Lecture: Optimizing Trainer Supervision and Trainee Learning in Cataract Phacoemulsification Surgery Part 2

DR GUPTA: Hello, everybody. It’s a real pleasure to be here again, to give a second Cybersight talk. Hopefully many of you will have looked and reviewed the first part of the presentation, of optimizing trainee and trainer supervision when learning cataract surgery. Hopefully you’ve had a chance to think about all of the things that I mentioned, and what I’d like to do is take that a little bit further, to provide you with a little bit more information, to try and make phaco surgery more enjoyable. So some of the images and videos are taken from my book. I’d like to firstly go over a little recap of what I mentioned in the first talk. And then talk about the realistic expectations of progression when you’re learning cataract surgery. I will provide additional examples of breaking down the key parts of the operation, so that you can learn it in a simple and easy fashion. And then talk about some of the pitfalls of what it’s like to be a trainer. And then finally, keep talking about feedback and how that can be used to promote lifelong learning. So the talk is for you. So do feel free to ask some questions, and I’ll try and answer them at the end. So some of the recap. We know that all of the trainees will progress from a beginning through advanced beginner to proficiency. And that beginner, remember, is somebody who’s nervous, lacks a little bit of confidence, and has little experience. They’re still learning to use both hands, their feet, and the instruments. And that advanced beginner is somebody who’s got a little bit more confidence. It could be somebody who’s done prior extracapsular cataract surgery, but is completely new to phaco. So they learn a little bit quicker, but they’re still anxious. And that advanced person may still find that they run into trouble. They can convert a routine operation into something that requires a little bit more technical skill, and that’s when they run into trouble. One of my trainees sent me a video. They started off. They were doing a list by themselves. And they made the corneal incision a little bit too limbal. And what happens? I’ll just go back a slide. Is that the conj starts to become chemosed. They didn’t correct it, or use a simple blade to make a small incision. The view became a little bit tricky. The water started pooling. But they still carried on. And that’s fine. They just converted it to a slightly trickier operation. By the end, you can see it’s fully chemosed. Here’s another example of where an operation can be completely out of your hands. Where the pupil starts off fairly big. But then as the operation progresses, the drops don’t seem to work. The pupil starts to come down, smaller and smaller and smaller, and more technical skills are needed to do that operation. And what happens is that as a trainee, your confidence starts to go down and down and down. So you stop making comfortable movements, and then it becomes harder and harder. And this is where, as a trainer, I had to keep going with the instruction and telling the person what they needed to do. So by the end, they can finish the operation, even though it took them a little bit of time. The expert is somebody who can make everything look fairly easy. The difference between proficiency and expert is that when you look at somebody operate, or you need to learn a new skill, you can work out what to do just by looking very easily. But when you’re still learning, when you’re an advanced beginner or a beginner, you really need somebody to explain those videos to you in detail. Remember how you learn. As you learn, it’s easy and your confidence is great. As you do a little bit more, it gets a bit harder and your confidence goes down, until you reach that point when everything makes sense, that inflection point, and you speed up to proficiency. As a trainer, we have to decide when our trainee does that. Remember, anything that causes stress in theater will reduce your training ability, and make everything much harder. And that could be the perception, what somebody tells you. This morning, when I was operating, I was told that a patient didn’t look well. But actually, they were absolutely fine. But it did make me a little bit nervous, even before I started. Ghost surgery, where there’s no instruction. Nothing is done to help that trainee operate and give them guidance, until afterwards. Misinterpretation. You need to know what to do. And you need to be able to recognize the clinical signs. So work out what things cause you stress in theater and try and avoid them. Let’s think about how we learn. Peyton’s four step. I’ve mentioned this before. The first step is demonstration. So you do something in realtime. And this is just a simple knot, courtesy of one of my colleagues, who — I went into his room and just said: I’m going to video you tying a knot. So you do that step in realtime. And then we’ll break it down into its component parts, and this will be the same for all the steps of cataract surgery. So I’m going to ask you a question. Whilst tying the knot, the suture holder was held in the surgeon’s right hand. This is a question about observation. What was held in the surgeon’s left hand? A, would you like the video to be shown again? Because you didn’t notice? B, nothing was in the surgeon’s left hand? C, there was a palmed pair of Vanna scissors, or a palmed suture tying forceps. Or there was something there, but you’re not sure what? Show the video again. The question is: Did you notice? I can see that many people have said 33% of you said the palm suture tying forceps, and that is correct. But some of you didn’t notice. And this is visual inattention. Where you don’t really notice something until somebody points it out. We’ll just advance the slide in a moment. And it’s important that you realize that when you’re learning something, you may just not notice what is going on. It’s too fast. Or there’s another distraction. We will just advance the video. So I think it’s just locked for a moment. And as we’re just waiting for the timer to go down, it will advance in a moment. >> You might have to click on your slides with your pointer, just after the poll.

DR GUPTA: Okay. Thank you. The next component of learning is to deconstruct it. So another question for you: How many steps can you see in just a simple tying of a knot? Is it two steps, three, four, or more than five? How many learning points are there? So let’s everybody vote. How many steps would you break this down into its key components? And I’ll just show that video again. So when you’re doing cataract surgery, imagine a more complex task of removing the fragments. Or doing a capsulorrhexis. How would you break it down into those key components? So most of you have said what 34% of you have said — three components. 31% of you said 4. And 28% of you said more than five steps. Absolutely. I think there’s more than five steps. And I’m going to show that to you. Oops. Let’s go back. So, in slow motion, I’ll let the video run. And you’ll see that firstly the instrument is palmed in the surgeon’s left hand. That’s step one. Go back to the first talk, if you need to learn how to do that. There are three throws in a forward direction. Notice that the left hand uses a finger to apply tension to the suture. So that the knot is placed perpendicular to the wound. Then a single reverse throw. And then the knot is pulled tight, and again, the left hand uses a finger to hold that suture and apply pressure. And when you’re learning to do this, you may not do that. But as an expert, you’ll do these movements without even realizing it. So again, that final throw in that left hand uses that finger to apply tension, so that it’s easy to lock that suture completely. So when you’re teaching somebody, remember: They can’t do it as well as you can, if you’re the expert. So you have to break it down into those bits. And then you need to check the comprehension of that trainee, when they say to you: This is how you did it. And then you watch them perform it. With feedback, I think this is one of the most difficult bits. Remember: What did the person do well? What could you do better? What do you think you should do next time? And this is what I suggest. And at the end of every theater session, just say: What five things did you learn today? And see what they say. So here’s an example of one of my colleagues. He was doing independent lists, but still struggling. He admits that his operations are taking longer than he would like, and occasionally got into issues. So I want you to watch the video. And he asked me, he said: Please don’t take over any of my surgery. Just give me some feedback at the end of the list on what I could do. So whilst you’re watching the video, ask yourself: How does it make you feel? Are you happy? Are you worried? Are there bits of it that you like? Are there bits of it that you don’t like? And every surgeon will be slightly different. And remember, when the feedback is given, you are assessing a simple task. And the task that we’re assessing here is just simply the removal of viscoelastic. Nothing else. We’re assessing viscoelastic removal. What is the good point? Well, did they achieve that task? Well, yes. They’ve removed all of the viscoelastic that you could see. But if I’m giving feedback, what did I write on my piece of paper to provide feedback later on? What would you say? What would you write down as feedback? So this is the third case on that same list. So I was worried about the excessive movements inside the eye and the fact that the irrigation aspiration port is facing downwards. And as a result, I was worried that tissue would be caught. You can see at the top of the screen the iris was caught and the patient flinched, because they were in pain. So just by watching, you can provide feedback to say… Look, I liked the way you removed the viscoelastic, because you achieved it. What I would do that I think is better is probably have the port facing upwards. And do less excessive movements. And that way, the trainee will gain confidence and a slightly better technique. It takes a while to become a trainer. While you’re being taught, just spare a thought that the trainer is still learning. And the assumption is that the trainee thinks you know how to teach. But you may be a proficient surgeon, having learned how to do phaco, but you may not be a proficient trainer or an expert trainer. And you are still gaining skills all of the time, to become very, very good. And the assumption from the trainer is that the trainee knows some basics. And it’s important to check with every new trainee that they have certain things. Like the microscope. They can use it. They know how to use the foot pedal. They know the sounds of the machine. And they know what to do with their hands. If you listen to this video, it is a simple way of checking whether a trainee understands the microscope. I’ll play that again. You can hear that the microscope is making a squeaking noise. And that is the microscope screaming in pain, telling you that they don’t know how to use it. If we go to the next one… And I play this… There is no noise as the microscope is moved. And that is because the handles are rotated to unlock the microscope, so it moves smoothly. So that there are no breaks. So I use simple little things to tell me what the trainee can do. Do they know about the light aperture? The pupillary distances? How to maintain sterility? Do they check to make sure that the lens of the microscope is clean? If they’re not doing those little things, make sure that they can do it. Because it tells you a lot about how they’ve been trained and where they are with their progression and confidence. We are all different sizes. I’m quite small. And I sometimes have to train people who are very tall. And as a trainer, we need to think about different people, and how we can make things easy for them. In the operation above, I’m operating, but the patient is severely kyphosed. They’re bent. And as a result, I can’t use the microscope in a normal fashion. So what I’ve done here is I’ve raised the bed, kept the patient comfortable, tilted the microscope, and I’ve also put my phaco pedal on top of a platform. That way, I convert it from a technically demanding case to a straightforward, routine case. It does mean that I’m balanced on one foot. And I can’t use the microscope to adjust. But think about it. When you’re teaching somebody. If they are very small, or they are very tall, don’t hurt their neck and back. Just use a foot pedal, and it will make it easier. It’s also important to look at their hand. If you have very small hands — I’ve seen people where they try to do hydrodissection using one hand. And they’re handed a syringe that is fully full. And they just can’t squeeze the syringe properly, because they’re at the limit of their hand size. And it hurts the base of their thumb. Imagine doing this for 20 years. You will get pain in your hands. It is much better to expel and get rid of some of that fluid before you use it, if you’re doing it as a one-handed technique. So either get rid of it yourself, or ask your scrub nurse not to overfill the syringe. It’s even better if you can switch to a two handed technique, where if you’re right hand dominant, you hold the syringe with your right hand and you use your left hand to push the plunger down. That way, you can direct the nozzle or the cannula wherever you want inside the eye. Whether you’re doing hydrodissection or you’re doing stromal hydration of the cornea. It’s a small thing, but it can make a big difference to the way that you operate. Here’s another little question. Notice that the globe position during the surgery is kept in the center of the eye. So the question is: How does this trainee, who operated just a couple of weeks ago with me, keep the eye in that position, so that all of the SLM can be removed fairly easily? Do they… Is it not a trainee operating, but me? And I’m fooling you? Are they using forceps to grip the eye and hold it in position, and that’s off the screen? Is it just that it’s a very good trainee, and they are very good and have good microscope control? Or is it that I’ve told them to relax and drop their shoulders? Or are they applying pressure to the posterior lip of the wound? So that the eye doesn’t roll downwards? So let’s see how you guys answer. And then I’ll show you what we can do to try and keep that red reflex. So… About 20% of you have said drop your shoulders. Which is an important factor. When you’re stressed, you raise your shoulders up and get tense. 28% of you said it’s a good patient. Well, I tend to get any patient for the trainees. I don’t worry too much about what they have to operate on. Because that is what they are going to get. And 31% of you said apply pressure to the posterior lip of the incision. And I must admit, that is what I do. So let’s have a look at that. Often when you watch videos of cataract surgery, you look at the eye, but you never look at the surgeon’s hands. You’re not sure what they’re doing with their hands. And it takes many years of practice to try and get to a point where you’re comfortable with your hands. But we need to shorten that down to the first few months of training. So often instruments are held with the left hand higher up the instrument than it needs to be. And as a result, the eye rotates downwards. It is much better to place your non-dominant hand or your left hand further down the instrument, and then you can push the instrument backwards, pushing against the lip of the wound. And then the eye rotates back. So you can see in that position applied pressure is quite easy. And then you can easily rotate your right hand to get the cannula or your IA or whatever you want into a better position. So in this operation here, I’ve just zoomed out. So the eye is out of focus. Because I wanted to show that left finger just applying pressure. When I don’t, you can see that the eye starts to rotate. By applying pressure, the eye comes back, and you can see that subincisional area a little bit easier when you’re removing the soft lens material. And it really does make it a little bit easier to keep that red reflex and the eye steady. Here we go again. Pull the eye back towards you. So that’s something to watch out for. And if you have a trainee that is one-handed, where they only operate holding the instrument in their right hand, try and correct that as early as possible. I get a lot of questions about what to do as a trainer. And what are the main problems I have. The main problem for me is assumptions. The ABC of being a trainer is: Assumptions leads to problems. And mainly I see problems occurring when I’m not watching. So this is the art of not watching or not training, or pseudotraining. In the case I showed before, of the pictures where the pupil became miosed, the trainee finished, and they were about to put the lens in, and I walked away from the microscope, thinking: They’re a senior. They should be able to put the lens inside the eye. When I turned back and looked down the microscope, this is what happened. They tried to put the lens in. And they released the plunger, and the iris prolapsed. So all the way during the operation, the wound had been secure, and then right at the last minute, when I wasn’t watching, it happened. So one of my top tips for being a trainer is: Keep watching. If you are the supervising person, keep watching, so you can give little handy hints all of the time. The video I’m going to show you now was taken several years ago, when I was at a stage of really figuring out how to become a proficient or an expert trainer. So many of the things that you do when you’re learning you may not do in two or three years’ time. And that’s absolutely fine. Don’t be hard on yourself. Everyone has to learn. And this video is a good example of that. So the ABC of dealing with vitreous… A trainee came to me and said: I’ve got no issues. I’m doing whole cases. And my trainer didn’t even have to scrub with me. So the first assumption I have is: They’re doing okay. It should be easy to train this person. So I watched them. I talked them through removing the cataract. And everything was going well. At the SLM removal stage, I walked away and left them to it. And then… They put the lens in, and I turned to look at them on the monitor… And I’m thinking… Okay. Everything is going well. And suddenly I go… Stop! The lens is suddenly tilted. I take over and I put some triamcinolone inside the eye. And you can see that the anterior chamber is full of vitreous. Let’s go back in time. Let’s see what the trainee is doing. So they’re injecting viscoelastic. And if you look carefully, there’s almost like a double ring on that right hand side. As the posterior capsule is lifted up and rolled over. So the trainee doesn’t recognize that clinical sign. The second thing is: That lots and lots of viscoelastic, possibly vitreous, is pouring out of the wound. And I call this: Viscoelastic bleeding. And the trainee doesn’t recognize that there’s positive pressure behind the eye, because the posterior capsule is ruptured. What they do instead is think: Oh, I need more viscoelastic. So they get a new vial and keep injecting it inside the eye. And a little bit goes in. But a lot more comes out. And the trainee’s solution to this is simply wipe it away and ignore it. Because they don’t recognize the clinical sign of a problem. Let’s go back even further. To the SLM removal. So I thought that the trainee was going to be okay, because they had previously done whole cases. I had watched them doing the phaco. But here you can see they’re removing SLM. But they caught the vitreous. And they’re pulling and pulling. And they’re actually rupturing it all the way through. So what did I learn? I learned that I needed to watch more often. And I now don’t leave a trainee until I’m absolutely sure that they are up to what I would call an advanced beginner stage. Where they can do all of the components fairly well. And I’ve demonstrated lots of clinical signs. So the next part of dealing with vitreous as a trainer is: Before you deal with that current problem, remember to protect the current vision and the remaining patients on the list. And you can learn lots and lots of supervising errors. So remember feedback. What was done well? We need to protect the future vision. And that protection is: I need to secure that lens. I don’t want it to drop all the way into the back of the eye. So I’ve widened the wound. Grabbed the haptic. And I’ve pulled it out. Now the lens isn’t going to drop. And I’ve previously put in some viscoelastic. Above and below. And I’ll put some more in. So what was done well? Well, secured the IOL and protect the endothelium. Great. What would I have done better next time? Well, look at the vitreous near the wound. Should I have cut it with a pair of scissors? Should I have cut it with the vitrectomy? That’s a decision. That’s a judgment call that you’ll have to make when you’re in that position. So the C now is confusion. When it happens to you and you’re learning, you’re going to go: What on earth do I do? If it’s the last person on the list, you can just keep going. Take your time. If it’s the first patient on the list, you have multiple patients still to operate, do you cut the lens out? Do you cut the vitreous? Or do you call for help? If you’re not sure, then call for help, where somebody can direct you. Because sometimes when you’re stressed you don’t think about what you’re doing properly. So if you’re unsure, just seek advice. It’s okay to do that. So let’s have a little look at cutting out the lens. Because that was the decision that was made. I’m not using a lens cutter. All I have on my tray is a pair of Vanna forceps. Many of you may not have fancy equipment, and that’s absolutely fine. So the idea of cutting a lens is that you want to cut it in half, completely. Ideally with a haptic on both sides. So what’s the feedback here? Did the aim of cutting the lens in half be achieved? Well, no. What would be said next time? Listen, it would be: Try and cut the lens in half. If you can’t do that, rotate the lens and cut it into quarters, so that you can remove those pieces a little bit easier. Remember the feedback. It’s important for your confidence and what you do. The next part is: Remember, don’t be too angry with yourself. As you’re doing this, you’ll be glaring at your trainee, thinking: You’ve burst the capsule. You’re giving me extra work to do. Remember, as trainers, we are the experts. We are the person that enjoys surgery. And here you can see: I’ve put the lens in. But what’s the problem with it? What’s the feedback? It’s got an S shape, which stands for: Stop. Your lens is upside down. So the trainee hasn’t done that. I’ve done it. And that’s because at that stage, several years ago, I wasn’t used to dealing with vitreous. I had a very, very low complication rate. And I tended to only see one or two, every year, year and a half. So now what do we do? We need to flip that lens over. And again, that’s a learning curve. The newest sulcus IOLs are injectable. Make sure you know how to use them. And if need be, before you use it, ask for a little instruction sheet. There may be one with that lens. So here you can see that I’m trying to rotate that lens. But unfortunately, the leading haptic stops it. So the way to do it is to gently hold the trailing haptic and allow a little bit more rotation, and then that lens goes in. So the new sulcus lens is inside the eye. And then you just need to position it. And I’ve already done the vitrectomy. Remember, the anterior capsule is still there. So there is support. The lens isn’t going to fall through, unless you put it into the capsule. And into the bag. So you just then gently lift it up. And do think about what you’re going to do when a complication occurs. Try and practice things when you don’t need it. So if you’ve got a routine case, after you’ve performed IA, try and fill the eye with a little bit of viscoelastic, using your non-dominant hand. Just to give you a little bit of practice of doing something one-handed. So remove the viscoelastic. Put in a suture. A week later, the vision is 6/9, and everything is good. So remember, when you’re learning things as a trainer, you will have to learn new techniques and deal with the complications. Let’s talk about rhexis. Lots of people ask me questions about this. And they say: Well, how do you do it? And my assumption is that a trainee will be stressed. They’ll be worried about takeover. And they always tell you that CCC is tricky. Well, the first thing is: Avoid that perception. Don’t tell them that capsulorrhexis is tricky. My expectations are: Often trainees make a rhexis too small. Takeover usually isn’t needed. But instruction is the key. And technique is important. Usually the first attempt of any trainee is always successful. And it’s when they get to about case number 10 that suddenly they find that they run into issues. Because their confidence is starting to go down again, as they try to do new things. The first capsulorrhexis usually takes about four minutes. Then after that, trainees tend to do it in less than two minutes. So let’s look at a case of a trainee performing their very first capsulorrhexis. The total operation time is about 25 minutes. And after they’ve done the capsulorrhexis, I will then go on to perform the lens removal. The trainee then takes over to do the SLM removal and put the lens in. So you can see here: The video may be a little bit blurred for you. But I just want to show you the principles. The trainee is making hardly any movements, and they’re very slow. So I’m gonna speed up the video. So at what point do you get nervous? As a trainer? Two minutes have gone by. And they’ve just about made an incision. At 3 minutes, they still haven’t turned the flap over. Four minutes, they’re still trying to push the flap over. Five minutes, they push the flap over. A little bit more viscoelastic. The rhexis is still well within the pupil. All is good. It’s just taking time. Seven minutes go by. So at this point, ask yourself what’s going to happen to the trainer’s confidence in this trainee. And what’s happening to the trainee’s confidence. At nine minutes, all of a sudden, right at the end, the rhexis goes off. And I have to take over. So I then have to recover that rhexis. And… Oh, I’ve skipped that bit of the video. I do apologize. And I take out the lens, put the lens in, and everything is fine. So the question is: What could I have done better as a trainer? That trainee didn’t meet my expectations, because usually a first attempt takes less than 4 minutes, and they took nearly 9 minutes. Should I have taken over sooner? Should I not have allowed that trainee to perform the rhexis, as really they’re not ready? Should I have used VisionBlue to stain the capsule to make training easier? Or should I have double checked their comprehension of the deconstructed technique before starting? So you’ll have lots of thoughts on this, on what should have happened. Let’s see what you all think. So 9% of you said I should have taken over much sooner. Most of you, 50%, said VisionBlue. To stain the capsule. I think this is a good idea. But VisionBlue can sometimes make the endothelium a little bit hazy. You’ll end up using it a lot, which can be expensive, if the person has to pay for their treatments. And lastly, double check the comprehension. And this is the key. Remember how we learn. Demonstrate, deconstruct, check comprehension. I didn’t check the comprehension of the trainee. And as a result, I assumed that they would know what they needed to do. So remember that suture knot. It was in more than five handy tips. How many steps are there to a capsulorrhexis? Well, let’s think about that. Step one. Focusing the microscope. Step two. Navigating the wound in a side to side fashion. I use a straight orange needle. Step three. The location of where you’re gonna make your initial stab. To the left of center and toward you. You then have to stab and slide across, using the cutting edge of the needle tip. When you get to the end, you come back along your cut edge, so that you can see where the tearing point is. And if the tip is too far underneath the capsule, you come back a little bit, and then you tent up and lift up the capsule. Tent it up. There’s the clinical sign. You can see it against the red reflex. And then you push to create the flap. Once the flap is created, you then turn your hand and come out. So here we have just some simple steps of the beginning of the operation. Next step is going past the cardinal points. This is where you want to make sure that the trainee knows where the cardinal points are of the eye. And you want them to go horizontally. So that the rhexis flap is then taken beyond that region. Let’s try and do this. The forceps go in. You may not be able to see as the trainer down the microscope. But you can see the red reflex. You can see the fold and the tearing point is at the end of that red reflex. Once they get past that cardinal, you change direction, and you pull straight back towards you, to get to the next cardinal point. Which is 3:00. If you need to make the rhexis bigger, you just go more horizontally past the cardinal. Or if it’s 3 and 9, more vertically. Once you get past 3:00, you then want to grab, and instead of a pulling technique, you want to change it to a push. So let’s show that. So from there, let’s show that again. You just pull it past the 3:00. Past that cardinal. And stop. Regrasp. And you change it from a pull to a push. So look at the forceps now. They’ll go from pointing to the left to pointing to the right. And then it’s just a push underneath the wound. Past that 12:00. And every now and then, you’ll see it cleanly, because of that red reflex. And then you just complete by going in a circle. So when we break down that rhexis technique, there are more than 20 steps to it. But you don’t realize that as a trainee, and as a trainer, you may do it so quickly, you may use a cystotome, you may go anticlockwise, clockwise, stop subincisionally, that is fine. Just work out what the steps are. So here we have a trainee who is having difficulty with rhexis. They’re taking a bit of time and they’re quite nervous. And as a result, their confidence keeps going down and down and down. They created the flap. And you can see the fold. And by grabbing that there, they’re going to take it past that 6:00, and you can see the red reflex. A little bit of distortion of the cornea. Which is always what happens when you’re learning. They pull it down in a straight line. Past that, 3:00, and now they run into trouble. So they are trying to grab the rhexis. And they’re just having difficulty. So the question is: A, do they need more viscoelastic? Are they having trouble because they’re causing too much corneal distortion? Is it C? They failed to close the forceps properly? Or is it D, they didn’t follow the instructions and they pulled the flap too far past the cardinal point? Let’s see if there’s a polling question for that. So the trainees come out of the eye, and I’m just giving them a little bit of instruction and confidence. Saying: Look, you’ve got no choice. You need to go back in. Grab the flap. And change it from a pull to a push. Just pinch and do the technique. So pinch, pinch, and change from a push to a pull. And see what you have. There we go. Technique works. Notice that they keep the flap very long here. I would have let go and restarted. So absolutely, 44% of you have said: They pulled the flap far too past that cardinal point. He’s converted it from easy to technically challenging. Because he couldn’t grab that flap in the subincisional. Normally for shallow anterior chambers, after the flap is created, I fill it with viscoelastic. For white cataracts, after you’ve created the flap, fill it with viscoelastic. Don’t wait ’til the subincisional, because it’s too late. Do it much earlier. Sometimes as a trainer, you’ll need to enlarge the capsulorrhexis. And trainees often make them much smaller than you think. And that’s fine. You can leave it if you want to. But there is a small risk of phimosis. So this is the capsular size that you can see against the red reflex. How do you make it bigger? Well… This is something to teach your trainees. So with a pair of Vanna forceps, you’re going to go into the eye, having filled it with viscoelastic. When you’ve put the lens in. So there should be viscoelastic there. And you simply just snip the capsule. Remember not to pull the Vannas closed, because you might have grabbed the capsule, and then you end up tearing it. Do release the Vannas after you’ve made the cut. And then you grab the edge of the capsule and create a flap. And then you just tear it in a normal way. But this is anticlockwise. To make that capsulorrhexis bigger. So if we’re thinking about feedback, what was done well? Well, the aim of the task was to make the capsulorrhexis bigger. And that was achieved. What could have been done better? Well, there’s a lot of distortion inside the eye with the corneal wound. So they need a little bit more practice with that. But the easiest way to make it better is: Instead of one cut with the Vannas, make two. That way, the rhexis enlargement will start from cut one and simply join cut two very, very quickly and easily, without having to pronate your wrist to complete that movement. And then that makes it very easy to do. Simple little tricks that you may not think about. One of the things for me is talking about phaco. And previously, I’ve spoken about: Make a space. How to groove. And use a widening, so that you get this kind of red reflex to see how deep. How deep do you go? Well, that’s up to your trainer to tell you to keep grooving. How to crack by doing a minor rotation. And using the long edge of the phaco. But one thing that’s important is to try and break the fragments onto little pieces. And I call this debulking. So that fragment has been pulled, and then the second instrument is used to break that fragment into a smaller piece, to make it easier to emulsify. And notice that the phaco isn’t really chasing the fragments. The piece is grabbed. The second instrument goes behind. Draws through the fragments. And then emulsifies away, and then that fragment that’s trapped by the second instrument is released, so that the phaco can continue to eat that fragment. I’ll let this video run, just so that you can see how this case was managed. And the trick to remember is to teach your trainees in steps. If you’re teaching them phaco from the outset, I would suggest as a trainer you split the lens into lots of pieces, and then gradually build them up, all the way up to heminuclei, and then grooving and cracking. So again, as a trainee, you’ll be watching these things. And cataract surgery is mesmerizing. You can watch multiple cases again and again. And look at it, and not really look at what you’re watching. So let’s break down that debulking technique. And the instruction of your trainer is: Simply debulk. So engage the fragment first. Then pull it into the anterior chamber, using those make a space techniques that I’ve mentioned previously. The second instrument is: Position behind the base of that fragment. The second instrument is then drawn through that fragment. To the left hand side. And you don’t want to take it to the phaco tip. Because the phaco tip is holding onto the fragment. So if you touch the phaco tip, you’ll knock the whole fragment off. And then you’ll have to start again. The left hand then pulls and separates. Almost like a cracking motion. You continue to emulsify that fragment on the right hand side. And then as it starts to disappear, you need to start thinking about releasing the fragment on your left hand side. You can see that the instrument is being pushed away, and the trainer simply says: Release. So there we go. Release. And now the trapped fragment will be aspirated towards the phaco tip, in preference to the capsular bag. And then you just repeat the process again and again and again. So, in summary, it does take time to gain the skills to become a trainer. Assess your trainees and see where they are. Are they still a beginner? Are they an advanced beginner? Don’t make assumptions. Keep watching them. And avoid that ghost surgery. Keep instructing during the operation. And give them lots and lots of tips. Watch their hands and how they’re using them to make life easier. Think about complications and how you can preserve that person’s sight. If it happens. And remember: When you’re a trainer, learning how to teach, it will take time. My complication rate is less than 1%. My trainees’ complication rate is 1.1%. It doesn’t happen very often. So you may find that actually you’re a little bit nervous when a complication does occur. Remember that four-step approach to your own technique. Whatever it is. That’s absolutely fine. But just break it down into the components. And remember to have a little bit of fun when you’re teaching, and change the way that teaching is perceived. I’m going to answer some questions. I’ll just put those questions up. Here we go. So I have some questions here. What are the indications for phacoemulsification? And this is a question… I suppose if you are in a situation where you are happy to emulsify, then I think cataract surgery — phacoemulsification — is absolutely fine. And what you have to realize is that some cataracts are going to be super dense. And you need to make sure that you have the settings of your machine set up correctly to deal with a dense setting. And you may need certain techniques like chop, in order to deal with that lens. If you feel that that cataract isn’t suitable for phacoemulsification, and you feel that the outcome would be better with an extracap, or small incision, whatever, then that’s what you would do. What is the best way to teach trainees about postocclusion surge and how to avoid a PC break? One of the things that I do when I’m teaching is that I make sure that I have constant irrigation on the instruments on the phaco probe. And the irrigation/aspiration. Often the postocclusion is because trainees will chase fragments, and they’re not allowing space inside the capsular bag for the fragments to come to the phaco tip. Secondly, they will have the phaco tip too far inside the eye. And as a result, the fragments again can’t come. So they end up using a lot of aspiration or phaco energy, and that ends up with complications. Remember, if you have a fragment that is here, it has to come up and to the phaco tip. So if the fragment is being trapped by other fragments, it can’t oscillate inside the eye. So it’s important that you think about that when you’re trying to get the fragments out. Do you prefer a trainee is advanced in manual technique before moving on to phaco? I must admit, I don’t do any extracap. I don’t expect the trainee to have done anything before they come to me. In preference, I prefer a trainee that has never done anything at all, because they have no assumptions. They don’t perceive that cataract surgery is difficult. They don’t perceive that a capsulorrhexis is difficult. They don’t perceive any of those things. So I can mold them into learning how to operate under instruction, because I take them through it step by step by step. Do you dilute VisionBlue? I must admit, I just asked the VisionBlue and I’m given it by the scrub team. I don’t think I dilute it at all. Some people put an air bubble into the anterior chamber to protect the endothelium. I must admit, if an air bubble goes in, I’m happy with that. I tend to leave the VisionBlue in for at least 40 seconds. One of the pitfalls of using VisionBlue is that you put it into the eye and then you wash it out straight away. And it hasn’t done its job in staining the capsule. Did you watch trainee or trainer to watch surgical videos? Absolutely. So what I did during COVID — a lot of the operations have been canceled. So what I’ve done is I’ve taken trainees with me, and I’ve said: Okay. We’re going to have an hour, where we’re going to sit down and look at some videos. And we go through, and they have to give me feedback on that video. I then use their video to teach somebody else. And we keep doing that. And then I show them some videos of my own surgery to say: Look, this is a different technique. This is possibly how you can get out of the surgery techniques that you’re doing, that aren’t quite working. There’s a question here about how to train your non-dominant hand at home. This is a great question. When I was training to do surgery, about 15 years ago, we used to use tomatoes to do capsulorrhexis. We used to use pieces of plastic to do operating. I was told to brush my teeth with my left hand. I’m not sure you need to do that. What you need is: Somebody to tell you to do things with your left hand when you’re inside the eye. Because trainees are so nervous, they don’t tend to make excessive movements too quickly. So the idea is that you say, if you want to rotate the lens, you will ask them to rotate it clockwise or anticlockwise. You will get them to debulk. Because that will get them used to using their second hand. The non-dominant hand. You will ask them to use their non-dominant hand to support their right hand. So you’ll use little tricks like that, to get them used to doing it. And then you’ll move from a divide and conquer to a heminucleus. Debulking, and then perhaps a chop technique, if that’s what you do. There is a question. Can you tell us more about make a space? It’s a great question. I have covered that in my first talk. I would suggest that you just review that video and look at the slides on that. Make a space is a method that you try and create space inside the eye. If you have two pieces of a broken cataract, that you’ve broken into pieces, they can jigsaw together. So as a result, as you’re rotating them in the eye, they don’t unlock. You have to make the space to make them unlock. And there’s different methods of getting the lens out of the bag. For instance, the first fragment that you remove you want to take the smallest fragment. And often trainees will break the cataract up into pieces. But they don’t look for the smallest fragment. So rotate the lens until you see the smallest fragment, and take that one out. Make a space. How do you advise trainees to be confident and not overconfident? And at the same time, not be scared to proceed? I think this is really important. And that is: All surgeons are gonna be nervous. Their hands are gonna have a tremor. They’re not going to blink. Their shoulders are going to be raised. So the first thing to do is make sure that you are not learning something new inside the eye without knowing what you’re doing. So the trainee, when they were doing the capsulorrhexis, was extremely nervous, because I hadn’t checked their comprehension. They didn’t know what they were doing. And as a result of that, it took a while. After that case, I sat them down. We went through the drawings. Went through the steps. They repeated it back to me. And then they did the next case. And I’ve got a video of that, if we have time. And they took just under four minutes to do the next capsulorrhexis, absolutely easily. And the next one after that, three minutes. And by week two, they were doing a capsulorrhexis in under two minutes. So you need to give them confidence by giving them positive feedback. I didn’t say to them: That rhexis was terrible. What you did there was awful. You could have blinded the person. You made my life difficult. Because that doesn’t help with your confidence. What you have to say is: Look, you did really well, you took your time. It did take nine minutes. But that’s absolutely fine. I didn’t feel nervous. You got all the way round, and it was only at the last moment that the rhexis went off. And really, that wasn’t your fault. It was mine as a trainer, because perhaps I should have taken over at that stage, because concentrating for nine minutes is a long time. So you can do these things to make the trainees’ confidence better. And during the surgery, when you’re talking, keep saying: That’s great. That’s brilliant. That’s lovely. That’s a beautiful capsulorrhexis. It may be a little bit small. It may be a little bit big. But give them that confidence. There’s a question here. If the trainee doesn’t have any manual surgery background, how do you teach them? And convert, when complication happens? So again, take them through the steps. Work out how you’re going to teach them. I teach them backwards. So I teach them how to remove viscoelastic above the lens. And to do the movements above the lens with the IA. I then teach them how to put the lens in. Then capsulorrhexis, hydro, small fragment removal. Big fragment removal. Grooving and cracking. And then corneal incision. When a complication occurs, the idea is to avoid the complication in the first place. So again, give them lots and lots of instruction and get them to practice movements. Or no movements. When a complication goes, you want their hands to be still. So practice holding your instruments inside the eye for 20 seconds, without moving. Or practice inserting viscoelastic through the side port with your right hand still as you can be. So imagine that you’ve burst the capsule, and you need to push the vitreous and the remnants back with viscoelastic. Because if you do it for real, your hands are gonna be shaking, and you won’t be able to find the side port. Question here. Is peristaltic good for trainees? Now, this is a difficult question for me. It’s a bit like driving a car. I can drive a car. But I couldn’t tell you what’s underneath the engine. So all I do is: I use my setting. And the trainee uses my setting. And I have two settings. One for normal cataracts and one for very dense cataracts. So I would suggest that you work out your settings on the machine. And if it works for you, then you need to let it work for the trainee. Because people talk about peristaltic and Venturi. But it just depends on your machine. If you have a peristaltic, that is the machine you have to learn on. If you have Venturi, that’s the machine you have to learn on. So it just depends on what you have. I wouldn’t necessarily change unless you have funding and money to do that. But it can be very expensive. So here in the UK, I know that we have instruments and things like that. But when you’re working abroad, I’m very aware that you may not have fancy equipment. And that’s why I tend to show videos with little handy hints on how you can do things. I tend to use four or five instruments. Literally a 30 degree blade, a keratome, a straight orange needle, because it’s very cheap and easy to use. If you’re using the orange needle, remember, when it’s on the syringe, just bend it with your fingers, so that it’s at a slight angle. That way it’s easier to navigate the wound. If you have to hold onto the wound, please do so. We’ve got a couple of minutes. I think what I’m going to do is play just a spare video. Let me show you that rhexis from the next person. So I’ve speeded up the video again. This is that second rhexis from the trainee that took nine minutes.

>> You just need to share your screen.

DR GUPTA: I’m sorry. Let me just do that for you. Share screen. There we go. So you notice that the trainee is having difficulty navigating the wound here. And that’s a common thing that happens. So make it easier for the trainee. They’re nervous. I just hold it with a pair of forceps. So you can get the instrument in. So remember the movement. Stab to the left. Slide. Come back. Tent. Push the flap. Turn. Flap created. They come out. You change the forceps. They now know what they’re supposed to do. Because I’ve checked their comprehension. And if my memory serves me, this was a 90-year-old patient. Because that was the only one on the list that I had left, and I wanted them to learn it. They’re taking it a little bit past that 3:00, but now changed to a push. Push push push. They grab it. Notice that the flap is easy to see against the red reflex. So you can convert them very quickly and learn tips very quickly. Let me just show you a different one. This is one for capsulorrhexis. And again the feedback is what do you do well? What could they do better? The person’s eye is moving. The eye has been stained with VisionBlue, because they had a lot of cortical. So what’s being done well here? Well, they’re holding the wound to make it easier to enter. They’re worried about the eye moving. So they hold the side port. That’s absolutely fine. Now, they’re going to do a stab, and they’re going to create the flap. So the good points here are that they’ve held the eye and navigated and entered the eye very nicely. Now, what could they do better? Look at the tension on the cornea. They’re pulling the eye so much, and secondly, the orange needle is right against the right hand side of the wound. So they can’t pivot. And it’s making it difficult for them. So next time I’m gonna get them to put that needle into the middle of the wound and pivot inside the eye. Just a small little thing. But each time, you can make it better and better. Here you can say: What is one of the tricks you can have if you have a poor view? I don’t like to grip the eye, because I don’t like to cause little bruises or distort the cornea. Instead, I’ll use my forceps to hold the speculum, to give me a little bit of room to enter the eye. And it gives my left hand something to do. If I need to let go with my left hand, I can, or I just keep it there. If I show you this video — I’m trying to use my fingers to move that drape. It doesn’t work. I’ll show you again. Use the forceps to get the view. I try not to ask the patient to keep looking down, because it’s a right pain. They look all the way down, then all the way back up. So use your left hand just to create that space. This is a silicone tip. We’ve recently had a few disposable instruments given to us to try. And it’s quite expensive. But it’s supposed to be a lot safer and decrease your risk of PC rupture. I must admit, I never teach with this. I always get them to use a metal tipped IA probe. Because — not that I want to make it harder. I just want them to learn the skill of how to use it properly. So that they don’t become complacent. And again, for the corneal incision, you can see in this photograph that I’m just moving the lid back, so I can make space to get the blade in. That’s the end of my slides there. If anyone else has a question, I can quickly answer it. There’s a question here: Do you prefer clockwise or anticlockwise? That’s a great question. I’m right-handed. So it is easier for me to go clockwise, moving to the right and going round in a circle. Because I have to move my wrist like this. If you go anticlockwise, you then have to pronate your wrist and you get to a certain point where it’s uncomfortable. And then what you have to do is move your elbow inwards. So you’re then in an awkward position. And what I tend to find is that right-handed surgeons who go that way often fall into trouble. And they then say: Oh, the subincisional is difficult. That’s why I’m having problems. Occasionally I will do it the other way, just for a little bit of fun or to show the trainee: Look, the rhexis has gone out. And you can’t rescue it. So you need to go the other way, in which case I might snip it with a pair of Vannas or the orange needle and then reverse. So I think after a while, when you go to a new trainer, they may have a clockwise direction or an anticlockwise, subincisional, they might use a cystotome, they might stab it with a keratome. What I would say is: Just learn their new technique, and then when you start operating by yourself, make up your mind which technique you like. So that your whole technique is a combination of lots of people’s. Thank you. I think that I’ve answered all of the questions. If anyone has any other questions, I would be more than happy to answer them. If you want any specific talks on bits of the phaco and how to teach it, I’m more than happy. Just let Cybersight know, and then I can try to put together a talk accordingly. Do have a little think about all of the little tricks that you can do to make teaching them phaco fun. It should be fun. We have the best job in the world. And saving somebody’s sight and making them see is a real skill. Thank you very much.