted into practical tips and guidelines, rather than mere theory. These are extremely important as far as mastering the technique is concerned. At the same time, 12you may feel that some important points are missing from this book. I have avoided them because they are well established and accepted facts, which can be read from a textbook on Phaco.
Just as you cannot learn swimming by reading a book on ‘How to Swim’ you can not learn any surgical procedure, unless you start doing it. So, get started; start doing Phaco; refer to the guidelines as and when required. Whenever you are in problem, refer to this book again. I am sure; phacoemulsification will soon be a friendly affair for you.
13Why Should I Shift to Phaco?
Whatever may be your ophthalmic specialty; you are bound to encounter a patient of cataract, because it still remains the commonest problem. So, why not adopt the latest in the field; especially when changing over to latest is beneficial to the patient as well as to surgeon?
Remember there was a storm in 1980s, when it was time to change over from intracapsular lens extraction to extracapsular lens extraction with intraocular lens implantation. The question then was, “Why shift over to extracapsular cataract extraction and IOL when I can give 20/20 vision with intracapsular cataract extraction and aphakic glasses thereafter? Extracapsular cataract extraction and IOL have chances of additional complications, while learning…” and so on. You know the history, how the new procedure miraculously changed the scenario for patients as well as for ophthalmologists that now we laugh at ourselves at the questions we had in minds at the time of changeover. We were afraid of complications—not of the procedure but complications during the learning phase. Later on we realized that it was not the technique that was at fault, but the problem was faulty way of learning a new technique.
Similarly, we now blame phacoemulsification for possibility of additional complications. In fact we need to 14master the technique by “proper way of learning”. If this happens we will not have to repeat the history and laugh at ourselves once again.
Whenever a new surgical technique is to be accepted and adopted it should first clear a Three-Way test based on scientific approach.
  1. Is it better than existing procedure?
  2. Is it safe?
  3. Is it economically viable or feasible?
Let us apply this test to phacoemulsification and weigh its efficacy.
 
 
Is it better than existing extracapsular cataract extraction with IOL procedure?
The advantages of phacoemulsification over extracapsular cataract extraction are well known and need not be elaborated in details. In brief, one can say that it is a small incision procedure, as well as least traumatizing, with no iris touch that usually invokes inflammation. “No Stitch, No Patch, No Injection Anesthesia” is the selling slogan for Phaco surgery. With corneal incision it is difficult to identify the eye that has been operated next day. This is because of least inflammation it invokes as compared to manual small incision cataract surgery.
 
Is it safe?
When an old surgical procedure is to be compared with a new technique, it is a wrong policy to compare results of new procedure done at the hands of inexperienced novice 15surgeon with that of old procedure done by an experienced surgeon. Ideally, comparison should be between new and old procedures done by an expert in respective techniques. Reason is simple. As narrated earlier, learning the technique may be at fault rather than technique itself. Surgeon may land up in problem and complications, while learning any new procedure. This is the reason that “we have to learn, how to learn”. If this dictum is followed, it is beyond doubt that Phacoemulsification has fewer complications as compared to routine extracapsular cataract extraction. It is a procedure with a better control.
 
Economic Feasibility and Viability
One feels that Phacoemulsification machine itself costs a great deal and then there are recurrent expenses as well. However, once you master the technique recurrent cost is much less and even comparable to extracapsular cataract extraction. As it happens with every electronic gadget, slowly the cost of machine is bound to come down. The earlier you buy a machine, the more you might spend but be sure, the most you will be benefited because you are then a “Phaco surgeon”, that distinguishes you from the crowd.
16
While thinking about ‘To be or not to be’, some more questions crop up in our mind. These questions may take out enthusiasm to learn phaco. The questions may be like these—
1. I am working at periphery or in camps. Patients' paying capacity is much less.
Once you master the technique, more number of patients can be operated in shorter time. Patient can be discharged as in day care center. Complications are less. Patients need not come for repeated follow-up. This automatically reduces overall cost of treatment. Also it is not mandatory to use foldable IOL; instead, 5.2 mm diameter Phaco lenses are good enough to solve the purpose. Even foldable IOL are becoming affordable now a days as lower priced foldable IOL are coming up. Phaco camp is no more an imagination. We have been doing it; anybody can do it.
2. I am new in practice. I don't have substantial volume of patients. Phacoemulsification is of no use to me.
A newcomer in the practice ought to have an edge over the established ophthalmologists. Then only he can make a place for himself. Then why not have with you an asset like Phaco, which can distinguish you from the lot. Remember, however, that learning should be without 17spoiling a single case. Patient's vision is of supreme importance. To know how to do it, you will have to go through the subsequent chapters.
3. I am an ophthalmologist of good reputation, doing significant amount of surgical work. I am happy with the results. Learning new technique will snatch away my prime time.
Learning is an investment rather than wasting time. Once you expertise, your time per case will be saved. Follow up headaches will be reduced. Ultimately phacoemulsification will be a time saver on a long run.
It seems to me that any future research in newer techniques will definitely be based on Phaco technique only. This is the reason learning phacoemulsification will soon become a basic requirement for any ophthalmic surgeon. When you are adopting Phaco, biomedical industry is with you all the time—when you buy a machine, when you have problems in learning the technique, or when you wish to update yourself by learning the latest in the field and they also help by continuously improving the machine.