Frank Celia, Lansdowne, Pa.

Nobel Prize winning physicist Niels Bohr once defined an expert as a person who has made all of the mistakes that can be made in a narrow field. While surgeons may not have made every possible mistake in the narrow field of clear corneal incisions, pioneers of the technique have learned a great deal from the past. In this article, they pass some of that hard-earned knowledge on to you. Whether you are considering adding clear cornea to your surgical skills, want to improve your management of these patients or are yourself an expert, you should find their experiences illuminating and helpful.

During one of his first clear cornea cases in 1992, Oregon surgeon Howard Fine, M.D., lost an intraocular lens (IOL) in the vitreous. He had just injected the lens and was cleaning out the viscoelastic in what looked to be a perfect case when the IOL blew through an unnoticed tear. To make matters worse, a television news crew was present, filming for a story on this new "bloodless" form of cataract surgery.

He remained calm. Dr. Fine told his assistant he thought the lens was "too small for the eye" and that it had to be removed. As he was performing the vitrectomy, the lens floated up into the anterior chamber and he grabbed the plate haptic lens and remove it from the eye. He then implanted a foldable three-piece IOL through the same incision and positioned it on top of the capsulorhexis. A potential disaster had been avoided, and the news crew never knew the difference.

Through later experiences, Dr. Fine learned that even if the lens had not floated into the anterior chamber, the case could have been salvaged, without sacrificing the benefits of a clear corneal incision. He could still have left the lens in the vitreous, performed a vitrectomy, and, as long as the capsulorhexis remained intact, injected a foldable, three-piece, appropriately powered IOL, and let it open in the anterior chamber. Then he could have dialed the haptics into the sulcus and prolapsed the optic through the capsulorhexis. In the two cases when he has lost lenses in the vitreous, Dr. Fine has given the patients the option of having them removed, and in both cases they declined. By leaving the lens in, they experienced only one minor side effect: When they got up in the morning they sometimes saw a rectangular shape moving upwards as the lens settled in the vitreous.

Dr. Fine says he will also inject a three-piece, foldable IOL using the above technique when he breaks the bag.

"Most people who break a capsule end up enlarging the incision and putting in the biggest lens they have," he says, "and I�m saying that�s not always necessary."

Sometimes the best audience is yourself. To avoid problems when starting on clear corneas, Dr. Alan B. Aker, M.D., of Boca Raton, Fla., suggests videotaping your surgeries. He found this to be an excellent tool for troubleshooting problems.

While watching the tapes, he observed long periods when nothing was happening to the eye. Too often, he was waiting for his staff to find the correct instrument. After working together to iron out these bugs, Dr. Aker and his staff significantly sped up their cases. They also created a safer environment for their patients, because the longer the eye is exposed, the longer it�s subject to infection and hemorrhage.

Dr. Aker also recommends dividing your staff into OR teams that always work together. This way, the staff will develop a routine and become accustomed to each others� habits.

R. Bruce Wallace III, M.D., Alexandria, La., another proponent of staff preparedness, suggests alerting your staff to the reality of the situation.

"You have to take a minute out and think of ways to remedy problems. Everyone has to pull together to get the best result," says Dr. Wallace.

During problem solving � after a broken posterior capsule, for example � Dr. Wallace recommends using a rehearsed protocol. Retrace your steps and review the chart for helpful information. Dr. Wallace also suggests having your staff keep a special kit available � a tip he learned from Dr. Skip Nichamin. It can be filled with instruments, blades, sutures and other equipment to get you through the challenge at hand.

Besides refining technique, avoiding infection is an ever-present goal on the minds of the best surgeons. James Gills, M.D., of Tarpon Springs, Fla., has always tried to protect his patients against endophthalmitis. He uses more antibiotics than the average surgeon and has had his O.R. installed with special ventilators and ultraviolet lights to minimize bacteria.

So he was very concerned when, after switching to clear corneal incisions 6 years ago, he noticed a significant spike in his endophthalmitis complications. His practice had gone from doing 17,000 cases without a single case of endophthalmitis, to having three in 1 year.

Knowing the bacteria that causes endophthalmitis originates on the patient�s conjunctiva, Dr. Gills and his surgeons checked to make sure their pressures were sound. Pressure and wound sealing were fine during surgery, but in about 10% of their cases, IOPs dropped significantly right after surgery, with many stabilizing by the next day.

"This made us totally change our way of doing things," Dr. Gills says.

Now his surgeons check pressures directly after every surgery. Anything less than 6 mm Hg is considered soft enough to allow bacteria to be sucked in. Their goal is to see 10 mm Hg and above. In cases of less than 6 mm Hg, the surgeons immediately administer topical antibiotics and patch the eye. In rare cases, they may encounter a 0 mm Hg, requiring them to refill the anterior chamber in the OR.

Dr. Gills� post-op exams take extra time and effort by him and his staff, but he says it�s well worth it. "Some days I�ll treat 20 one-eyed people," he says, "and I�m going to do everything I can to give them more value-added service. I don�t care about the cost."

While Dr. Aker was performing a capsulorhexis on the father-in-law of his scrub tech of 10 years, he noticed vitreous seeping in around the superior pole of the lens. The patient had only one eye, so the situation was serious. After having a tape put in the video recorder, Dr. Aker switched from his usual "phaco flip" technique to removing the lens with "zero vacuum phaco," turning the aspiration to almost zero and doing a slow, divide-and-conquer technique.

The low aspiration helped prevent further damage to the capsule. He also performed a little vitrectomy above the lens to clean up the vitreous. The man ended up with 20/20 vision in the eye. The case taught Dr. Aker that being flexible with phaco is important for preserving the capsule. Usually, the "phaco flip" works best if hydrodissection is successful.

If he can�t achieve satisfactory hydrodissection, he will use the divide-and-conquer technique. The danger with this technique is that the surgeon is carving down on the densest part of the cataract, putting pressure on the back of the capsule. An inexperienced surgeon may carve down too far and go through the capsule.

Working with dense cataracts puts the capsule in danger and takes more time than a normal case. That�s why, now, Dr. Aker puts his cases in order of difficulty, from easier to more difficult, based in part on the density of the cataract. His staff gives each case a difficulty rating, from "A" to "E." An "A" is an easy case with a well-dilated pupil. A "D" rating might be for a rock hard cataract with a small pupil. An "E" might be for a rock hard cataract with a small pupil, pseudo exfoliation and loose zonules. This approach prevents a difficult case from bottlenecking your schedule. You also get a chance to "warm up" on easier cases and prepare for the tougher ones ahead.

Because pupil size is a factor in ordering the cases, Dr. Aker instructs his staff to measure pupil size at the end of every patient�s clinic exam, just before the patient is booked for surgery. The measurement step helps the staff get an idea of what pupil size to expect on the day of surgery and how long it will take the patient to dilate to that size.

As you know, clear corneal mishaps are not everyday events. In some ways, small failures are the most frustrating, preventing you from achieving maximal outcomes. To that end, leading surgeons encourage you to think of creative ways to change techniques that may be undermining your goals.

For example, Dr. Wallace says less-than optimal outcomes for patients with astigmatism motivated him to innovate with the temporal approach, which helps him manage astigmatism better. The temporal approach can also help you avoid damaging the capsule because you can visualize the lens better by observing it from the side instead of over the brow, and you can bear down more lightly, minimizing pressure on the capsule.

The key to trying new techniques, says Dr. Wallace, is to practice with mock surgeries and to get your staff behind you.

"A lot of patients pick up on the frustration of the surgeon and staff when you�re going through something for the first time or encountering difficulty," he says. "If you have a problem, staff will verbalize this when the doctor�s not in the room."

To avoid these problems, he suggests you keep staff for a pre-arranged half hour or so for 2 days after surgery. Together, you can experiment with how to move equipment, where to position the patient�s head, how to set up the scope and where staff should be lined up to make the transition to a new or refined technique as smooth as possible. "Once you get through that adjustment, you�ll be fine," says Dr. Wallace.

Because he made this transition 6 years ago, Dr. Wallace sends away many more patients who don�t require spectacle correction because of less astigmatism. Not only is he maximizing outcomes, he�s growing a word-of-mouth referral base through satisfied patients.

The good news about clear corneal incisions is that most mistakes are reversible. Robert M. Kershner, M.D., F.A.C.S., of Tuscon, Ariz. suggests that surgeons never be afraid to retreat to the familiar territory of the sclera or to use a suture if surgery goes awry.

He remembers a case that seemed to go well until the end. The wound seemed to seal well and the anterior chamber appeared to inflate properly at the end of the procedure. But during gentle pressure testing, the incision looked as if it might leak. He made the mistake of leaving it alone and hoping for the best, and the next day the patient showed a shallow chamber.

Dr. Kershner put a bandage contact lens on the patient, but after 48 hours the chamber didn�t return to normal. He was forced to bring the patient back into the OR to reinflate the anterior chamber. The problem could have been avoided by one suture during the first operation. It�s better to hedge your bet with a suture than to risk having the patient back in the OR again, he says. Most patients will tolerate a suture, but very few will take kindly to having to go back to surgery.

In another case when a suture became necessary, Dr. Kershner was demonstrating live clear cornea surgery before an audience of 200 Scandinavian surgeons. After performing two temporal clear cornea cataract incisions flawlessly, he was asked to perform surgery on an elderly medical school professor who had 7D of astigmatism in the nasal meridian of his left eye. To impress the observing surgeons on how the technique could be performed through a nasal clear corneal incision, he performed the procedure using the keratolenticuloplasty technique. This would help him correct astigmatism during the cataract surgery.

Just as he was finishing "what seemed to be endless phaco," he thought he saw a small zonular dialysis infero temporally. After completing the irrigation and aspiration, he injected a one-piece plate lens into the bag only to watch it dislocate temporally. Realizing the zonulas weren�t going to support a capsular lens, he asked for a hook to retrieve the lens.

"As fate would have it, the lens didn�t want to come," Dr. Kershner recalls. "The more I tugged the worse it got."

Reluctantly, he enlarged the incision with a diamond keratome. After removing the lens, he implanted a one-piece PMMA IOL into the cillary sulcus and placed a single "X" 10-0 nylon suture.

Feeling defeated, Dr. Kershner stepped into the conference room expecting a shocked audience but instead met with a standing ovation.

"It seems the surgeons were much more impressed with the difficult time I had converting the case back to a surgical procedure with which they were more familiar than my attempt at impressing them with my facility through the smallest clear corneal incision possible," Dr. Kershner explains.

The following day, he was delighted to learn that the patient�s entire 7D of astigmatism had been corrected, and the patient was thrilled to be seeing 20/20 without glasses.

Mastering clear corneal incisions can be frightening. It�s natural to worry about making mistakes. Dr. Aker found it was advantageous to seek help from another surgeon who had experience with clear corneals. For example, early on, Dr. Aker found it worrisome to let patients leave the OR without a shield.

But after speaking with an experienced surgeon, he felt better about it. He now doesn�t worry about the lack of bandage and has confidence in his wounds; he lets his patients resume normal activities directly after surgery. In fact, one of his patients took a nasty fall shortly after surgery, and the wound remained sound.

Experienced surgeons say worrying about making mistakes can be the most damaging blunder of all, if it prevents you from offering a service, like clear corneal incisions, that can enhance the lives of your patients.

"The biggest disease that can be treated," says Dr. Gills, "is the one 2 inches above the eye � people worrying about things that aren�t so." OM

Think about a 6-mm optic sitting in front of a 5-mm capsulorhexis, says Dr. Howard Fine. You then nudge one edge of the optic under the capsulorhexis and pull it until the entire edge clears the capsulorhexis. Then you pull the edge on the other side of the haptics until it goes under in the same fashion. This converts the shape of the capsulorhexis to an oval because the haptics remain on the outside of the capsulorhexis.

"It�s the most stable centration possible," he says. "It�s also a good reason for keeping the capsulorhexis smaller than the size of the optic."

Dr. Jim Gills warns against stretching the tissue when inserting the lens. He suggests that beginners use a slightly larger incision, getting as close to a 17-degree angle of incidence into the anterior chamber as possible. His incisions are between 2.5-mm and 2.7-mm long. At one point, he worked his incisions down to 2.1 mm, but found it put him at risk for compromising the wound. "It was love�s labor lost," he says. "We really weren�t accomplishing anything by doing it."

Dr. Robert M. Kershner suggests that beginners start with steel blades instead of diamond knives. Besides being difficult to care for, diamond knives can be too sharp for the hands of beginners. If the eye moves, just before the incision is made, a diamond knife can cut too deep, too quickly. A steel knife that is sharp enough allows for a slow progression that the surgeon can watch every step of the way. He has found the best shape for his incisions is almost square, about a 3 to 2 ratio of length to width, with the length going into the eye.

Are you seeing too many anterior capsulotomies go bad? R. Bruce Wallace III, M.D., Alexandria, La., suggests it may because of increased eye movements associated with topical anesthesia.

To ensure that the capsulotomy is more controlled and predictable, Dr. Wallace suggests you use an instrument to fixate the globe during the procedure."You�ll maintain the integrity of the capsulotomy and have a much better outcome," he said.

Also, for patients with more eye movements than most, Dr. Wallace suggests adding a second viscoelastic, such as Amvisc-Plus, under thicker Viscoat to help maneuver the capsulotomy and using forceps, not just a needle. The more forgiving Amvisc-Plus will help you control the advancement of the capsular tear under topical anesthesia.