We couldn't have accomplished what we've accomplished without the work of Charles Kelman, M.D. This month's Viewpoint (page 3) pays a most appropriate tribute to Dr. Kelman, the inventor of phacoemulsification. Dr. Kelman's innovation allows each of us to become more efficient. It allows us to perform an elegant procedure, reduce the risks to our patients and eliminate some of the perplexing variables of cataract surgery that were present in both intracapsular and extracapsular cataract extraction.

Whether you're performing phacoemulsification using the elegant divide and conquer technique of Howard Gimbel, M.D., one of the various phaco chop procedures or the PhacoFlip procedure of David C. Brown, M.D., you can achieve an extremely high degree of efficiency. (To read more about PhacoFlip, see "Cataract Revolution," in the July 1998 issue of Ophthalmology Management.)

I asked Dr. Brown for a few comments on achieving efficiency, and he offered several thoughts. First, to minimize expenses, cataract surgeons definitely must operate more efficiently. But patient care doesn't have to be sacrificed to reduce our surgical time and increase our productivity.

Efficiency isn't a matter of focusing on the clock. We become more efficient by adopting efficiency as an attitude, expressed through all aspects of patient flow. As surgeons, our responsibility begins with a willingness and a commitment to change. This attitude will be reflected to each member of your staff, and your patients will appreciate your respect of their time as well. A happier work environment, smoother surgical days and happier patients will be the end results of efficiency.

Speed has been the main attraction to many when they want to become more efficient. Although it's certainly a major advantage, other advantages to being efficient are more important. For example, with efficiency comes a more predictable result. Staff members are better prepared and become more confident when they know what you want for each case. Conversely, changing phaco settings continually or requesting different instruments from case to case is disruptive and causes staff to become hesitant about being prepared. It becomes much too easy for the staff to wait for you to enter the operating room if they think you're going to give them new instructions each time. You also become hard to please in their eyes.

High-quality surgery with predictable results comes from repetition and completing each case in the fewest steps possible. The phaco technique you use will also affect how much time you spend in the eye maneuvering the nucleus. Consistency in your instruments, the types of surgical procedures you perform, and pre- and post-op instructions all contribute to a smoother surgical experience.

Efficiency comes into play before surgery as well. Proper patient scheduling is key to fewer disruptions and quicker turnover. Schedule your patients according to procedure. For example, it's difficult to insert a trabeculectomy case in the middle of your cataract schedule. Schedule these less frequently performed procedures at the beginning or end of your day. Don't stop the train.

A common mistake that surgeons make is to reduce staff size to save money. There are a couple of things to learn here. Operating room personnel don't all have to be highly paid registered nurses. Many ancillary duties related to prepping and transporting patients don't require licensed personnel. In addition, nurses will appreciate help with the smaller tasks and be able to endure a longer day, when needed. And when your OR personnel are efficient, they'll be able to finish on time and save you overtime expense.

Efficiency as an attitude will lead to improvements in other areas of your practice, too. Keeping an open mind about new procedures and new products is important to maintaining a high level of efficiency. The latest instruments and equipment are geared toward promoting efficient procedures. That's why it's important to experience all of the available technology and not be afraid to make changes.

If you don't look forward to your surgical day and come away feeling refreshed and excited about what you're able to offer your patients, then you may not be working at your maximum efficiency. Take the time to visit other facilities and compare your overall surgical experience and staff morale to theirs. Time away from the office, if it results in a more efficient system for you, is never time wasted.

Dr. Brown is certainly regarded as the master of efficiency, and by following his suggestions, you'll find that you can eliminate wasteful steps and unnecessary instruments and maneuvers, which only increase your operating time and potentially increase the risk of infection.

To help you further in that quest, consider the following changes I've made to improve my phaco efficiency:

• Breaks in technique are the enemy. A break in technique is anything that interrupts the progression of your procedure. For example:
• having to wait for an instrument
• having to talk
• needing an instrument that's not on your basic tray
• having to suture.

• Decreasing down time and operating room turnover time.
We videotape and scrutinize our cataract procedures to identify non-productive spots, or "dead" time. These viewing sessions have resulted in changes in procedure so that when I enter the operating room, my staff members have already properly positioned and draped the patient and have put the foot pedals and chair in place. The speculum and microscope are in place. After the procedure, post-op personnel are ready to move the patient, continuing to use the same stretcher. The tighter we can work as a team, the less talking we have to do during procedures, which goes a long way toward increasing our efficiency.
• Other changes related to surgery.
As you become more efficient and your volume increases, consider adding another autoclave. We found that adding a third unit allowed us to process trays at a comfortable pace. When we only used two, often the instruments were still too hot to use when it was time for the next case. Having an additional autoclave also means that if one breaks down, we still have enough sterilization capacity to get through the day.
We've also switched to using pre-cut surgical drapes. I had been concerned that a pre-cut drape wouldn't provide enough infection protection, especially for the eyelashes, but because of our efficiency and reduced operating time, our infection rate remains remarkably low.
• Custom packs.
Custom packs are a must. Without them, staff members would have to spend time on the day of surgery preparing the needed items for every case. The chances that something will be forgotten are much higher. For special cases, when we'll need items not contained in the pack, such as a different viscoelastic, the surgery scheduler alerts the proper staff members, who have the extra item(s) ready.
Stay current with what you need in your packs. Each time you drop or adopt a new technique, consider which items should be deleted or added. Over the years, we've revised ours 28 times to better suit our needs or to take advantage of lower priced items that perform as well as what we'd been using.
We order close to 2,000 packs at once, but many companies will supply custom packs for smaller practices.
• Instrument tray.
We always look for ways to streamline our instrument tray. Less is more. Our most recent set-up includes seven instruments. We've increased our number of trays to six, rotating through two operating rooms. This way, a tray is always ready, and the rotation causes less wear on the instruments. We also save time by having staff members remove the phaco handpiece and diamond blades from the room as soon as I'm finished with them. The rest of the tray, of course, remains in the OR until the case is completed.
For cases that aren't routine, we have extra peel-packed instruments on hand. For example, if I encounter a non-sealing wound, the circulating nurse automatically brings in a sterile pack containing suture scissors and a needle holder. This is another reflection of everyone's involvement and commitment to efficiency -- she's watching the procedure closely and can anticipate what's needed. Communication and foresight are key in non-routine cases. Staff members examine the patient schedule ahead of time, so if, for example, I'm doing a lens exchange, a Sinskey hook is ready for that case.
• Patient scheduling.
How your practice schedules cases has a lot to do with how smoothly your day of surgery goes. We grade our cataracts as follows:

1. 1 to 3 NS with pupil 5 mm or more
2. diabetic
3. pupils less than 5 mm
4. hypermature or 4+ NS
5. cataracts with endolaser. E indicates that the procedure must be performed in the OR having the endolaser.
6. straight endolaser, miscellaneous surgeries, limbal relaxing incisions, lens exchanges, secondary IOLs, etc.

In truth, these are lessons I've learned over the years by watching the truly great surgeons and listening to the great teachers, such as Howard Gimbel, David C. Brown and many others who are so well known to all of us. I urge you to watch, listen and learn as they continue to teach us how to maximize the efficiency of Dr. Kelman's phacoemulsification technology.

This is what brings us to where we are with cataract surgery in the year 2000. It's what allows us to take phaco to that next level, where we can positively affect not only our patients' lives and our own lives, but also our bottom lines.

On a recent trip to Florida, Dr. Kelman and I watched Dr. Brown perform his PhacoFlip procedure. Dr. Kelman's comments to me on the flight home centered on the exquisite efficiency and reproducibility that characterized the surgery.

There were no breaks in techniques, no surgical "hiccups" during the entire afternoon of surgery. It flowed as though it were choreographed from start to finish -- because it was. And that is precisely the secret of performing highly efficient cataract surgery.

As my colleague Dr. Joseph Markoff says, phacoemulsification is a procedure that must be properly mastered and remastered. To that end, I've adopted three of the latest phaco-related advances. They've had an enormous impact on efficiency and have markedly improved the experience of cataract surgery for me and my patients. They are:

• Topical anesthesia
. Topical anesthesia allows me to avoid the known risks of retrobulbar or peribulbar anesthesia. It promotes rapid visual recovery for patients, who can resume normal activities almost immediately. Patching isn't required because ocular motility and eyelid closure aren't altered. I no longer have the 5 minutes or so of downtime while the nurse anesthetist or anesthesiologist sedates each patient in preparation for the injection. Ocular massage to prevent bleeding isn't necessary either.
Topical anesthesia also allows for a more interactive surgery. I'm more comfortable with a patient who's awake and who can hear me and follow my instructions. My patients seem to prefer the topical strategy as well. More of them are asking right away when they can have surgery on the fellow eye. They also have less post-op sickness and other concerns. In the past, I'd receive at least one call a week from a patient or his family wondering why his face was still droopy several hours after surgery. Furthermore, recent studies indicate that we may be able to safely curtail preoperative testing by using topical anesthesia.
• Temporal clear corneal incisions
. Temporal clear corneal incisions similarly represent a giant leap forward in patient satisfaction and surgical efficiency. I prefer a direct entry, but the technique allows for surgeon flexibility. For example, groove incisions and Langerman hinge incisions are also beneficial. With clear cornea incisions, I can steer clear of conjunctival peritomy. The temporal location also gives me a much better view of the operative area. Prominent brows are a non-factor. Turnover time is drastically reduced. These incisions are better tolerated by patients, improving outcomes. Healing is more rapid, and less astigmatism is induced.
• Chop technique.
Adoption of a phaco chop technique has also improved my efficiency. I use a "stop and chop" modification, which is facilitated by high vacuum settings and flatter or flare phaco tips. Ultrasound energy is less; operative time is shorter; and corneas are clearer postoperatively. There's no need to emulsify four potentially large quadrants at the iris plane, or worse, in the anterior chamber. Chopping the nucleus into smaller wedges allows for more controlled removal.

Robert D. Behar, M.D.
Philadelphia, Pa.

Under the ever-present scrutiny of those who seek continued reduction of cataract surgery reimbursement, we have to describe efficiency properly. First of all, it's not speed we strive for. Rather, we strive for efficient and reproducible quality surgery that is free of postoperative complications because of the care and attention to detail during the surgical procedure itself.

Furthermore, a commitment to efficiency requires investing in new equipment and taking the time to learn new surgical skills.

Alan B. Aker, M.D., F.A.C.S.
Boca Raton, Fla.

Although I use every modality available for cataract surgery, including many under FDA investigation, I still prefer phacoemulsification because it has such a dramatic impact on the quality of my patients' lives. In addition, it's a high-skill technique that I can strive to improve because it's much more under my direct control than, for example, LASIK, which depends heavily on automated equipment.

One of the most important recent changes in my own technique has been the use of power modulations available in the new equipment developed by industry. Power modulations, used in conjunction with chopping techniques, allow me to perform phacoemulsification with dramatic reductions in the ultrasound energy I put into the eye. Because I'm disassembling the nucleus by chopping, using mechanical forces, rather than by grooving and cracking using phaco forces, and because I'm evacuating nuclear material by high vacuum, rather than converting the cataract to an emulsate, I've eliminated as much as 99% of the energy that I put into the eye.

Power modulations include burst mode, which has panel control of power and surgeon control of the interval between bursts, or pulse mode (2 pulses/second), which gives me linear power but a set interval between each pulse. Using power modulations along with chop techniques has allowed me to reduce the energy into the eye to single digits, somewhere between 2 and 10 joules per case.

This compares with previous reports in the literature that listed divide and conquer techniques somewhere between 2,000 - 3,000 joules and chopping somewhere between 700 - 800 joules. Putting so much less energy into the eye allows safer surgical procedures with more rapid visual rehabilitation.

I continuously strive to improve my technique and work with industry to improve the technology. This has made phaco an ongoing adventure that has been both personally rewarding and beneficial to my patients.

I. Howard Fine, M.D.
Eugene, Ore.

Just when it seemed we'd reached the end of the cataract surgery rope, with little ability to economically survive any additional cuts in reimbursement, refractive surgery became a life preserver for many practices. There was eager anticipation of the approval of the excimer laser and all it might mean to so many struggling practices.

But PRK got off to a slow start, and it was only with the introduction of LASIK that there was truly a sense of excitement, not just within the ranks of ophthalmologists, but among the public as well, as they anticipated the possibility of ridding themselves of glasses or contact lenses.

Although the practices that have embraced LASIK or other forms of refractive surgery certainly have achieved some relief from the economic crunch felt by cataract surgeons across the nation, even that may ultimately be threatened by the numerous discount LASIK operations that are springing up in many large metropolitan areas. So, our survival as ophthalmic surgeons may depend most on our ability to perform an efficient procedure. Because of the high overhead, this is especially true in the area of phacoemulsification.

Alan B. Aker, M.D., F.A.C.S.
Boca Raton, Fla.

With use of the latest tools and techniques, phacoemulsification is a quick, efficient and gratifying procedure. However, occasionally a rent in the posterior capsule with vitreous loss occurs. I'd like to share with you the protocol that I've begun using that usually turns this unfortunate intraoperative event into an excellent visual outcome for my patients.

When a posterior capsule tear occurs, I have five objectives:

• remove the remaining nucleus and cortex to prevent iritis, cystoid macular edema (CME), secondary glaucoma or pigment deposits on the intraocular lens (IOL) post-op
• avoid vitreous to the wound to prevent CME post-op
• implant a foldable posterior chamber IOL into the sulcus, which requires enlarging my 2.6-mm clear corneal incision to 3.4 mm and using a 10-0 nylon suture for 2 weeks (I usually implant plate lenses, but as you know, a plate lens would be contraindicated in this situation.)
• avoid radial tears in the anterior capsule, which could compromise support of the foldable IOL and possibly lead to lens subluxation post-op
• avoid broken zonules that impair the stability of the anterior capsule and therefore the stability of the IOL in the sulcus post-op.

When faced with this situation, my first step is the slow and careful removal of remaining vitreous and lens material. I do this through a new, 2.6-mm clear cornea incision, placed inferiorly. (If you use a side port incision, you can begin there, after enlarging your incision.)

If I'm unable to remove the remaining lens material through this incision to my satisfaction, I make a 2.6-mm incision at the pars plana superior temporally without a conjunctival flap. Persistent superior residual cortex is easily removed through this incision. I can then close the incision with a 10-0 vicryl suture, which remains for 1 week post-op.

Following this plan has allowed me to accomplish my five objectives, and my patients have been satisfied with the results.

James B. Carty, M.D., F.A.C.S.
Bryn Mawr, Pa.

Making use of the latest phaco technology is a must for improving efficiency. Four companies are currently developing or waiting for FDA approval of laser phaco systems that you'll want to consider. The promise of laser phaco includes ease of use and increased control for surgeons, which will result in increased safety for patients.

The laser energy is low and cool, and the lack of sharp edges on the related instruments means protection for eye structures, including the iris and capsule. Minimal energy dissipation in the incision area significantly reduces the risk of corneal burns. Michael Limberg, M.D., lead clinician for trials of the Paradigm Medical Photon system, explained how that system works:

"The Photon system removes cataracts using photodenaturation, photoacoustic and photothermal energy. Using a proprietary photon trap, Nd:YAG pulsed laser energy is injected directly into the lens, starting the processes of photodenaturation and photothermal breakdown. Laser energy not absorbed by the lens produces a photoacoustic pulse when trapped by the titanium backstop, further disrupting the lens architecture. The backstop of the photon trap also serves as the aspiration port, synergistically coupling the fluidic energy of aspiration with laser lens disruption in one focal site, the photon trap.

This approach differs greatly from ultrasonic techniques in that the low energy levels applied create almost no heat, typically less than 1% of the heat energy released by ultrasound. At these low energies, the lens capsule is impervious to the laser, and the iris shows very little laser effect even with prolonged application. Only lens tissue is effectively altered by the laser energy, which makes this technique extremely selective and safe for use in the anterior chamber."

While some surgeons aren't satisfied with the speed of laser nucleus removal, the safety profile is unprecedented. Because laser phaco is so well suited for soft cataracts, it will be ideally suited for another procedure that's growing in popularity-- clear lens exchanges.

For more information, contact:

Paradigm Medical Industries, Inc.
www.paradigm-medical.com
(801) 977-8970
Paradigm's Photon Laser Cataract Removal System will also have ultrasound capabilities, allowing surgeons to switch between the two modes during the procedure.

Premier Laser Systems, Inc.