Eyeworld

EW RESIDENTS 31 starts with using a simple sheet of paper and a pair of forceps. This al- lows us to discuss flap management, where to grasp the flap, and most importantly to review vector forces used at various parts of the capsu- lorhexis. We then proceed to the lab, where we practice the curvilinear capsulorhexis on pig and/or syn- thetic eyes. It is important that the pig eyes are fresh and that the eye chosen for use has a clear cornea. To achieve a more realistic experience when tearing the curvilinear capsu- lorhexis, we first use a cornea-clear- ing solution 1 to clear marginal corneas. Second, we use a capsule- staining solution 2 that both stains the capsule and reduces its elasticity. We have also used synthetic eyes purchased from EC Phillips. In our experience, we have found that the pig and synthetic eyes cover the two extremes of capsular texture: The pig eyes have very elastic capsules (much like infant capsules), and the synthetic eyes have more friable cap- sules (much like you would find in a fragile diabetic or very elderly pa- tient). There are programs that have utilized surgical simulators. The University of Iowa has purchased a VRmagic simulator (Mannheim, Germany), and the surgical instruc- tors find this of value with helping residents master the mechanics of tearing a curvilinear capsulorhexis. The disadvantage of this solution is the cost of the simulators. Unfortunately, as much as we prepare the resident for the tearing of a curvilinear capsulorhexis, each patient is unique, and hands-on ex- perience is required. In the OR, we have found the most important as- pect is to define a "zone of safety," outside of which the surgical staff intervenes by returning the rhexis within this zone before turning the case back to the resident. In this way, safety is maintained while pro- viding excellent surgical results. Arlene Bagga, M.D. Associate professor of ophthalmology, University of New Mexico, Albuquerque In learning continuous tear capsu- lorhexis, keep three main goals in mind. First, create an opening of ad- equate size to provide access to the lens during surgery. Second, ensure overlap of the intraocular lens im- plant all the way around to prevent shifting of the lens and reduce the incidence of posterior capsular opac- ity. Third, be consistent in size and shape: 5.0 to 5.5 mm, round, and centered within the pupil. Basic capsulorhexis technique begins with good visualization of the capsule. Early in your practice, select patients who dilate easily in the clinic and who have a good red reflex during clinical examination. Choose moderately dense nuclear sclerotic cataracts to ensure pre- dictable behavior of the capsular tear. Lenses that are too soft or too mature can increase the risk of a ra- dial tear. Despite a large pupil and red reflex, it is useful to use trypan blue for every case until you have re- fined your technique. Control of the capsular tear re- quires a flat anterior surface of the lens during the entire step. Often resident physicians will experience a radial tear in the last quadrant of the capsulorhexis because pressure on the wound allows egress of viscoelas- tic and rounding of the anterior lens surface. Begin by filling the anterior chamber with adequate dispersive viscoelastic, and refill as often as needed during the step. To initiate the capsulorhexis, use a bent needle cystotome to cre- ate a radial incision from the center of the lens to the desired radius of the capsulorhexis, then pull down to create a flap. Creating a flap that is too short will result in an opening that is too small. It is important to make a deliberate movement with the cystotome but not press too hard into the cortex of the lens. This will obscure the view of the flap. From here, use capsulorhexis forceps to complete the sub-incisional por- tion first, as this area is often the most difficult to visualize. Think of the capsulorhexis as a square rather than a circle. Pull the initial flap down directly toward the wound, then regrasp and turn 90 de- grees to the left or right and peel to the desired size, then regrasp and turn 90 degrees again and peel away from the wound, and so on. This concept allows for superior control of the flap and a consistent capsu- lorhexis size in each case. EW References 1. E.S. Liu, K.T. Eng, and R. Braga-Mele, Using medical lubricating jelly in human cadaver eyes to teach ophthalmic surgery. J Cataract Refract Surg, 27 (2001), pp. 1545-1547. 2. B.A. Henderson, K.J. Grimes, R.E. Fintelmann, T.A Oetting, Stepwise approach to establishing an ophthalmology wet laboratory. J Cataract Refract Surg, 35 (2009), pp. 1121- 1128. Contact information Bagga: abagga@salud.unm.edu Ramanathan: saras.ramanathan@gmail.com Thliveris: atthlive@wisc.edu Saraswathy Ramanathan, M.D. California Pacific Medical Center, San Francisco Arlene Bagga, M.D. Associate professor of ophthalmology University of New Mexico, Albuquerque Andrew Thliveris, M.D., Ph.D. Associate professor, University of Wisconsin, Madison November 2011 http://www.ascrs.org/12am/inner.cfm?page=residents-fellow-program Resident membership application form (U.S. based residents in training) ASCRS Resident and Fellow Program Sponsored by the ASCRS Resident Task Force, ASCRS Young Physicians and Residents Clinical Committee and the ASOA Physician Relations Committee New in Chicago – FREE ASCRS Resident and Fellow Program (For domestic U.S. Residents and Fellows) 30-33 Resident_EW November 2011-DL-3_Layout 1 11/4/11 11:55 AM Page 31

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