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No one forgets their first phacoemulsification

No-one-forgets-their-first-phacoemulsificationST3 Ophthalmology trainee Dr Gwyn Williams remembers when he first performed cataract surgery

No-one ever forgets their first experience of driving a car. The memory of my 17th birthday is dominated by the build up and subsequent hideous disappointment of going for my first driving lesson with my father.

I was studying A-levels in the main science subjects at the time, and I naively assumed that if the basic scientific principles of operating a motor vehicle were known, then learning the practicalities would be a piece of cake.

“Stop, stop – STOP” my father shouted. “The starter motor will burn out if you keep the key turned for so long” – the day had not gone well. Having stalled 13 times over the first hour it dawned on me that driving was as much an art as a science, and I was at the foot of a long learning curve. To this day I still recall with a shudder the feeling of helplessly being carried along the road by a ton of metal, with only a rudimentary knowledge of how to guide the untamed beast away from pedestrians, cyclists and other cars.

Although that indescribable feeling receded into my unconscious mind, it was unexpectedly pushed to the fore again when I started learning cataract surgery.

Although that indescribable feeling receded into my unconscious mind, it was unexpectedly pushed to the fore again when I started learning cataract surgery

Learning how to perform modern cataract surgery, where the cataract is destroyed and extracted in a process termed phacoemulsification, has been a long and difficult learning curve. I suspect this is the closest a surgeon will ever come to operating a one-man band.

During the operation the right hand holds the main instrument, the phacoemulsification probe; with the left controlling the vital second instrument, the job of which is to break apart the cataract in a way that allows successful extraction. The left foot controls the microscope with movements forward and to the side affecting zoom and focus. The right foot is akin to the accelerator on a car.

By moving the foot forward or back the destructive power of the phacoemulsification probe is altered; turning the foot right or left alters the amount of suction pulling fragments out of the eye.

The progress of the operation is viewed by both eyes through the operating microscope – binocular vision is essential in judging the depth of the various structures seen. Lastly, the machine running the probe is tuned in such a way as to emit sounds of various tone and pitch, dependent on how much power is being used, the degree of obstruction of the probe tip and the amount of suction being used.

Ophthalmic trainees are prepared in various ways, before being let loose with all this technology on the eye of an unsuspecting patient. I attended the compulsory basic microsurgical skills course run by the college, in which trainees are taught through lectures and tutorials the science behind the operation.

Vector forces are explained, as are the merits of the various settings on the phacoemulsification machine. All very straightforward I thought to myself, as I descended the stairs to the practical session involving real instruments and plastic eyes, held in the basement.

Having seen real cataract surgery performed by experienced consultant colleagues prior to doing the course, it all fitted together nicely. A harmony of man and machine, in which the very latest technology was gently guided by the human operator using common sense scientific principles, with the aim of restoring sight to those afflicted by cataract. As easy as learning to ride a bike, or perhaps driving a car.

After attending the course I spent several months learning easy steps in the operation, those that did not require much adjustment of focus, or any use of the phacoemulsification probe, and my belief that I’d soon be as good a cataract surgeon as my seniors was utterly undiminished.

Chomping at the bit for more action, the day finally came when I could use the probe for the first time and be a proper phaco surgeon. Having inserted the probe into the eye I gently touched the cataract and pushed the right pedal forward with my foot. “No no no” my consultant grimaced. “Push deeper, but hold on… that’s too fast, slow down.”

Chomping at the bit for more action, the day finally came when I could use the probe for the first time

I hadn’t expected the experience of using the pedal and probe to be so difficult. Judging how far to press or depress the pedal, interpreting the sounds and analysing the movement of the cataract through the microscope, were all superficially simple things to do, but together, the task seemed Himalayan.

Coupled with all this I had always assumed my motor skills were smooth and well controlled, but under the uncompromising magnified glare of the microscope and beamed for all to see on a screen on the theatre wall, my movements seemed jerky and tremulous.

My first attempt at phacoemulsification was brought to a swift conclusion when the consultant asked me to remove the probe as he was worried my experimental forays were stressing the zonules – the supporting ligaments of the crystalline lens. I cannot remember if I managed to hide my crushing disappointment, but what I do remember most vividly about that first attempt at phacoemulsification was the return of that feeling of being powerless in the face of dangerous technology first experienced on my 17th birthday.

Over time my skill has improved, much the same way as I was eventually able to drive to school and back without ending up in a hedge. It is said that advancing technology will at some point make the surgeon either redundant, or at the very least reduce his role to that of a mere technician operating machinery to achieve their surgical aim – I disagree.

With expanding technological horizons fine touch, eyesight and hearing are more important than ever to the surgeon, with an ability to assimilate all three to form a concerted plan of action the most precious skill of all.

Dr Williams works at Singleton Hospital in Swansea.