Going Solo
Anxiety is inevitable when facing your first surgery on your own.  Keep worries in check by following these simple steps.
Robert J. Noecker, M.D., M.B.A.

People often say buying your first home, getting married and becoming a parent are some of the most stressful situations you'll ever face. Those of us who survived residency and went on to perform our first solo cataract surgery know that, despite the gravity of those other milestones, nothing compares to the anxiety associated with operating without the safety net of a senior surgeon at your shoulder.

You may have logged 100 or more cataract procedures during your residency, and even though no one held your hand, you never were really on your own during your training. As a resident, performing cataract surgery was all about removing the cataract and implanting an IOL without any major complications.

Operating room schedules or ambulatory surgery center flow just weren't concerns of yours. Nor were you particularly interested in what model phacoemulsification equipment you were using or what type of IOL you were implanting. All that is about to change.

Be Prepared

Once you're out in the real world with a real job and you realize how many decisions need to be made before, during and after each cataract case, you may feel overwhelmed. To lighten that load, take a page from the Boy Scout Handbook: Be prepared.

To reduce your level of stress to an absolute minimum, choose an "ideal" patient for your first solo case, then be prepared with the essential instruments you'll need for the case (see "Your Instrument Checklist").

Be prepared with Plan B if your Plan A surgery technique fails. You should be prepared to adjust phaco machine settings to levels with which you're comfortable. And finally, be prepared to know where to hang your hat in the hospital or ASC well before you arrive to perform surgery.

Select an 'Ideal' Patient

You can't go wrong if you select a patient who has everything in his or her favor. Look for someone who:

• Is cooperative
• Is not taking any medications that can complicate the procedure
• Has a moderately dense cataract that can be removed easily with a technique you've used successfully as a resident
• Has a pupil that dilates well
• Has no complicating conditions, such as exfoliation syndrome
• Is not extremely myopic or hyperopic.

For instance, if you're comfortable doing clear corneal cataract surgery under topical anesthesia, choose a patient whose case will work out well with this technique.

What cases should you avoid? The first time you're on you own in the OR, don't schedule a patient you know. Now's not the time to operate on your grandmother or your neighbor.

You should also avoid someone with whom you'll have difficulty communicating, for instance a patient who is mentally challenged or has a language barrier. If you've previously operated on elderly patients only, your first solo surgery isn't the time to remove a traumatic cataract from an 18-year-old.

Other patients you'd do well to avoid for your first few cases are those with meticulous, type-A personalities, who tend to be extremely difficult to satisfy, and active,
middle-aged professionals who might have a relatively mild cataract and may want a presbyopia-correcting IOL.

These lenses can provide excellent vision and significantly reduce spectacle dependence, but they require precise preoperative biometry and IOL calculations in order to fulfill their potential. You'll have plenty of time to work with these lenses later when your results and confidence curves even out.

Operating on an average easygoing patient will help keep you calm, boost your confidence and impress your OR staff and colleagues. They'll be judging your performance during your first surgery, so you might as well do whatever it takes to make a good first impression.

Keep It Simple

I often hear residents talk about how anxious they are to try the newer techniques, such as chopping or clear corneal incisions, when they get into practice. I cannot stress enough just how important it is to avoid trying anything new for at least the first month. In your new role, you'll be worrying about the flow and operations of the OR, the phaco machine settings, IOL choices and numerous other details more than you ever did as a resident. These concerns should be enough to convince you to stick with a simple surgical plan.

Once you're familiar with the new OR, comfortable with the different equipment and confident without a senior surgeon looking on, you can think about incorporating new techniques into your repertoire — but only one at a time. You'll want to make sure you master each additional technique before making any further changes to your surgical plan for two reasons. First, it makes sense from a patient-safety standpoint, and second, the only way to evaluate the origin of an adverse outcome is by isolating each variable.

Consider that when you walk into a new OR, there are already at least 10 things that are changed for you by default. So if, for instance, you want to do more topical anesthesia, make sure you have the rest of the procedure down pat before you take that step and do topical for all of your cases, even though you may have used topical anesthesia previously in a more controlled situation in your residency.

Understand the Lay of the Land

Visit the OR or ASC where you'll be operating well before your first surgery. This will give you the opportunity to find out if you need a code or an I.D. number to get into various parts of the building; to find out where the locker room is so you'll know where to leave your personal belongings; and even to find
out where the rest room is. These
concerns might not seem vitally important in the grand scheme, but having this information beforehand absolutely will reduce your stress level on the day of your first surgery.

During your visit, take the opportunity to introduce yourself to the OR nurses and to gather information. Find out what type of phaco system you'll be using and what type of software it's running, as well as what type of phaco tip and tubing you'll be using.

The major manufacturers of phaco machines are AMO, Alcon and Bausch & Lomb. Each model has distinctive features, and each manufacturer tends to introduce an upgrade every year or two in either the platform or the software that runs it. For instance,
if the facility uses the AMO WhiteStar System, you should find out if the ICE upgrade has been incorporated, because the upgrade affects the vacuum, aspiration and irrigation settings.

If the system you'll be using is the same as the one you used as a resident, you can program your old settings into the new machine. If the system is different, you'll need to calibrate the settings you used on your previous system with those of the machine where you'll be operating.

Don't make the mistake of assuming that whatever settings the surgeon before you used will be fine. They may be the settings of a very conservative surgeon, and you may feel like the vacuum and aspiration levels are far too slow for you. Or the settings may be those of a surgeon whose claim to fame is getting in and out of the OR in less than 5 minutes, and the vacuum is set so high that before you know it, you've sucked up the patient's iris.

Visiting the facility before your first surgery gives you a good opportunity to learn the preoperative pattern and ask some key questions, such as:

1. Are you expected to mark the patient's eye before the patient can enter the OR?

2. What kind of sedation do the anesthesiologists/nurse anesthetists typically give patients before the case?

3. How do the nurses want the pre-op and post-op orders written?

4. Where will you talk to the patient and his or her family after the procedure?

Knowing the answers to these questions before your maiden voyage will ensure a smooth OR flow on surgery day, which should minimize your stress level — and endear you to the nursing staff.

During this visit, you can let the OR nurses know what kind of dilating drops you prefer and what anesthesia you like to use. If your preferences are not available at this facility, you'll know in advance and be able to modify your plan.

Also, check out the type of stretchers used in the OR. If your surgical plan is based on a temporal approach, you need to make sure you can sit at the side of the bed and that the microscope can go high enough. If no other surgeon uses a temporal approach, the facility may not have this type of bed or microscope.

Get Your Head in the Game

Watching videos of cataract surgeries you performed during your residency or reviewing videos of other cataract surgeons' cases is an excellent way to mentally prepare before your first surgery.

Reviewing the case, including your patient's IOL calculations, also should be part of your preparation. You should have decided well in advance which IOL best suits the patient and have ensured that it and a back-up are available.

Finally, don't be afraid to ask a mentor – a surgeon you like and trust – to join you in the OR during your first surgery. More than likely, your skills will ensure an excellent outcome for your patient, but having that extra support may be just what you need to ensure an excellent experience for you, as well.

Your Instrument Checklist Before embarking on your surgical career, obtain the instrument list of an attending surgeon you think does the best job — or gather several lists from several surgeons — and use them to help guide you in selecting the instruments you'll need to get started. The bare necessities include: Lid Speculum (Barraquer) Paracentesis blade for 1-mm incision (diamond or disposable) Keratome blade (diamond or disposable 2.75 mm to 3.0 mm) for phaco incision Viscoelastic Cystotome or bent 25-gauge needle Utrata forceps 27-gauge cannula and syringe for BSS injection Specific chopper/lens manipulator Specific type of irrigation/aspiration tip Specific degree and type of phaco tip Specific lens injection system Sinskey hook For back-up, you'll need: 0.12 toothed forceps Needle Holder Westcott scissors Van Ness scissors Lens loop Lens manipulator (spatula or chopper) Blade for tunneling 10-0 nylon on a cutting needle Other instrument for stabilizing globe (i.e.Thornton ring, etc.) Some of these instruments will be necessary only if the lens does not cooperate with your best phaco efforts and you're forced to extract the nucleus manually. Although it's highly unlikely that this will happen during your first surgery — especially if you choose your first patient carefully — it is possible. In that case, you'll need the necessary instruments handy to perform an extracapsular extraction, implant an IOL and suture the eye. The ASC or hospital will supply some of these items, but having an all-encompassing list is a good idea so you can confer with the facility administrator or head OR nurse beforehand to ensure you'll have access to whatever tools you might need.

Robert J. Noecker, M.D., M.B.A., is vice chair and director of the glaucoma service at the University of Pittsburgh Medical Center Eye Center, Eye and Ear Institute.