Learning to use the non-dominant hand - ASCRS PHACO...
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EW RESIDENTS October 2011 89 late development. Practicing or learning musical instruments can be helpful. Playing sports with an effort to use both hands is challenging. Once you are able to use both hands effectively in cataract surgery, you will be well on your way to per- fecting your technique. Kenneth L. Cohen, M.D. Phacoemulsification is now the most successful operation performed in the United States. For the novice surgeon to become a competent sur- geon, the path is complex. There are many acceptable techniques for each stage of the operation. One constant is that the novice must learn to co- ordinate two hands and two feet. Practice in the wet-lab is essential. To become comfortable using the non-dominant hand, my ap- proach is to eliminate the use of the foot pedals. The novice resident fo- cuses the microscope at the location of the corneal incisions. Only then is the resident handed a fixation ring and a blade. The resident con- centrates on using both hands to create incisions. Sculpting is per- formed by placing two hands on the phaco handpiece, the non-dominant hand stabilizing the handpiece. After creating a groove, the hand- piece is handed to the scrub tech and viscoelastic is injected. Then, the non-dominant hand uses a Drysdale nucleus manipulator placed through the side port inci- sion to rotate the nucleus 90 de- grees. A crossing groove is sculpted. For cracking the grooves, the hand- piece is again given to the scrub tech and viscoelastic is injected. Using two Drysdales, one placed through the main incision and one through the side port incision, the crossing grooves are cracked and the nucleus rotated. The novice does not have to think about fluidics. The novice Learning to use the non-dominant hand W ithin the tight confines of the anterior segment, the non-dominant hand plays an important role in cataract surgery. Used properly, it assists with positioning and sta- bilization of the eye, mobilization and ma- nipulation of tissues within the eye, and can protect structures during phacoemulsi- fication. But until this is mastered, the non- dominant hand can actually impede efficient and effective surgery by interfer- ing with followability, gaping wounds, dis- torting the cornea, misdirecting the globe, or even damaging ocular structures. For the large majority of surgeons who are not ambidextrous, use of the non- dominant hand is unnatural for the very reason that it is non-dominant. We gain skill in using the non-dominant hand through training, experience, and time. We have asked three experienced cataract in- structors for specific tips and techniques to improve the awareness and agility of the non-dominant hand. Our hope is that these ideas will help accelerate that learning curve for trainee surgeons. Sherleen Chen, M.D., and Roberto Pineda, M.D. Sherleen Chen, M.D. Instructor in ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary Linda M. Tsai, M.D. Cataract surgery is one of the most technical procedures to perform, ne- cessitating the use of both hands and feet simultaneously. In fact, the additional use of the senses of sight, touch, and hearing are required dur- ing phacoemulsification. The ability to use both hands adeptly is a ne- cessity for excellent cataract surgical technique. In much of cataract surgery, one hand is needed to manipulate an instrument. The second hand is needed for stabilization or manipu- lation of a second instrument. Even when it is not actively being used, the second instrument must be sta- ble. Care must be taken to ensure the second instrument hand does not cause problems during the pro- cedure due to inattention. Using both hands during bimanual irriga- tion and aspiration and bimanual vitrectomy allows access to 360 de- grees of the eye. Rarely, due to phys- ical architecture challenges of the eye and face, it may be necessary to switch hands. It has been clearly shown that dexterity can be developed with practice. Handedness is believed to be innately determined from birth, although there are studies of effec- tive “coerced” training of the non- dominant hand, particularly in left-handed individuals who are trained to write with their right hand. This training is believed to ef- fect cortical reorganization of the brain. What can you do to improve your non-dominant hand? You can practice as much as possible. Try using your non-dominant hand during the day for daily activities such as brushing your teeth, comb- ing your hair, locking and unlock- ing doors, eating with utensils, opening screw-top containers, and picking up small objects. Fine motor skills, such as writing and drawing, are usually reserved for your domi- nant hand, but attempt these with your non-dominant hand. Some even advocate writing from right to left in an effort to stimulate brain development. Doing things in tandem, such as swirling both hands in water or throwing two balls at the same time and juggling, can be ways to stimu- continued on page 90 concentrates on using the dominant hand and the non-dominant hand in a stable intraocular environment. As the resident progresses from novice to advanced beginner, em- phasis increases on using the domi- nant and non-dominant hands together. After cracking the nucleus, using aspiration, each quadrant is safely brought to the center of the pupil for emulsification. If the phaco needle becomes embedded in the quadrant in a lollipop fashion, the non-dominant hand inserts a Seibel nucleus chopper through the side port incision to gently disen- gage the quadrant, allowing carouseling and emulsification of the quadrant using partial-occlusion phaco. A useful maneuver to im- prove the use of the non-dominant hand with the dominant hand is bi- manual irrigation and aspiration to remove viscoelastic. The IOL optic protects the posterior capsule. The resident is instructed to keep the ir- rigation and aspiration instruments on the surface of the IOL optic. The advanced beginner needs 25 procedures to feel comfortable using both hands and one foot pedal so that learning chopping can begin. Evan L. Waxman, M.D. Fully formed surgeons take use of their non-dominant hand for granted. We use our second instru- ments to help hold back and protect the posterior capsule, to manipulate nuclear pieces into the phaco tip, and to rotate, crack, and chop. We use the shaft of the second instru- ment to assist with eye position. We take for granted that our second in- strument will not wander off and become an implement of destruc- tion, wreaking havoc on the iris, an- terior capsular rim, zonules, or posterior capsule. Linda M. Tsai, M.D. Associate professor of ophthalmology and visual sciences Washington University, St. Louis Kenneth L. Cohen, M.D. Professor of ophthalmology University of North Carolina at Chapel Hill Evan L. Waxman, M.D. Assistant professor of ophthalmology University of Pittsburgh School of Medicine Cataract tips from the teachers
Transcript of Learning to use the non-dominant hand - ASCRS PHACO...
EW RESIDENTSOctober 2011 89
late development. Practicing orlearning musical instruments can behelpful. Playing sports with an effortto use both hands is challenging.
Once you are able to use bothhands effectively in cataract surgery,you will be well on your way to per-fecting your technique.
Kenneth L. Cohen, M.D. Phacoemulsification is now the mostsuccessful operation performed inthe United States. For the novicesurgeon to become a competent sur-geon, the path is complex. There aremany acceptable techniques for eachstage of the operation. One constantis that the novice must learn to co-ordinate two hands and two feet.Practice in the wet-lab is essential.
To become comfortable usingthe non-dominant hand, my ap-proach is to eliminate the use of thefoot pedals. The novice resident fo-cuses the microscope at the locationof the corneal incisions. Only thenis the resident handed a fixationring and a blade. The resident con-centrates on using both hands tocreate incisions. Sculpting is per-formed by placing two hands on thephaco handpiece, the non-dominanthand stabilizing the handpiece.After creating a groove, the hand-piece is handed to the scrub techand viscoelastic is injected. Then,the non-dominant hand uses a Drysdale nucleus manipulatorplaced through the side port inci-sion to rotate the nucleus 90 de-grees. A crossing groove is sculpted.For cracking the grooves, the hand-piece is again given to the scrub techand viscoelastic is injected. Usingtwo Drysdales, one placed throughthe main incision and one throughthe side port incision, the crossinggrooves are cracked and the nucleusrotated. The novice does not have tothink about fluidics. The novice
Learning to use the non-dominant hand
Within the tight confines ofthe anterior segment,the non-dominant handplays an important rolein cataract surgery. Used
properly, it assists with positioning and sta-bilization of the eye, mobilization and ma-nipulation of tissues within the eye, andcan protect structures during phacoemulsi-fication. But until this is mastered, the non-dominant hand can actually impedeefficient and effective surgery by interfer-ing with followability, gaping wounds, dis-torting the cornea, misdirecting the globe,or even damaging ocular structures.
For the large majority of surgeonswho are not ambidextrous, use of the non-dominant hand is unnatural for the veryreason that it is non-dominant. We gainskill in using the non-dominant handthrough training, experience, and time. Wehave asked three experienced cataract in-structors for specific tips and techniques toimprove the awareness and agility of thenon-dominant hand. Our hope is that theseideas will help accelerate that learningcurve for trainee surgeons.
Sherleen Chen, M.D., and Roberto Pineda, M.D.
Sherleen Chen, M.D.Instructor in ophthalmology
Harvard Medical SchoolDirector of Cataract and
Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary
Roberto Pineda, M.D. Assistant professor of ophthalmology
Harvard Medical SchoolDirector of Refractive Surgery
Massachusetts Eye and Ear Infirmary
Linda M. Tsai, M.D.Cataract surgery is one of the mosttechnical procedures to perform, ne-cessitating the use of both handsand feet simultaneously. In fact, theadditional use of the senses of sight,touch, and hearing are required dur-ing phacoemulsification. The abilityto use both hands adeptly is a ne-cessity for excellent cataract surgicaltechnique.
In much of cataract surgery,one hand is needed to manipulatean instrument. The second hand isneeded for stabilization or manipu-lation of a second instrument. Evenwhen it is not actively being used,the second instrument must be sta-ble. Care must be taken to ensurethe second instrument hand doesnot cause problems during the pro-cedure due to inattention. Usingboth hands during bimanual irriga-tion and aspiration and bimanualvitrectomy allows access to 360 de-grees of the eye. Rarely, due to phys-ical architecture challenges of theeye and face, it may be necessary toswitch hands.
It has been clearly shown thatdexterity can be developed withpractice. Handedness is believed tobe innately determined from birth,although there are studies of effec-tive “coerced” training of the non-dominant hand, particularly inleft-handed individuals who aretrained to write with their righthand. This training is believed to ef-fect cortical reorganization of thebrain.
What can you do to improveyour non-dominant hand? You canpractice as much as possible. Tryusing your non-dominant handduring the day for daily activitiessuch as brushing your teeth, comb-ing your hair, locking and unlock-ing doors, eating with utensils,opening screw-top containers, andpicking up small objects. Fine motorskills, such as writing and drawing,are usually reserved for your domi-nant hand, but attempt these withyour non-dominant hand. Someeven advocate writing from right toleft in an effort to stimulate braindevelopment.
Doing things in tandem, suchas swirling both hands in water orthrowing two balls at the same timeand juggling, can be ways to stimu-
continued on page 90
concentrates on using the dominanthand and the non-dominant handin a stable intraocular environment.
As the resident progresses fromnovice to advanced beginner, em-phasis increases on using the domi-nant and non-dominant handstogether. After cracking the nucleus,using aspiration, each quadrant issafely brought to the center of thepupil for emulsification. If thephaco needle becomes embedded inthe quadrant in a lollipop fashion,the non-dominant hand inserts aSeibel nucleus chopper through theside port incision to gently disen-gage the quadrant, allowingcarouseling and emulsification ofthe quadrant using partial-occlusionphaco. A useful maneuver to im-prove the use of the non-dominanthand with the dominant hand is bi-manual irrigation and aspiration toremove viscoelastic. The IOL opticprotects the posterior capsule. Theresident is instructed to keep the ir-rigation and aspiration instrumentson the surface of the IOL optic.
The advanced beginner needs25 procedures to feel comfortableusing both hands and one footpedal so that learning chopping canbegin.
Evan L. Waxman, M.D.Fully formed surgeons take use oftheir non-dominant hand forgranted. We use our second instru-ments to help hold back and protectthe posterior capsule, to manipulatenuclear pieces into the phaco tip,and to rotate, crack, and chop. Weuse the shaft of the second instru-ment to assist with eye position. Wetake for granted that our second in-strument will not wander off andbecome an implement of destruc-tion, wreaking havoc on the iris, an-terior capsular rim, zonules, orposterior capsule.
Linda M. Tsai, M.D.Associate professor of ophthalmology andvisual sciences Washington University, St. Louis
Kenneth L. Cohen, M.D.Professor of ophthalmologyUniversity of North Carolinaat Chapel Hill
Evan L. Waxman, M.D.Assistant professor of ophthalmology University of PittsburghSchool of Medicine
Cataract tips from the teachers
EW RESIDENTS90 October 2011
The ophthalmic surgeon intraining (OSIT) can be so entrancedby the action at the business end ofthe phaco tip that he or she losestrack of the second instrument. Inthe best circumstances this results ina longer case. In the worst circum-stances this results in a consultationwith a retina colleague.
So how do we make our OSITaware of the non-dominant handand second instrument?
The technique of saying, withincreased urgency, “Pay attention toyour non-dominant hand” can beeffective but is limited by the wake-ful state of the patient. Furthermore,in the time it takes for this longphrase to come out of your mouthand make it into the ears and brainof your OSIT, the chopper can findits way halfway back to the opticnerve.
A technique that has helped mewith this and other aspects of surgi-cal training is pre-operative focus ad-justment—of the resident. Prior tosurgery, OSITs are asked to watchsurgical videos. They are instructedto watch not as if they were watch-ing the latest episode of AmericanIdol, but instead paying attention tosecond instrument position and use.They are asked to describe, out loud,what they noticed. Before the case a
code word is agreed upon that isused to refocus the resident on thenon-dominant hand when attentionwanders elsewhere.
After doing a few cases with thisin mind it seems to require only oc-casional reinforcement to keep non-dominant hand awareness issues atbay. EW
Contact informationTsai: [email protected]: [email protected]: [email protected]
Learning continued from page 89
Sugar takes onsweet new roleby Jena Passut EyeWorld Staff Writer
The journal Cornea is getting atransplant.
Alan Sugar, M.D., professorof ophthalmology, Kellogg EyeCenter, University of Michigan,Ann Arbor, will take over as edi-tor on Jan. 1.
“I’ve been involved with sev-eral journals over many years,and I have an interest in that, aswell as an interest in clinical re-search,” Dr. Sugar said.
Dr. Sugar, 67, has servedsince 2008 as an associate editorof Cornea, which is publishedmonthly by Lippincott Willliams& Wilkins and has a core audi-ence of corneal specialists andgeneral ophthalmologists inter-ested in the subspecialty. Editorsserve in 4-year terms.
Dr. Sugar belongs to morethan 20 professional societies andhas had 183 articles published invarious journals. He also has writ-ten or co-written 53 book chap-ters on ophthalmology.
Gail Reggio, executive direc-tor of The Cornea Society, whichsponsors the journal, said Corneashould benefit from Dr. Sugar’svast experience, both with thejournal and over his distin-guished career in ophthalmology.
“Dr. Sugar will continue toprovide excellent leadership atCornea,” Ms. Reggio said.
