Opening Your Mind to New Ideas

Mark Packer & Howard Fine

Several years ago, at a meeting of the European Society of Cataract and Refractive Surgeons, we volunteered to help teach a wet lab on complications of phaco.  The lab was held down a dingy corridor in some forsaken corner of the “Congress Centrum.”  The lead instructor, Brian Little, briefly described a technique for saving the errant capsulorhexis and showed some gorgeous videos with high magnification views of popping zonular fibers.  The technique involved a counter-intuitive maneuver, essentially pulling the flap in precisely the wrong direction.  Nevertheless, the capsule consistently behaved itself beautifully and the capsulorhexis was saved.  The impression Brian gave was that he had learned this technique from a cataract surgeon much more important and probably a lot more famous than himself.  In fact, it seemed to us that he had probably learned it from a well-established textbook of cataract surgery and that we had perhaps skimmed that chapter a bit too lightly.   Brian said, “I promise you this will work every time.”  Trying it on our own in pig eyes seemed to support his argument, but we were still somewhat hesitant to throw ourselves wholeheartedly into the technique.  As with anything new, we tried to look objectively at the potential benefit to our patients rather than focus on our own anxiety.  We did indeed try, and after repeated rhexis-preserving moments at Oregon Eye Surgery Center we knew that Brian really had a winner.

Sometime after that, during a casual conversation with Brian at a subsequent meeting on our home turf, while he was importuning us to contribute material for a video textbook of Ophthalmology, it came as a shock to discover that Brian had in fact come up with this little trick all by himself.  Relief, that we had not missed an important chapter on cataract surgery, was mixed with awe, that he had not yet published the technique himself.  “Too busy to write it up,” he said.

A couple of years later, while we were giving Grand Rounds at a well known university in the western United States, Brian Little’s technique came up again.  One of the faculty members, a cataract surgeon, interrupted the lecture to explain that the maneuver actually involved grasping the torn edge of the capsular flap as close to the point of its origin as possible and pulling in the direction one wanted it to go.  We stopped, and emphasized again, in several different ways, with lots of hand waving, that the pulling was in fact in the direction opposite to that in which one intended to go.  There was an awkward pause.  We weren’t sure if we’d gotten the message across or not, but in any case there were no further comments.  The lecture resumed.

Some techniques take a moment, or longer, to be fully grasped.  Some may take a lifetime.  Brian Little’s technique takes some getting used to because it is probably different from what one was initially taught, and it is also different from what one might expect.  But, of course, innovations tend to be unexpected.  Another example of an innovation that requires a moment’s reflection, or more, is cortical cleaving hydrodissection.  Just saying it may require some reflection (it is not cortical “cleavage”).  Cortical cleaving hydrodissection actually does permit aspiration of most if not the entire cortex during removal of the epinucleus, most if not all of the time.   How is this accomplished?  The key is decompression of the capsular bag and rotation of the lens after the fluid wave.  Injection under the rim of the capsule causes the lens to bulge forward as fluid is trapped within the bag behind the lens.  Pushing posteriorly on the lens will force the trapped fluid to come forward around the lens, lysing the connection of the capsule to the cortex.  A good rotation of the lens will strip away any bridging cortical tendrils.  The cortex is now loose, and will wash into the phaco tip with the epinucleus.   Any few remaining strands of cortex can be teased away when viscoelastic is removed after IOL insertion, thus avoiding I/A as a separate step in the procedure most of the time. 

As Wayne Dyer says, “You’ll see it when you believe it.”  (Parenthetically, you may wish to gauge the openness of your own mind by honestly evaluating your inner reaction to what you have just read, including any preconceived notions you may have about Wayne Dyer, the “new age” or Oprah).  Regardless, a conceptual understanding of cortical cleaving hydrodissection and a high level of confidence in that understanding (“believing it,” if you will) absolutely must precede the successful application of the technique in your own hands (“seeing it”).  Even if it occurs by accident in your OR one day (even the proverbial monkey typing random keys on a laptop will eventually write Hamlet’s soliloquy) you will not be able to consistently and repeatedly perform the technique unless the mind first grasps what the fingers need to do.  That’s just the way the world works.  (Can you really doubt the primacy of mind over matter, when you consider the incredible achievements that have come from the seeds planted years ago by Harold Ridley and Charlie Kelman?)

The best lessons in life come from experience, not from books, video tapes or journals (sorry, but we’ll wager that the publishers agree).  What makes experiential education so valuable is that we don’t forget what we’ve learned.  That heart-stopping moment in the OR when you thought you lost it, but Brian Little’s maneuver brought it back, is not going to be forgotten.  You will recall that moment through many if not all of your upcoming capsular adventures.  For this reason cataract surgery must ultimately be taught and learned in the operating room, where sight is on the line, where a real human being, a real patient with real feelings and the real desire to see, is lying there behind the eye you are working on.  Only that intensity focuses all the desire and skill in the world to bring about a happy ending.  Only that intensity will serve to remind you of what you need to know in the nick of time.