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Hand positioning important during cataract surgery
Good hand positioning leads to successful outcomes for patients and comfortable surgery for ophthalmologists.
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When performing microsurgery, particularly intraocular surgery such as cataract surgery, a high level of precision is required. The surgeon’s hand positioning is critical in order to safely and efficiently perform the procedure. Keeping in mind the principles of pivoting within the incisions and maintaining the eye in the primary position, there are ways that we can position our hands to maximize success.
Bracing the hands
The surgeon’s hands should be braced against the patient’s head or, alternatively, a wrist rest. Avoid hovering with the hands in the air because this provides no support and decreases precision. Typically, the pinky finger and/or the ring finger of each hand is used to brace the hands against the patient’s cheek, forehead or orbital rim. This also provides a degree of safety because if there is inadvertent movement of the patient’s head, then the surgeon’s hands move as well in the same direction and at the same time.
The hands are also positioned so that the view through the microscope is not impeded or blocked by a gloved hand. If using a fixation ring for incision creation (Figure 1), the nondominant hand tilts the fixation ring handle away from the surgical field while the dominant hand uses the keratome to create the phaco incision.
Source: Uday Devgan, MD
Using both hands together
We can also gain additional stability by using two hands to hold the instrument, such as the forceps used in capsulorrhexis creation. But the disadvantage is that the surgeon is unable to use each hand to do a separate task. In patients with difficulty fixating on the microscope lights, I recommend using the nondominant hand to hold the eye by using a chopper to hook the paracentesis incision. Now the dominant hand can use the forceps to create the capsulorrhexis in a perfectly still eye (Figure 2).
Instruments entering via incisions on the left half of the eye should generally be held primarily with the left hand, while the right hand does the same for that half of the eye. This prevents having to cross one hand over the other to access the eye.
From a young age, we are taught to hold a pencil with a particular grip. We then spend decades writing thousands of pages of notes using this same grip, thereby building great dexterity. Keeping this same pencil grip makes for a natural transition to intraocular surgery. It is no coincidence that many of our key instruments, such as the phaco probe, are designed to function like pencils. This pencil grip is likely to give the highest level of precision for most surgeons, and it is what I recommend for all beginning residents.
When dealing with injectable medications and fluids, care should be taken to hold the junction where the cannula attaches to the syringe (Figure 3). Some of our syringes feature locking mechanisms to prevent the cannula from becoming dislodged, while others use simply a friction fit. If the cannula is partially blocked, pushing on the plunger can create very high pressure that can cause the cannula to shoot from the tip. This acts like a projectile and can cause serious intraocular injury such as iris damage, lens dislocation or vitreous cavity penetration.
The natural pencil grip
Finally, remember to keep an ergonomic and comfortable position during surgery. Ophthalmologists perform tens of thousands of surgeries during the course of a career, and repetitive stress injury is common and can be disabling. We want to help as many patients as possible, and having proper hand positioning and good ergonomics ensures a safe and efficient surgery for our patients and a long future in the operating room for us.
Full videos of these cases can be found at CataractCoach.com, which is a free teaching website.
- For more information:
- Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.CataractCoach.com.
Disclosure: Devgan reports he owns the CataractCoach.com website, which is free and noncommercial.