Eyeworld

EW CATARACT 32 July 2017 YES connect by Liz Hillman EyeWorld Staff Writer also make sure the scope is aligned with the eye as much as possible," he said. Dr. Wade provided similar advice. "If needed, I will decrease the oblique light to improve the red re- flex or decrease the aperture if light reflecting from outside of the cornea is bothersome," Dr. Wade said. Dr. Wade cited a study by Ci- onni et al. that evaluated the red re- flex and surgeon preference between nearly collimated beam illumination and focused beam illumination mi- croscope systems. 1 The research de- termined via a survey that surgeons found the red reflex was maintained over greater distances from the pu- pillary center and at a greater depth of focus with the nearly collimated illumination. "Most participating surgeons (≥64%) reported a preference for the microscope with nearly-collimated illumination with regard to red re- flex stability, depth of focus, visual- ization, surgical working distance, and perceived patient comfort," Cionni et al. wrote. "The larger red reflex of the nearly collimated microscope can be helpful in the case of patient movement," Dr. Wade said. "The "The concept is similar to starting a refraction in the '+' range to prevent a young patient from accommodating during the refrac- tion," Dr. Cionni explained. Sumit "Sam" Garg, MD, vice chair of clinical ophthalmology, and medical director, Gavin Herbert Eye Institute, University of California, Irvine, advised dialing in a little mi- nus (–0.75 to –1 D). Start high and focus down, he said. Dr. Garg also suggested looking across the room prior to starting a case. As for the microscope's actual position, Dr. Cionni said he finds tilting more comfortable and less likely to produce neck strain. "It also allows me to get my knees under the stretcher comfort- ably. The only limit to tilt is my arm length. I prefer to keep my arms bent instead of stretched out far," he said. Drs. Wade and Garg, in contrast, said they prefer leaving it perpendic- ular to the floor. Dr. Garg said this position can help prevent parallax, while Dr. Wade likes the red reflex this position provides. To maximize red reflex while making the capsulorhexis, Dr. Garg said he uses coaxial light and minimizes the surround light. "I One trick that Dr. Wade offered to avoid over accommodating is to have those in training zoom in all the way. Then, using the microscope handles, adjust the focus so the cornea is in focus. From there, zoom back out until the field of view is sufficient. "Any further fine focus with the microscope pedal should be minor," Dr. Wade said. "If they press on the fine focus for an extended period of time they are likely accommodating. This method helps them get the case started correctly." "Being young has many advan- tages, but accommodating during cataract surgery is not one of them," said Robert Cionni, MD, The Eye Institute of Utah, Salt Lake City. "After a day in the OR, headaches are certain if accommodating all day long. I have a routine that helps me minimize accommodation." This routine, Dr. Cionni said, in- cludes adjusting his PD starting with the oculars wider than his expect- ed PD. From there he brings them together slowly until he achieves binocularity. When adjusting the microscope's focus, he starts with the focus point above the eye and slowly focuses the scope down until the eye is just in focus. Minimizing accommodation, scope position, illumination type, maximizing red reflex, and more T hough not the sexiest of topics when it comes to pearls for perfecting cata- ract surgery, basic micro- scope settings are one of the most fundamental and foun- dational steps to set the stage for a clear operation. "I often work with residents who are new to using the operating microscope. They are often nervous and can easily over accommodate during the surgery," said Matthew Wade, MD, assistant professor, Gavin Herbert Eye Institute, Univer- sity of California, Irvine. Microscope settings for cataract surgery E ach surgeon has his or her own slightly different technique for cataract surgery, but underlying the success of every case is the ability to clearly and comfortably visualize the surgical tissue during manipulation. One is much more likely to encounter a complication when visualization is a struggle. Certainly there are instances when a clear view is out of the surgeon's control, such as a corneal opacity, but every surgeon should be well versed in optimizing microscope settings to obtain the best possible image for every case. Robert Cionni, MD, Sumit "Sam" Garg, MD, and Matthew Wade, MD, share their approaches to adjusting the operating microscope to minimize accommodation, maximize depth of field and red reflex, and improve overall ergonomics. These funda- mentals are paramount, as young surgeons without an understanding of these principals may be at higher risk for surgical complica- tions, ocular fatigue, and chronic back/neck pain. The discussion also covers some of the differences between nearly collimated beam illumination and focused beam illumination microscopes, which may be helpful to the surgeon in the market to buy a new scope. Zachary Zavodni, MD, YES connect co-editor

• Blank Page
• Blank Page (1)