Learning the Basics from the Masters at Winter ESCRS YO Programme

The Young Ophthalmologists Programme at the 26th European Society of Cataract & Refractive Surgeons Winter Meeting (ESCRS Winter Meeting 2022) was a great event that had some of the best ophthalmologists from all over Europe sharing their wisdom with newcomers in the field. The experts in their fields shared lots of great advice, from the advantages of 3D simulators to tips on lens insertion, here are some of the highlights…

Dr. Richard Packard’s Tips for New Trainees

The Capsulorhexis Clock Face Technique

Also known as the ‘Packard C’ technique, capsulorhexis can be made simpler by imagining a clock face on the cortex. The surgeon is always at 12 o’ clock, and thinks of himself as pulling the capsular edge almost all the way around the clock face.

  • To begin, draw a C with the tip of the cystotome from the center towards the wound. The flap will be twice the size of the C you create
  • Grasp the flap which is now in front of the wound and pull towards 9, 8, until 6
  • Regrip and pull to 6, 5, 4, 3, 2, 1
  • Regrip and pull to 2, 1, 12, 11, 10
  • Finish by pulling away from you towards 6


Many people struggle with hydrodissection, but Dr. Packard has a few tips to help with this tricky technique:

  • Make sure that the hydrodissection cannula goes peripherally, at either 3 or 9 o’clock injecting a little as you go.
  • Inject smoothly and look for the primary fluid wave.
  • Press the nucleus backwards and across, at the opposite pole from the injection location and see the secondary wave.
  • Change your hand position to hold the syringe like a pencil in order to rotate the nucleus.
  • Push backwards as you turn with a rowing motion.
  • Turn the nucleus through 360 degrees.

Nuclear Removal and the Four Quadrant Nucleofractis Technique

Also known as ‘divide and conquer’, this technique is the first method of nuclear removal that Dr. Packard teaches residents.

  • When sculpting your groove remember the shape of the nucleus, lift the phaco tip after the centre of the nucleus is passed to prevent sculpting through the nucleus.
  • Keep your passes controlled and smooth, and the bevel exposed to avoid occlusion.
  • Bear in mind that, if you are using a Kelman tip, the hand must be held lower to avoid burying the tip in the center of the nucleus

To crack the nucleus successfully you must get the ergonomics right.

  • The trench needs to bisect the angle between the two instruments you’re using to make it.
  • The instruments are placed at the bottom of the trench.
  • Push backwards a little before pushing sideways.
  • Allow a little time for the crack to propagate.

Now that you have successfully cracked the nucleus you can move on to segment removal

  • Use minimal ultrasound power to bury the phaco tip.
  • Lift your foot into position 2 and allow the vacuum to hold.
  • Wait until full occlusion and vacuum is reached, then pull the segment slowly towards the centre for removal.

Avoiding ‘Lens Iris Diaphragm Retropulsion Syndrome’ in Highly Myopic and Vitrectomized Eyes

The aim is to avoid sudden AC deepening, so every time you re-enter the eye you must repeat the process.

  • Begin by dropping the irrigation bottle height to 40 cm 
  • Place the phaco needle and sleeve into the eye with fluid off
  • To allow easy egress of fluid, put the second instrument in the side port 
  • Now, lift the iris opposite the side port
  • Press the foot pedal to position 2 and allow eye to fill, but also draw fluid out
  • Return the irrigation bottle to normal height

If performed correctly there will be no change in the AC depth.

On phaco machines with no bottle to lower, use IOP ramp set at 2 or 3 seconds accompanied by the iris lift.

Wound-assisted Approach for Lens Insertion

When under topical anesthesia, ask the patient to look at you when you have placed the mouth of the lens cartridge into the wound opening. This gives counter traction when you are doing wound-assisted IOL insertion, and with this extra counter-pressure, the lens is inserted easily.

Dr. Roberto Bellucci on Teaching the Teachers

The Characteristics of the Teacher and the Trainee

A good teacher needs a passion both for the job and for teaching. They must closely observe both the physical and psychological characteristics of the trainee to assess what is needed, and talk with the trainee about the best way for them to learn. In turn, a good trainee must be humble and respect their teacher, but above all must want to learn.

Teachers must have time to get to know the students, be prepared to answer all kinds of questions, and be honest about their own mistakes and learning process. Students must ensure they check the literature. The internet is full of information, so there is no need to repeat bad initiatives and manoeuvers.

New Developments in Training 

Modern technology means trainees can now observe recorded surgery online and attend meetings happening all over the world. All this information means the trainee can learn techniques that are outside the speciality of their teacher and gain a lot of second-hand experience.

Online courses are a useful addition to the curriculum, and can be done at whatever hour and location is convenient for the trainee.

Simulated surgery is the greatest step forward in teaching in the modern era. These 3D simulators allow exceptionally realistic training, and have been repeatedly shown to improve outcomes when trainees then operate on real patients. 

Wet lab surgery on both animal and artificial eyes is now commonly available. Both have their own advantages and disadvantages dependant on cost, availability and training parameters. When assessed, wet lab training has a similar positive impact to 3D simulation.

Many surgeons are not getting as much training suturing skin before their ophthalmology training begins. In order to practice suturing corneal incisions, a phaco test chamber can be attached to a support and cut with a phaco knife. The silicone’s stiffness is similar to that of a cornea. 

Performing Surgery

The first real-life surgeries the trainee undertakes should be carried out on simple eyes, without any complications. In addition, it’s a good idea to do the procedures early in the day, as complications can be time consuming and delays after a long day are frustrating.

When learning surgical steps a trainee may well make a mistake, which makes the next step harder, and the next step harder again. Instead, use a reverse approach – start with the last step, perfect it, next time do the penultimate step as well, perfect it, etc. This way, when learning a new step, the rest of the surgery has already been perfected and errors will not start to pile up.

Editor’s Note: The 26th European Society of Cataract & Refractive Surgeons Winter Meeting (ESCRS Winter Meeting 2022)was held virtually from February 18-20, 2022. Reporting for this story took place during the event. 

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