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EW NEWS & OPINION 12 Small adjustments in the use of the surgical microscope can play an outsized role in assessing chamber depth or rhexis construction during cataract surgery T he quality of a surgeon's view of the eye during cataract surgery can have a large impact on the quality of the procedure. Some key steps can improve the sharpness and consistency of the surgeon's view and help ensure the best outcomes. Roger F. Steinert, MD, professor and chair of ophthalmology, Univer- sity of California, Irvine, said young residents and fellows require adjust- ments to minimize accommodation on the scope at the beginning of the case, including adjustment of the oculars so that a video image is in focus. "If the young surgeon accom- modates, you dial in minus power to counteract the plus power of the surgeon's eyes," Dr. Steinert said. Sumit (Sam) Garg, MD, vice chair of clinical ophthalmology, and medical director, Gavin Herbert Eye Institute, University of California, Irvine, agreed that the starting point is for surgeons to ensure that their refractive error is dialed in. "If you have a tendency to over accommodate, you can dial in a little minus into the oculars (–1 to 1.5)," Dr. Garg said. "Also, make sure pupillary distance is appropriate and accurate." For younger surgeons, Dr. Garg suggested starting high and to "focus down" to avoid accommo- dating. For instance, Marjan Farid, MD, associate professor of ophthal- mology, University of California, Irvine, moves the microscope as high as possible while still maintain- ing focus—to ensure that she is not accommodating. Matthew S. Ward, MD, in pri- vate practice, Provo, Utah, likes to begin cases by zeroing the focus to ensure he is starting from a neutral position. He then adjusts the view by manually moving the scope into position until the view is as clear as possible while "looking through" the image to relax accommodation. "For young surgeons, I think taking time periodically to 'look through' the image can give you a sense for whether or not you are accommodating and how much," Dr. Ward said. "Just pretend you're 'zoning out' and you can force your ciliary muscle to relax." Obtaining the red reflex In order to maximize the patient's red reflex while creating a capsu- lorhexis, Dr. Farid tilts either the microscope or the patient's head as needed. She also minimizes the paraxial lights and increases the July 2014 by Rich Daly EyeWorld Contributing Writer Tweaks maximize cataract surgical views Among the benefits of using coaxial illumination for capsulorhexis is its ability to provide red reflex illumination only, as shown by the bright red reflex with dim surroundings. Pictured here is the ability of the illumination to highlight the pseudoexfoliation material on the anterior lens capsule. This image shows the appearance of the capsulorhexis with red reflex illumination only—while also providing clear visualization of the rhexis. This image shows the red reflex with use of surrounding illumination, which slightly washes out the details of the red reflex. When surrounding illumination only is used the red reflex is lost, which is why older microscopes that lack a red reflex illuminator complicate visualization of the capsulorhexis. Source (all): Sumit (Sam) Garg, MD E arly on, many components of microsurgery can be daunting, from controlling the foot pedals to the view itself. Ergonomics and positioning can make all the difference between surgi- cal ease and clumsiness. Elbows should be tucked in against the torso in order to mini- mize the use of the larger muscles groups, which also helps to prevent tremors. Main- tain your hands at approximately the same height level as your elbow placement. If you sit too high and your hands are positioned much lower than your elbow placement, this can inadvertently lead you to push down too much on the eye. The reverse situation, with your hands up higher than your elbows, can limit your range of motion and be awkward with instrument manipula- tion. This article contains other fine tips presented by Drs. Farid, Garg, Steinert, and Ward to help surgeons operate the microscope to its fullest potential. Elizabeth Yeu, MD, Cataract and refractive surgical fundamentals editor Cataract and refractive surgical fundamentals 12-29 News_EW July 2014-DL_Layout 1 6/30/14 8:38 AM Page 12

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