Eyeworld

EW RESIDENTS October 2011 89 late development. Practicing or learning musical instruments can be helpful. Playing sports with an effort to use both hands is challenging. Once you are able to use both hands effectively in cataract surgery, you will be well on your way to per- fecting your technique. Kenneth L. Cohen, M.D. Phacoemulsification is now the most successful operation performed in the United States. For the novice surgeon to become a competent sur- geon, the path is complex. There are many acceptable techniques for each stage of the operation. One constant is that the novice must learn to co- ordinate two hands and two feet. Practice in the wet-lab is essential. To become comfortable using the non-dominant hand, my ap- proach is to eliminate the use of the foot pedals. The novice resident fo- cuses the microscope at the location of the corneal incisions. Only then is the resident handed a fixation ring and a blade. The resident con- centrates on using both hands to create incisions. Sculpting is per- formed by placing two hands on the phaco handpiece, the non-dominant hand stabilizing the handpiece. After creating a groove, the hand- piece is handed to the scrub tech and viscoelastic is injected. Then, the non-dominant hand uses a Drysdale nucleus manipulator placed through the side port inci- sion to rotate the nucleus 90 de- grees. A crossing groove is sculpted. For cracking the grooves, the hand- piece is again given to the scrub tech and viscoelastic is injected. Using two Drysdales, one placed through the main incision and one through the side port incision, the crossing grooves are cracked and the nucleus rotated. The novice does not have to think about fluidics. The novice Learning to use the non-dominant hand W ithin the tight confines of the anterior segment, the non-dominant hand plays an important role in cataract surgery. Used properly, it assists with positioning and sta- bilization of the eye, mobilization and ma- nipulation of tissues within the eye, and can protect structures during phacoemulsi- fication. But until this is mastered, the non- dominant hand can actually impede efficient and effective surgery by interfer- ing with followability, gaping wounds, dis- torting the cornea, misdirecting the globe, or even damaging ocular structures. For the large majority of surgeons who are not ambidextrous, use of the non- dominant hand is unnatural for the very reason that it is non-dominant. We gain skill in using the non-dominant hand through training, experience, and time. We have asked three experienced cataract in- structors for specific tips and techniques to improve the awareness and agility of the non-dominant hand. Our hope is that these ideas will help accelerate that learning curve for trainee surgeons. Sherleen Chen, M.D., and Roberto Pineda, M.D. Sherleen Chen, M.D. Instructor in ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary Linda M. Tsai, M.D. Cataract surgery is one of the most technical procedures to perform, ne- cessitating the use of both hands and feet simultaneously. In fact, the additional use of the senses of sight, touch, and hearing are required dur- ing phacoemulsification. The ability to use both hands adeptly is a ne- cessity for excellent cataract surgical technique. In much of cataract surgery, one hand is needed to manipulate an instrument. The second hand is needed for stabilization or manipu- lation of a second instrument. Even when it is not actively being used, the second instrument must be sta- ble. Care must be taken to ensure the second instrument hand does not cause problems during the pro- cedure due to inattention. Using both hands during bimanual irriga- tion and aspiration and bimanual vitrectomy allows access to 360 de- grees of the eye. Rarely, due to phys- ical architecture challenges of the eye and face, it may be necessary to switch hands. It has been clearly shown that dexterity can be developed with practice. Handedness is believed to be innately determined from birth, although there are studies of effec- tive "coerced" training of the non- dominant hand, particularly in left-handed individuals who are trained to write with their right hand. This training is believed to ef- fect cortical reorganization of the brain. What can you do to improve your non-dominant hand? You can practice as much as possible. Try using your non-dominant hand during the day for daily activities such as brushing your teeth, comb- ing your hair, locking and unlock- ing doors, eating with utensils, opening screw-top containers, and picking up small objects. Fine motor skills, such as writing and drawing, are usually reserved for your domi- nant hand, but attempt these with your non-dominant hand. Some even advocate writing from right to left in an effort to stimulate brain development. Doing things in tandem, such as swirling both hands in water or throwing two balls at the same time and juggling, can be ways to stimu- continued on page 90 concentrates on using the dominant hand and the non-dominant hand in a stable intraocular environment. As the resident progresses from novice to advanced beginner, em- phasis increases on using the domi- nant and non-dominant hands together. After cracking the nucleus, using aspiration, each quadrant is safely brought to the center of the pupil for emulsification. If the phaco needle becomes embedded in the quadrant in a lollipop fashion, the non-dominant hand inserts a Seibel nucleus chopper through the side port incision to gently disen- gage the quadrant, allowing carouseling and emulsification of the quadrant using partial-occlusion phaco. A useful maneuver to im- prove the use of the non-dominant hand with the dominant hand is bi- manual irrigation and aspiration to remove viscoelastic. The IOL optic protects the posterior capsule. The resident is instructed to keep the ir- rigation and aspiration instruments on the surface of the IOL optic. The advanced beginner needs 25 procedures to feel comfortable using both hands and one foot pedal so that learning chopping can begin. Evan L. Waxman, M.D. Fully formed surgeons take use of their non-dominant hand for granted. We use our second instru- ments to help hold back and protect the posterior capsule, to manipulate nuclear pieces into the phaco tip, and to rotate, crack, and chop. We use the shaft of the second instru- ment to assist with eye position. We take for granted that our second in- strument will not wander off and become an implement of destruc- tion, wreaking havoc on the iris, an- terior capsular rim, zonules, or posterior capsule. Linda M. Tsai, M.D. Associate professor of ophthalmology and visual sciences Washington University, St. Louis Kenneth L. Cohen, M.D. Professor of ophthalmology University of North Carolina at Chapel Hill Evan L. Waxman, M.D. Assistant professor of ophthalmology University of Pittsburgh School of Medicine Cataract tips from the teachers 89-93 Resident_EW October 2011-DL32_Layout 1 9/29/11 4:35 PM Page 89

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