EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/115557
126 EW RESIDENTS March 2013 Nucleofractis continued from page 125 with the phaco tip. Vacuum builds when the phaco tip is occluded within a nuclear fragment. When the tip bores through the fragment the elevated vacuum is suddenly released, drawing the posterior capsule to the phaco tip. A round hole in the posterior capsule results. If this complication is recognized early enough and appropriate action is taken, vitreous loss can be avoided. Use low flow settings (epinucleus settings) when removing the last fragments from the bag. When using a Kelman tip I always turn the bevel to the side when removing the last fragments. This position places the tip 2-3 millimeters further from the posterior capsule than having the bevel pointing straight down. Many surgeons recommend using a blunt second instrument to hold the posterior capsule back when removing the last nuclear fragments. Evan (Jake) Waxman, M.D. Program director, ophthalmology, University of Pittsburgh We're presented with a hole in the posterior capsule with some nucleus left in the eye. In other words, it's another Thursday morning in July. The first question is "How did we get here?" It was noted that the OSIT (Ophthalmic Surgeon in Training) had difficulty with chamber stability during the nuclear disassembly. While chamber stability issues can be caused by a poor choice of settings (too low a bottle height for the aspiration flow rate, for instance) most of the time they are caused by leakage at an incision. Leakage at an incision can in turn be caused by either poor incision construction and/or by "heavy" hands. We don't have the space to tackle a detailed review of the pitfalls of incision construction. It will be sufficient to note that incisions that are too short are placed at an angle that results in too much torsion during the case and are more likely to leak. "Heavy" hands are a very common problem for the OSIT. It's natural as you're paying attention to what's going on inside the eye to lose track of what's happening at the incisions. It's natural to rest some of the weight of your instruments and hands on the eye and in doing so apply pressure to the posterior lip of the incision resulting in leakage. Solutions for this can include wrist rests, arm rests, careful positioning of hands to ensure that the hypothenar eminence is well supported, and a conscious effort early in training to lift rather than rest the instruments during surgery. This conscious effort early in training becomes automatic after just a few dozen cases. When presented with a resident having mild chamber stability issues, the preceptor may choose to raise the bottle height or lower aspiration rate to compensate. Other tips continued on page 128