How to Graduate from SICS to Phacoemulsification

 When you think of modern day cataract surgery, Phacoemulsification (PE) immediately comes to your mind. It is time tested, best cataract surgery in the world. So every eye surgeon in India and Abroad wants to learn this technique. Medical education in India is such that not many of the post graduate medical colleges are teaching this technique practically. Most of our postgraduates pass their exam without doing even a single case of Phacoemulsification (PE).  Manual small incision Cataract Surgery (SICS) is the most commonly done eye surgery in India. Most of the eye surgeons and post graduates are able to do it. So everyone who is not doing PE wants to graduate from SICS to PE.

There are a few mental and technical prerequisites before making the transit from SICS to Phacoemulsification.

Mental prerequisites:

·         Remove fear & gain confidence.

·         Back up of experienced surgeon in OR (preferable)

·         Master one technique (copy one surgeon)

·         Case selection

Let’s elaborate on this- When one decides to leap ahead and shift to Phacoemulsification, it is best to introspect first. Am I prepared? One must ensure what exactly he/she is going to do and preferably start in presence/guidance of an experienced surgeon. One should have no confusion regarding the technique he is going to opt, rather try to copy the senior’s technique and then try to innovate later.

 Imagine your plan A for the whole case and introspect after every case for further improvement. Plan B must always be ready to take care of catastrophe. One must be able to identify the complications early and should be prepared to convert the case back to SICS or ECCE with no place for ego in mind.

Before choosing a case for phaco, co-morbidities must be seen before hand. Ensure a clear cornea, well dilated pupil and a NS 3 cataract. Have an eagle’s eye for deep set eyes, zonular dialysis, pseudoexfoliation, high myopia, posterior polar and very soft/hard cataracts.

The surgery should not be kept on a busy day. You should attempt when you are relaxed and not tired at all. Patient should be having good vision in his other eye and should not be very demanding.

It would be a piece of cake if you plan your OT with a senior surgeon, as his/her presence would not only boost up your confidence but also help you out in situation of crisis if any.

Technical prerequisites:

·         Hand, eye and foot co-ordination

·         Amphi-dextricity

·         Being friendly with machine

·         Ability of good wound construction & capsulorrhexis

·         Good microscope and phaco machine

·         Choice of anesthesia it should be Peribulbar or posterior sub tenon’s

SICS/ECCE surgeon must start making side ports, using instruments in the non-dominant hand and doing good capsulorrhexis.

I would suggest beginners not to start on a 2^nd or 3^rd hand machine as this makes our journey further difficult. The machine should be user friendly and the surgeon must understand the parameters for every step he/she is going to do. The simple tip here is again to copy someone whom you have seen operating and have an access to discuss the same.

Always plan before you enter and be ready to introspect, discuss and kill your ego whenever required.

Always use sharp blades, and be liberal with the use of viscoelastics, trypan blue and other consumables if required.

Manual SICS is a simple surgery. First of all two side port incisions are made at three and nine o’clock positions. Chamber is filled with visco-elastic and capsulorhexis is performed from the side port. Though capsulorhexis is preferred, Manual SICS can be performed even without complete rhexis or even after “Can-opener” capsulotomy. Here after undermining the conjunctive heamostesis done. A frown incision is given just behind the limbus. It is astigmatic neutral zone. Using crescent knife a sclera- corneal tunnel is made. Here we make deep pockets on both sides. Cornea is entered by 2.8 mm keratome and tunnel is extended on both sides by enlarging keratome.  Hydro dissection is done to prolapse out the nucleus. Nucleus is rotated to make it free from the bag.

There are various methods to bring the nucleus out of AC. I prefer ‘Sandwich technique’.  In this, after putting viscoselastic (OVD) above and below the nucleus, Wire vectis is kept behind the nucleus and Sinskie hook above it. They are gently pressed together and withdrawn slowly. They come out with nucleus in between them. Visco- expression of cortical matter is done. Rest of cortical matter is removed by Simcoe canulla. OVD is put again to form the chamber. Single Piece PMMA less is inserted in the bag. After hydrating the wound on both sides, OVD is removed by Simcoe canulla and chamber is formed. We press on top the cornea to check the integrity of wound. It is padded for at least 3-4 hours.

On the other hand, Phacoemulsification is a totally equipment based surgery. In Phacoemulsification after making side port incision, chamber is filled with OVD. In superiotemporal part of the limbus, a scratch incision is made at the 9 o’clock position.  From this incision, we make about 2mm of corneal tunnel by 2.8 mm keratome. Rhexis is performed from side port. Some people prefer to do rhexis from main corneal tunnel using Utrata’s forceps. Hydro dissection is performed to separate the nucleus from the capsule. Here we perform cortical cleavage hydro dissection. We press the centre of nucleus after each hydro dissection. We see the fluid wave travelling behind the nucleus. After this, a central trench is made in the nucleus. Nucleus is divided into two halves. Finally, they are emulsified one by one.

If you are not already doing capsulorhxis in all your cases of SICS, start doing it in all cases. Here is how you should start. After making side port incision trypan  blue dye is put in to the AC under Air (that is first air and then dye is put in the AC) after 5 seconds dye and air is replaced by OVD put into the eye from the side port. A cystitome is made from 26G- 27G needle. Cystitome is taken into eye from side port and 2.5mm incision is made on the anterior capsule of the lens starting from centre towards periphery. Then this is lifted up to make a flap which is engaged by the tip of cystitome and rotated circumferentially to complete the capsulorhexis. Ideally capsulorhexis should have 5.5mm diameter.

Before entering with phaco probe into the eye of a patient one should have feel of doing phacoemulsification eb externo. For this remove various density of nuclei by SICS and try to emulsify them in a bowl of water. If you keep rubber cap of a injection vial in bowl and keep nucleus inside its cup , then this simulates as you are working in anterior chamber (AC).You should try different nuclei  and have the feel how easy or tough is to emulsify these nuclei. Other methods is using Kimura eye. This has been developed by a Japanese scientist. In this you can practice rhexis as well as actual phacoemulsification.

 The third method is to practice on goat’s eye. Get fresh goats eyes from a butcher. Keeping it under microscope, we make side-port incisions fill it up with OVD and do the rhexis. Make the tunnel Incision as Phacoemulsification and do some central sculpting so that it can accommodate human cataract nucleus. Open the eye from the other side as ECCE and put Nucleus previously removed by SICS. Close the incision by sutures. Now do the Phacoemulsification from the other incision we made for this purpose. This way it is closest to doing Phacoemulsification in human eye.

Another way of transit to phaco can be through “Modular Training” but it has to be carried out under supervision. Here the learning surgeon initially starts with I/A and starts getting friendly with the machine. Also he/she develops the feel of foot pedal in the meanwhile. Thereafter he learns to “eat up” the broken pieces of nucleus and finally takes up the job of breaking up of nucleus into pieces. Wound construction and capsulorhexis is done by the experienced surgeon till the last so that inadvertent complications can be managed well and there are lesser chances of conversion back to SICS/ECCE.

Start as you do in SICS. After doing rhexis and making incision, make a sclero-corneal  tunnel as you do in SICS. Enter the Anterior Chamber with kerotome and do not enlarge it. After Hydro-dissection and rotation of nucleus enter with Phaco-probe and make a deep trench in the center of nucleus. The depth of trench should be at least 2/3 of thickness of nucleus. Now enlarge the tunnel and withdraw the nucleus by SICS. Now check the depth of the trench, initially when you think you have made a deep trench it is not at all deep. This way you will know how deep the trench should be. In initial few cases of Phacoemulsification whole case can be done, starting like this without extending the sclera-corneal tunnel.

Now you are ready for Actual modern day Phacoemulsification.

After cleaning and draping, speculum is inserted. Two side port incisions are given at 9 o’clock and 2 o’ clock positions. Chamber is filled with OVD and a corneal tunnel incision is given at 11 o’clock is 2.8mm keratome. Length of tunnel ideally should be 2mm. Now rhexis is done through side port or main incision. Cortical cleavage hydro dissection is done to separate the capsule and cortex. Nucleus is rotated and a deep central trench is made in the nucleus. Now the nucleus is divided into two halves using two Sinskie hooks or one Sinskie hook and a chopper. Rotate the nucleus to bring one half at six o’ clock position.

Take phaco-probe and impale in the centre of nucleus half and from the other hand (Holding Sinsekie hook or chopper) divide this into two segments. Take the segments one by one and emulsify them. Now bring the other half at six o’ clock position and do the same. Now take the I-A hand piece and remove the cortical matter. Otherwise initially you can use Simcoe canulla to remove the cortical matter. Now fill the chamber with OVD and inject a foldable IOL in the bag. As the first haptic goes in the bag and later you dial the trailing haptic into the bag. Using I-A Canulla OVD is removed. Tunnel is hydrated on both sides. Side port incisions are also hydrated. Wound is checked for any leak.

There are few common problems that a beginner encounters and surgical pearls-

1.       Often, there is a premature entry with iris prolapse. It is suggested neither to postpone the case, nor to continue from the same port. Iris should be reposited, wound sutured and another site should be chosen for wound construction.

2.       Ballooning of conjunctiva is another annoying yet trivial issue. The wound should not be constructed too posteriorly and if it happens, the fluid can be expressed.

3.       Tight wound leads to hydration of cornea leading to visibility problems. The wound should be revised instantaneously.

4.       Hypotony and shallow chamber should be avoided at every step.

5.       Too much push and pull should be avoided with the injector. It is better to slightly enlarge the wound and push the IOL smoothly.

6.       Adequate size of capsulorhexis is of primordial importance in phaco. One should aim for a rhexis between 5 and 6 mm. It is suggested not to proceed with a compromised/ extended capsulorhexis in beginning. The case should be converted to SICS/ECCE.

7.       It must be clearly understood that our aim is not just to complete phacoemulsification, but to do a better surgery with better visual rehabilitation. Hence, corneal protection is a must and maneuvering in the AC must be away from cornea.

8.       Choice of main port (superio-temporal) is better. I would suggest an ECCE/SICS surgeon to initially go with superior main port to have a more habitual environment.

9.       Choice of I/A (coaxial/bimanual) is again personal. It is just a matter of comfort of surgeon.

10.   Capsulorhexis can be done either with cystitome or with Utratas’ forceps depending upon the surgeon’s comfort. Preferably it should be done through the side port under a good cohesive viscoelastic.

11.   Trying fancy things like direct/vertical chop, chip and flip, iris hooks/CTRs, polishing the capsule should be attempted after the sample size crosses the 100 mark. There would be innumerous occasions to innovate, improvise and improve.

12.   In case of large PCR, a sulcus PCIOL can be attempted by the beginner, but things like ACIOL should always be kept handy. Things like SFIOL should be taken up as a secondary procedure.

Never treat yourself as a beginner. Stick to your plan, give respect to the tissues and graduate step by step as you studied one class after the other. In no time you will see that you have become the master of the Phacoemulsification. All the best!

 Dr vipin Sahni

Kaushalya Devi Eye Institute

Pilibhit UP

www.practicesolutions.in 

Ophthalmic practices The Indian scenario

Ophthalmology Practices - The Indian Scenario

      Ophthalmic practices in India are in variety of shapes and sizes. They start from single ophthalmologist working in a small room to large enterprises with hundreds of branches who are planning their IPOs. There are places where a patient is brought from their home and after treating them fully sent back free of cost. There are other places where for a minor chalegion treatment patient pay thousands of Rupees (more than Rs. 25000/-). I am describing here few of the common practice models. These models can help you plan out your career and practice development options.There are hundreds of variations on how you can practice ophthalmology, such as  Large practices or small business-like practices and Practices offering only a narrow subspecialty like retina/refractive only or ones offering every conceivable eye care services.

The kind of practice you join or build is under your control. And yet relatively few young surgeons I have met, thought deeply about where and how they would like to spend their 30-50 years career. Even fewer middle-aged surgeons already in practice draw up plans to achieve one particular endpoint model.

While everyone knows there are lots of potential practice models, no one has thought of the varieties of practices and laid out their similarities and differences, the advantages and disadvantages of each. I would like to enumerate that for you here, so that one can choose one or the other way of practicing ophthalmology. Don’t think too much about theses arbitrary categories. There is a lot of overlap and mix-and-match potential among these alternatives, and the boundaries between one type and another can be blurred. I have concentrated on the most common private practice models and their various scales and variations, this does not include governmental, military, educational, and similar institutional settings, where the ophthalmologist is a full time associate and with  no entrepreneurial opportunities.

Small solo practice

For the sake of this discussion, let’s arbitrarily set this as a practice with less than Rs. 24 lac in annual collections. Such a practice may either be kept small intentionally for peri-retirement or lady ophthalmologist, who wants to work less to stay more time at home, and give time to family and kids. Or may be held back by marketplace or limitations of the ophthalmologists to provide just OPD care or not able to provide full services.

Strengths: From a lifestyle perspective, nothing beats a small solo practice, unless you are in such a practice involuntarily. With just two or three loyal staff and a slow clinical pace, I have seen few surgeons in such practices who relish what they can do with their time off and who are perfectly comfortable with the accompanying low income.

Weaknesses: Given the high fixed costs of modern practice and the need for a minimum number of patients to cover these costs, the profit margins are much lower in this setting. But in small cities where expenses are very less (where a good compounder takes any thing between 1500/- to 6000/- and other staff is also less paid) they survive easily.

Earning potential: May be as low as Rs. 40000/- to 2.0 lacs per month

Larger solo Practice

You are on your own, you are the only boss and you have to answer no one. In India most of the happiest surgeons I know are in this category, with no partners to interfere and a comfortable business that usually does not exceed Rs. one to two crore in annual collections.

Strengths: The chief strength of this practice model is control, you have on every thing. On the fees you want to charge to the patients, number of patient you want to see daily, hours you want to work may vary accordingly. You can make management decisions on a whim, by adding employees, ophthalmic assistants or even ophthalmologists, you can preserve control while still ramping up the scale.

Weaknesses: In addition to the unshared fixed costs of a solo practice of any scale, even the most robust solo practices are really solitary. And beyond this subjective feeling, the objective reality is that as a solo practitioner you are vulnerable to the encroachment of larger practices in your practice area, it is also difficult to maintain good health and continued enthusiasm to pull yourself up all the time. Prolonged illness or just a little extra time away can be economically punishing.

Earning potential: Pre-tax income typically lies between Rs. 50 lacs to 2.5 crore. Dispensary, optical dispensing and other sources of passive income are also exploited

Visiting Ophthalmologist Practice

You need not have a single setup. A large number of subspecialists and even generalists practice largely, out of many clinics (visiting many Nursing homes or hospital to provide Eye care). Using the facility, staffing, marketing, and patient resources of such hospitals, you can avoid the complications of business ownership and still enjoy the pleasure of independence. This career approach can be unsettled as you don’t have anything of yours.

Strengths: Like a clever parasite, such eye surgeons move in and use the host’s resources to provide patients, staff, facilities, and systems etc. basically everything. Some of these are doing very good business.

Weaknesses: With this approach to practice, even after several years you will feel like a permanent visitor everywhere you work, except perhaps for your personal office at home. You will not be an employee, but not a free agent either. And since your host practice is likely to change visiting providers on a whim, you are susceptible to loose an important part of your income overnight.

Earning potential: You share the earnings in that set up. This can be any thing like 50-50 to 75-25(If instruments are yours). It is typical as a long-term visiting provider for many years in the same practice, either you have to pay a fixed rent or share the profits. As such, your income will be proportional to your personal ambitions. You will probably make significantly less than if you run your own fixed-site practice, but you will have fewer headaches and lower fixed expenses.

Single subspecialty practice

 This is a practice with just retinal care or just glaucoma subspecialists or only pediatric ophthalmology. Unless in a large metro market or high referral practice, such practices are difficult to survive without bread and butter - cataract surgery

Strengths: In a pure subspecialty practice for example, a pure retinal or oculoplastics or glaucoma setting, margins are higher. This is not like a multi-subspecialty practice, where the naturally higher profit margins of retinal care, as one example, are often not accounted for, resulting in a financial subsidy flowing from subspecialists to generalists.

Weaknesses: The most prominent weakness of this practice model can be access to patients. With multiple subspecialists to feed in a single group, it sometimes becomes necessary to stretch satellite locations hundreds of miles from the main office, reducing both efficiency and profits.

Earning potential: When it works and there are enough patients to care for, this is the most profitable setting for any subspecialist ophthalmologist.

Larger, All subspecialty practice

 You will find at least one of these practices in most of the large cities of the country. These are typically the practices with virtually all primary care, general ophthalmology and subspecialty services available under one roof, with ancillary medical and optical coverage. A hub office with many spoke offices may be there. Most practices are more than 20 years old; many of them are multigenerational.

Strengths: These are the largest eye care Institutions in the market. It is a relief to become an associate in these larger organizations because, once developed, they are hard to dislodge from their primal position. Such practices will be first in line at the managed care if efforts to limit provider panels resurface with any vigor in the years ahead. These positives are potentially outweighed by the weaknesses.

Weaknesses: There is a tendency for practices on this scale to be elephantine in their decision-making and execution. New ophthalmologists who join such large practices, often take some time to settle into a bureaucratic tempo that can be unaccustomed and frustrating. And if you think you have joined the big boss and now every thing will be well than you are wrong. There is a lot of internal competition for surgical cases as there are many specialists for each sub-speciality. At the end of the day, with proper management these largest practices can be made smarter enough to stay durably in the lead.

Earning potential: Being a provider in such practices is often gratifying; with colleagues galore and a sense of secure tenure in the community, but this is not the most profitable setting.  Typically, on higher overhead levels and somewhat slower management decisions, which can allow smaller and more nimble competing providers to pull ahead. In the long run, the security of the income of doctors in this model can make up for the somewhat lower year-on-year earnings.

Multi specialty Medical Practice

 It is hard enough working with five or 10 fellow ophthalmologists in a mid sized eye clinic. Imagine the complexities and conflicts that arise when a few ophthalmologists are just one department in a 50- or 500-doctor group. Despite the extensive growth of multi specialty practices in most parts of the country since the advent of prepaid health care and the tendency for such practices to skip adding eye departments due to high costs and difficult recruitment, this opportunity is still open to you if you are looking for a job today.

Strengths: The chief advantage is access to contracts and a tendency in larger clinics for the doctors to be blissfully un www.practicesolutions.inengaged with the business details of their practices, which is great if you hate management burdens.

Weaknesses: As a provider in such settings, your voice is limited, and any policy you influence is influenced slowly. Your favorite saying has to become “I can live with that.”

Earning potential: The greatest concern among specialty doctors in multispecialty clinics is high overhead and the almost inevitable subsidy that flows from specialists to primary care providers. There can be a profound diseconomy of scale that leaves many general ophthalmologists and subspecialists in such settings taking home only 20% to 30% of their personal collections.

Small Charitable Practice

Small charitable Practices are usually opened by some organization to get some fame in the general public. To fulfill the aim, they invest some money collected from public as infrastructure. In religious organizations most of the infrastructure is usually present, so they invest in some instruments/equipments. But now a day’s many new practitioners are opening this type of practice to avoid competition. Initial registration is low, then they charge extra for everything.

Strengths: Ophthalmologists join these charitable hospitals in initial days (just after their post graduation) to practice surgery and get some experience of practice in private setup. If patients number is good in such charitable hospital, ophthalmologists join this so that they get some fame in the city, which help them, later when they open private practice. You have nothing to loose in this setup. 

Weaknesses: Some times in these setups, number of surgeries is very low and instead of learning surgeries you forget good practicing habits and your attitude becomes “every thing is OK”

Earning potential: Income in this set up is usually only salary, which is also very low.

Large Charitable Institutions

     These are old Charitable Institutions which are providing quality

     eyecare at affordable price to poor as well as to those who can

     pay. And I tell you they are minting money like any private

     institution. Basically these are volume players. If a practitioner is

     doing 2-3 surgeries a day he has to fulfill all expenses, his salary

     and bring return on his investment from these, so he has to

     charge more. But when you have  lot of surgeries than cost is

     distributed in all, so pricing can be kept moderate or even low and

     even then you can earn more profits.

Strengths: Founder/ Initial eye care providers of these institutions were very smart and hardworking. They used their surgical as well as entrepreneur skills to develop these practices from public money and donations and most of these have become giants and giving all private eye care providers run for their money. These are volume players most of them are charging nominally but numbers are so much that these are earning hand fully. But established senior ophthalmologists here are now getting salaries at par with private players.

Weaknesses: Junior ophthalmologists get poor salaries here. They have to work more hours per day, this may be anything between 10 to 14 hours a day.

Earning potential: Incomes are fixed and usually less than their private counter parts.

Using this informal guide, you can see that some practice models are more profitable while others are more secure. If you are ready to build, join or re-engineer a practice, use the broad categories above to guide your thinking. Don’t settle unconsciously for whatever opportunity happens your way. Plan and dream your way to the practice setting you deserve.

Dr Vipin Sahni

drsahni@practicesolutions.in

www.practicesolutions.in