America’s Got Talent: Premium pearls in refractive cataract surgery
Founts of knowledge in the ophthalmic industry offer tips that can improve premium surgery outcomes.
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The popular TV show America’s Got Talent brings all types of undiscovered talent of all ages — singers, magicians, comics, musicians, ventriloquists and more — before celebrity judges who decide who moves on in the competition each week.
The audience learns the backstories of these amazing people, with the grand prize being a life-changing $1 million. No different from our real world of refractive cataract surgery, in which many premium surgeons discover great pearls along their career path that can make such a great difference in optimizing outcomes in the long run. Here is an abbreviated list of some perioperative personal pearls in no specific order that I have enjoyed in an already-abbreviated COVID year.
1. Proper draping of the eyelids: Karma for the premium cataract surgery starts with covering the lashes completely and even using a solid blade crank-type lid speculum. Loose drapes and free lashes continue to impair proper surgical instrumentation use and operative field visualization throughout the case (thanks to many of my colleagues).
2. Corneal incisions: The coupling effect with astigmatic corneal incisions will leave a residual refractive spherical equivalent of the preoperative refractive error (thanks Uday Devgan, MD).
3. Globe stability: Using a dry Weck-Cel sponge to provide counterpressure on the globe when making the main wound incision guards against unnecessary subconjunctival hemorrhages postoperatively. Cosmesis is what a patient remembers postop (thanks Sam Masket, MD).
4. Capsulorrhexis: Before femtosecond- and Zepto-assisted (Centricity Vision) capsulotomy, the ability to make a continuous curvilinear capsulorrhexis (CCC) was critical for effective IOL position and the ability to optic capture an IOL in the event of posterior chamber rupture. Remember not all cases are femtosecond or Zepto assisted, so learn a good CCC and stick with it (thanks Howard Gimbel, MD).
5. Hydrodissection and hydrodelineation: Freeing up the cataractous lens so it rotates freely in the bag before starting phacoemulsification gives the premium surgeon so many more phaco technique options, avoiding overfill with viscoelastic simultaneously to avoid the dreaded main wound iris prolapse (thanks David Chang, MD).
6. Phacoemulsification: Use all known techniques and learn as many techniques as possible (divide and conquer, horizontal chop, cross chop, vertical chop, flip and chip, etc.) as each case, soft to dense to mature to brunescent to pseudoexfoliation, will bring surprises in which the premium surgeon needs to change approach on the fly (thanks Tim Page, MD).
7. Avoiding intraoperative floppy iris syndrome in patients with a known current or prior use of alpha antagonists ending in “-osin” by using Omidria (phenylephrine 1% and ketorolac 0.3% intraocular solution, Omeros) has been a tremendous gain in reducing intraoperative complications, the need for pupil expansion rings and the need for perioperative opioids (thanks Denise Visco, MD, Keith Walter, MD, and Eric Donnenfeld, MD).
8. Bimanual anterior vitrectomy in time of need — a must for all premium surgeons — gives stability to the anterior chamber and the ability to recover in the case of posterior chamber rupture so a posterior chamber IOL can still be placed in the sulcus or as optic capture (thanks Dick Lindstrom, MD).
9. Most recently, the use of Dextenza (dexamethasone ophthalmic insert 0.4 mg, Ocular Therapeutix) has been a great addition to reduce pain and inflammation after cataract surgery and especially helpful in optimizing the ocular surface in premium IOL cases. A new technique involves placing unused viscoelastic (dispersive or cohesive) at the end of the case in the dilated punctum to viscodilate the punctum and canaliculus to allow for easier insertion of the insert (thanks Terry Kim, MD).
10. There are so many more premium surgeons, colleagues, industry scientists and clinicians who have helped me with so many pearls along the way in my 31-year career in ophthalmology that it is impossible to name and thank them all. Just saying, there are many seasons of America’s Got Talent with many more to go, and there are many past, present and future leaders in our field with talent and so many more pearls for us to learn as we move forward. The grand prize is better outcomes for our patients. Stay safe and healthy and continue to enjoy the talent ride.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
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