Dr Suresh K Pandey's  Journey as an Eye Surgeon in Three Continents

Learning and Fine-tuning Cataract Surgery and Lessons Learned during Past 2 Decades

Dr Suresh K Pandey,

MBBS, MS (Ophthalmology, PGIMER), Anterior Segment Fellowship, (USA), Director, SuVi Eye Institute & Lasik Laser Centre,

C 13 Talwandi, KOTA, RAJ., INDIA; Phone +(91) 93514-12449 (mobile)
E-mail:suresh.pandey@gmail.com, Website: www.suvieye.com

Visiting Assistant Professor, John A Moran Eye Center, University of Utah, USA and Sydney Eye Hospital, Save Sight Institute, University of Sydney, Australia

INTRODUCTION:

Cataract surgery with intraocular lens (IOL) implantation has become the most common and most successful of all operations in ophthalmology. My first exposure to ophthalmology was during my childhood as I had seen my grandfather performing intracapsular cataract surgery (ICCE) using Von Graefe cataract knife. He was trained in cataract surgery (ICCE) by a British Ophthalmologist when India was under British rule. We used to play with aphakic glasses and that was the beginning of my desire to become an ophthalmologist!  

THE VERY FIRST CASE- ECCE with RIGID IOL: After completing medical school, I was fortunate to get ophthalmology residency in India’s premier training institute in Chandigarh. I did my first cataract surgery (ECCE) and intraocular lens (IOL) implantation in the year 1995, and even though it was less than 2 decades ago, it seems like a whole era (and more) has passed since then. This surgery was done as an ophthalmology resident at the premier training institute in India- Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. It was an extracapsular cataract surgery (ECCE) with implantation of a rigid monofocal, PMMA IOL. I had seen and assisted many surgeries by that time, and like all trainee assistants, would be itching to get my chance as it all seemed so simple when done by the consultants.

Patient Details: My patient was a 55 year old man with a mature white cataract in the left eye. It may seem bizarre now, but in those days, most ophthalmology residents would start of their training with mature white cataracts, because most patients turning up for surgery in teaching institutes would come with advanced cataracts. Also, intra-capsular cataract surgery (ICCE) camps were just phasing out in India at the time and the mindset continued, where white mature cataracts were considered “ripe” to be “easily plucked”!! And most ophthalmology residents were also happy, as no matter what happened during surgery, the postop vision would surely be better than the Perception of Light vision seen in these cases!!

Surgical Technique: We were taught extracapsular cataract extraction (ECCE) through an incision extending for 4-5 clock hours. Most of the trainee surgeons were taught to perform can-opener capsulotomy with a bent 26 gauge needle giving multiple nicks in the anterior capsule. Since trypan blue /ICG dyes were not available for anterior capsule staining, an envelope or can-opener type of anterior capsulotomy was used for these white cataracts. The nucleus could be easily removed, with some pressure at the inferior limbus and with depression of the posterior scleral lip, using an irrigating Vectis. Cortical aspiration (of the little cortical material) was done using a Simcoe canula. The IOL used was a rigid PMMA IOL (6 mm optic with dialing hole) with PMMA haptics. The IOL was held with a lens (IOL) holding forceps and implanted into the capsular bag through the envelope capsulotomy. We were taught to dial the trailing haptic into the bag with a McPherson’s forceps, which was the trickiest part and then the remaining capsule was removed using Utrata’s capsulorhexis forceps. A good anterior chamber wash was given and I placed five to six interrupted 10-0 nylon sutures. The change from the white cataract to the clear red glow was quite dramatic and thrilling! The surgery had been performed under peribulbar block, and yet the patient was little uncooperative by the end of the surgery, which was to be quite expected, considering I had taken a little over one hour in the entire surgery!!

Visual Outcome: The vision on first post op day after removing the bandage (yes, we had a full bandage overnight for all our cataract surgery cases!!) was 6/36 with the naked eye, improving to 6/12 with pin-hole. The patient and the surgeon were both thrilled, and this was almost better than expected!

MY EXPERIENCE WITH SICS: My first case for small incision cataract surgery (SICS) was a white mature cataract with preoperative vision of hand movements close to face. After performing conjunctival peritomy, I carefully created scleral pocket incision. This was followed by trypan blue assisted anterior anterior capsulorhexis (CCC). I then used technique of hydrodissection to prolapse the nucleus out of the bag removed via small “self-sealed” incision using Fishhhok technique (popularized by Dr. A. Henning from Nepal). This was followed by cortical wash using Simcoe Cannula. A rigid PMMA IOL was implanted in the capsular bag.  The post operative recovery was 6/12 unaided and 6/6 with pin hole.

Video link for SICS with IOL Implantation: http://www.youtube.com/watch?v=u___Bjr1A3Y&feature=c4-overview&list=UU12vTF4P0xWnhvjGbG2h94w

CATARACT SURGERY EXPERIENCE DURING MY RESIDENCY TRAINING: All patients presenting with cataract were admitted in the hospital one-two days before surgery, their eyelashes were trimmed on the night before surgery, and some surgeons also put an overnight test bandage, which  was opened on the day before surgery and a conjunctival swab taken and sent for microbiological evaluation. The patients were also kept overnight following the surgery and discharged the next morning, thus ensuring a hospital stay of more than 3 days! Postoperative follow up schedule included instillation of antibiotics/steroids eye drops 4-6 times a day tapering them over a period of 6 weeks. After waiting for 6 weeks, the patients were prescribed final spectacles. It was not uncommon to see postoperative refraction needing a cylinder of 1 to 3 diopters (against the rule astigmatism) in most of these cases. Postoperative intraocular pressure (IOP) spikes were also not uncommon as residents were apprehensive to go beneath the IOL to remove the OVD and almost always left some ophthalmic viscoelastic devices (OVD) in the capsular bag, but since we used only methylcellulose and not Sodium hyaluronate etc., these IOP spikes were not hugely problematic. Suture removal was not done routinely, but many of these patients needed suture removal for suture related discomfort (foreign body sensations etc), loose suture, exposed knots etc. Some patients also ended up with iris prolapse and we had to go back to the operation theatre to reposit the prolapsed iris or to reform the anterior chamber Some patients also had mild ptosis postoperatively, due to peribulbar block and superior rectus bridle suture. As the expected visual recovery was in the range of 6/24 to 6/18 unaided, and there was a definite time frame for postoperative recovery, most patients were advised surgery only when their vision had dropped significantly due to cataract. Operating on 20/30 cataracts for glare or mild posterior subcapsular cataracts causing visual discomfort was unheard of in those times, and was considered a sacrilege in teaching institutions!! During our resident teaching, a lot of emphasis was placed on teaching the skills of suturing so as to induce less astigmatism, to carefully bury the knots, to have equidistant sutures of equal and appropriate length, and to ensure proper IOL positioning in the capsular bag and ensure that anterior chamber was well-formed at the end of surgery.

CATARACT SURGERY: MY EXPERIENCE IN USA & AUSTRALIA: After completion of my residency training in Chadigarh, India, I had limited experience with phacoemulsification as this technique was just introduced in India in 1990s and most of the teachers were mastering it at the time, including my mentor Professor Jagat Ram.   I was fortunate to get an opportunity to get fellowship at Storm Eye Institute, Medical University of South Carolina, Charleston, SC, USA and at John A Moran Eye Center, University of Utah, Salt Lake City. I practiced phaco chop techniques in post mortem eyes using Miyake Apple posterior video technique and was also involved with research using Miyake Apple technique.^1-4 Finally, I moved to Sydney at Sydney Eye Hospital, Save Sight Institute, University of Sydney, Australia and thanks to Dr Anthony Maloof and Dr John Milverton for refining my surgical skills while dealing with complex phacoemulsification procedures. It was in their guidance, that I honed my surgical skills in phacoemulsification, learned to master phaco using both hands and even had my first  opportunity to perform live surgery during the Video Catarrata international conference at Milan, Italy (October 2005). (Figure 1).

I owe a lot to my mentors who instilled great interest in mastering the art of cataract surgery thus shaping my professional career in ophthalmic microsurgery . The first was Prof Jagat Ram (PGIMER, Chandigarh, India) who helped me to get a preceptorship with Professor David Apple at Medical University of South Carolina, Charleston, SC, USA. Dr. David Apple and the USA experience at Storm Eye Institute, Medical University of South Carolina, and Moran Eye Center, University of Utah was a rich and rewarding experience and helped me to get international recognition during the ASCRS/ESCRS and AAO conferences (Figure 2).⁵

EXPERIENCE IN INDIA:

After gaining 7 years of international experience in USA and Australia, I returned to India (together with my spouse Dr Vidushi Sharma, who is also an ophthalmologist) and we established SuVi (Su for Suresh and Vi for Vidushi) Eye Institute Lasik Laser Center at Kota, India. Due to our wide experience in the field of ophthalmic microsurgery, our practice attracted several patients after its inception. I continued my interest to teach complex phacoemulsification in conferences by presentations and performing live surgeries (Figure 3).

In our practice, we counseled cataract cases and offered them the most appropriate IOLs. Majority of patients in our practice opted for small incision phacoemulsification surgery in topical anesthesia using 2.2 to 2.8 mm incision and implantation of premium IOLs (toric, multifocal and multifocal toric and accommodating IOLs),  as well as preloaded IOLs became more and more common.

VIDEO LINKS:

1. Pearls for Toric/Multifocal Toric IOL Implantation http://eyetube.net/video/pears-for-acrysof-restor-toric-and-acrysof-toric-iol-implantation/
2. Pearls for Tecnis Toric IOL Implantation http://eyetube.net/video/managing-cataract-with-astigmatism-surgical-pearls-for-implantation-of-tecnis-toric-iol/

Experience with India’s First Toric Multifocal IOL Implantation:  We had the opportunity to perform India’s first Tecnis toric multifocal IOL (AMO Tecnis)  implantation in a 55 year old gentleman who had cataract in the right eye with co-existent corneal astigmatism. His preoperative vision was 20/60 with glasses. After discussing various options, we settled for implantation of a multifocal-toric (AMO Tecnis) IOL in his left eye.

The phaco surgery and implantation of toric multifocal IOL procedure was done under topical anesthesia, and yet the patient was quite comfortable as the entire surgery took about 10 minutes during which time, I was constantly talking to the patient, to allay any anxiety. Our team probably spent more time on the investigations (topography, OCT and IOL power calculation) than during the surgery and a much greater time in patient counseling than in surgery plus biometry combined!!

I used an AMO Signature phaco machine with Ellips transversal ultrasound and a bimanual irrigation-aspiration to remove the cortical material. The IOL (AMO Tecnis Toric Multifocal IOL) was implanted in the capsular bag using an Emerald Injector system. The patient was made to read a newspaper immediately after surgery. The vision on the first post – op day was 20/20 unaided and N6 unaided. The patient was thrilled with visual outcome (Figure 4).

 Video Link for Tecnis Toric Multifocal Implant:

http://www.youtube.com/watch?v=6VUF0mHX0XA

While there was almost no discussion about type of IOL during my ophthalmology residency days, now the bewildering range of options in IOLs leaves most patients quite confused. So, the surgeon/ counselor has to spend a lot of time gently guiding the patient to choose the most appropriate IOL, while still leaving the decision in his/ her hands. Starting with the AMO Array IOL in the late 90’s, now we have an array of multifocal IOLs as well!!

During my residency days, ophthalmic surgeons also used the general surgeons’ dictum “Big surgeons make big incisions”!!! These big incisions definitely made it easier and safer to deliver the nucleus without any complications, but we now use an incision less than one fourth the size and the race to get smaller and smaller continues. Smaller is definitely better, and therefore newer advances in phaco machines and IOL injector delivery systems constantly try to minimize the size of the incision further. Availability of preloaded IOL delivery system is a great achievement considering avoiding IOL manipulations, contamination and implant loading difficulties.

VIDEO Link for Implantation of Alcon AcrySof IQ IOL Using AcrySert C Pre-loaded IOL Delivery System

http://www.youtube.com/watch?v=kmEpK0B3_Ig

Implantation of Hoya IOL Using Hoya iSert Pre-loaded Delivery System

http://www.youtube.com/watch?v=p-wpZfZ8jzo

Phaco and IOL Implantation in Postural Disorders: I have opportunity to perform topical phaco and Multifocal IOL (AMO Tecnis) implantation in a patient in sitting position (on 2 chairs) and the surgeon in standing Position. This patient as unable to lie flat on the operation table due to cardio-pulmonary problems. Postoperatively, this patient regained 20/20 and N5 vision (unaided). 

Video Link: Phaco in  Postural Disorders

http://www.youtube.com/watch?v=jb0yXVVpajM

CATARACT SURGERY TEACHING & TRAINIING- REACHING GLOBALLY-CONNECTING THROUGH  EYETUBE/YOUTUBE: 

Our interest in documentation and sharing complex cataract surgery prompted us to make a YouTube channel dedicated to cataract surgical videos (http://www.youtube.com/user/Drsureshkpandey) which attracted many views (304,882) and subscribers (328). This helped us to make new connections with ophthalmic colleagues, and it was our privilege to have ophthalmologists come over to SuVi Eye Institute & Lasik Laser Center, Kota, India for surgical training from as far away as Azerbaijan, Saudi Arabia, Switzerland, USA and Ireland. Their journey from a distant country to a small Indian city (Kota, Rajasthan) is a testament to the rising influence of social media interactions (Figures 5 and 6).

Figure 5A. Dr Mubariz Qahramanov, an eye surgeon from Azerbaijan visited Kota, India for few weeks to learn & fine-tune his surgical skills in phaco and anterior segment surgery. Figure 5B. Visiting ophthalmologists from USA and Switzerland for training in complex phacoemulsification cases and premium IOL implantation.

VIDEO LINK: Social Media and Training in Ophthalmic Surgery: http://www.youtube.com/watch?v=SO233GCcLZk

CONCLUSIONS: Cataract-IOL surgery had undergone significant advancement during the past few decades. The recent innovations in intraocular lens (IOL) technology have been some of the most exciting advances in ophthalmology to date. Because of this we now have the ability to offer patients improved postoperative vision by greatly diminishing their spherical correction (ashperical IOL), astigmatism (toric and multifocal toric IOLs), cataract and presbyopia (multifocal and accommodating IOL), the level of satisfaction after surgery is at an all-time high.

I have come across too many advances to list here, but a few stand out in my mind as exceptional. The first was the progression from the large (scleral tunnel) incision to the smaller (clear corneal) incision (thus making cataract surgery bloodless!). Second, the folding technology now employed by the majority of intraocular lens implants has delivered a huge benefit to patients in the form of shortened postoperative recuperation. The concept of cataract surgery’s eliminating preexisting astigmatism as a postoperative goal gave birth to the “refractive” cataract surgeon. IOL injection systems, from folding forceps to injectors and now preloaded IOLs, have bred an entirely new field of discovery, experimentation, and triumph. Studies of light adjustable lens (LAL) will provide surgeon to avoid IOL explantation as a result of refractive surprise during the postoperative period.  Use of micro-phacoemulsification instrumentation in development may, in all likelihood, shrink the size of a main surgical incision to less than 2 mm for the majority of operations. Finally, femtosecond laser-assisted cataract surgery represents a potential paradigm shift in cataract surgery. All these advancement will help surgeon experience "20/happy" goal ". Cataract surgery has taken giant leap with the introduction of femtosecond laser system that will further improve the visual outcome.

REFERENCES:

1. Pandey SK, Werner L, Escobar-Gomez M, Visessook N, Peng Q, Apple DJ. Creating cataracts of varying hardness to practice extracapsular cataract extraction and phacoemulsification. J Cataract Refract Surg. 2000;26(3):322-9.
2. Pandey SK, Werner L, Escobar-Gomez M, Roig-Melo EA, Apple DJ.

Dye-enhanced cataract surgery. Part 1: anterior capsule staining for capsulorhexis in advanced/white cataract. J Cataract Refract Surg. 2000 Jul;26(7):1052-9.

3. Werner L, Pandey SK, Escobar-Gomez M, Hoddinott DS, Apple DJ. Dye-enhanced cataract surgery. Part 2: learning critical steps of phacoemulsification.J Cataract Refract Surg. 2000 Jul;26(7):1060-5
4. Pandey SK, Werner L, Escobar-Gomez M, Werner LP, Apple DJ.

Dye-enhanced cataract surgery. Part 3: posterior capsule staining to learn posterior continuous curvilinear capsulorhexis. J Cataract Refract Surg. 2000 Jul;26(7):1066-71.

5. Pandey SK, Werner L, Apple DJ. Interlenticular Opacification: Video award during the ASCRS Symposium on Cataract IOL and Refractive Surgery.

LINK FOR VIDEOS:

1. Small Incision Cataract Surgery (SICS) with Rigid IOL Implantation http://www.youtube.com/watch?v=u___Bjr1A3Y&feature=c4-overview&list=UU12vTF4P0xWnhvjGbG2h94w
2. Pearls for Toric/Multifocal Toric IOL Implantation http://eyetube.net/video/pears-for-acrysof-restor-toric-and-acrysof-toric-iol-implantation/
3. Pearls for Tecnis Toric IOL Implantation http://eyetube.net/video/managing-cataract-with-astigmatism-surgical-pearls-for-implantation-of-tecnis-toric-iol/
4. Pearls for piggyback IOL Implantation:  http://eyetube.net/video/piggyback-implantation-of-toric-and-multifocal-iols-exploring-uncharted-territory/
5. Phaco in  Postural Disorders http://www.youtube.com/watch?v=jb0yXVVpajM
6. Social Media and Training in Ophthalmic Surgery: http://www.youtube.com/watch?v=SO233GCcLZk
7. Implantation of Alcon AcrySof IQ IOL Using AcrySert C Pre-loaded IOL Delivery System

http://www.youtube.com/watch?v=kmEpK0B3_Ig

8. Implantation of Hoya IOL Using Hoya iSert Pre-loaded Delivery System

http://www.youtube.com/watch?v=p-wpZfZ8jzo

9. Tecnis Toric Multifocal Implantation:

http://www.youtube.com/watch?v=6VUF0mHX0XA