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“There is no “right” or “wrong” technique for cataract surgery.”

Interactive session with Dr.Uday Devgan, MD, FACS, FRCS(Glasg)


Uday Devgan, MD, FACS, FRCS is an international expert in ocular surgery, with a special interest in cataract, refractive lens implant, and LASIK surgery. Dr. Devgan is both in private practice, where he specializes in the full spectrum of vision surgery, as well as in academic medicine as Associate Clinical Professor at the Jules Stein Eye Institute at the UCLA School of Medicine.Dr. Devgan has operated a highly successful cataract and refractive lens practice for the past 10 years in Los Angeles and Beverly Hills, California. His expertise in the areas of cataract removal, refractive lens exchange, and accommodating / multi-focal lenses provides patients with more surgical options.After graduating as valedictorian of Santa Monica High School, Dr. Devgan accepted multiple scholarships to UCLA where he majored in microbiology and molecular genetics. He earned his M.D. with Highest Distinction at the top of his class at the USC School of Medicine where he was co-president of the Alpha Omega Alpha medical honor society. He trained at the Jules Stein Eye Institute at UCLA, where he won awards for outstanding achievement as well as research.He has personally taught surgery to every UCLA ophthalmology resident surgeon for the past decade in his position at Chief of Ophthalmology at Olive View-UCLA Medical Center. Dr. Devgan is the only faculty member to have won the annual UCLA teaching award twice, and annually he awards the best UCLA resident ophthalmologist with the Devgan Award for Surgical Excellence.

 


eOphtha: First of all, where in the evolution of cataract surgery, is phacoemulsification placed if we consider the room for future development too?

Uday Devgan: Ophthalmology is a field that is always moving forwards – never sitting still. And while we see phacoemulsification as a great procedure now, there’s no doubt that there will be a better procedure in the future. Look at today – the way you do cataract surgery now is quite different that it was done just 10 years ago. Just think: what if we could emulsify the cataract while still in the capsular bag using a femtosecond laser, then make a small 1-mm peripheral rhexis through which we would aspirate the entire lens material, and then fill the capsular bag with an injectable polymer which would provide accommodation? I’m simply daydreaming about the future, but there will be something better for sure.

eOphtha: What are the areas where one can improve comprising the method or the surgical skills?

Uday Devgan: Surgeons must be able to use both hands comfortably. All resident or registrar surgeons should practice doing their daily activities such as brushing teeth, shaving, eating, or even writing with their non-dominant hand. No matter how surgery evolves, it will require a surgeon and if you are adept at using both hands you will have an advantage.

eOphtha: While learning the art of phacoemulsification, some take a little bit of longer time as compared to those who pick it up very early. Does this early learning or fast grasping help make a better surgeon?

Uday Devgan: Everyone has to climb the learning curve for cataract surgery – no one is born as an outstanding ocular surgeon. While some people can master a technique a bit faster than others, I think it takes thousands of hours of practice for any surgeon to truly be outstanding. I have personally trained more than 100 ophthalmology residents over the past dozen years and I can tell you that just about any surgeon can master cataract surgery with drive, determination, and hard work.

eOphtha: So far as the teaching institutes are concerned, do you think the simulator does a good job, for new surgeons to at least get a hang of things before being exposed to the real life situations?

Uday Devgan: While I have my own private clinic in Los Angeles and I am a partner in a large ocular surgery center in Beverly Hills, I still spend time every week teaching residents at a teaching hospital. I am on the clinical faculty of the Jules Stein Eye Institute at the UCLA School of Medicine and I am Chief of Ophthalmology at Olive View UCLA Medical Center in Los Angeles. We are fortunate enough to have purchased a surgical simulator device which is truly amazing and quite expensive. And I think this device is helpful to develop hand-eye coordination and fine motor skills for working under a microscope, but it is not a substitute for actually doing surgery on real patients while being mentored by an experienced surgeon.

eOphtha: Coming to the technique, since there are a wide variety of choices, how should we go about choosing one from the other?

 

Uday Devgan: You should try all techniques and then decide which ones are best in your hands. There is no “right” or “wrong” technique for cataract surgery. Some surgeons prefer phaco-chop while others prefer divide-and-conquer. You tell me, which is best in your hands?

eOphtha: Some surgeons find the twin port irrigation and aspiration inserted separately can perform better than a single port.  Your comment.

Uday Devgan: Again, both are very reasonable choices for cataract surgery. The question is which technique is most comfortable in your hands and which produces the best and safest results for your patients.

eOphtha: With the amount of leap in the field of refraction and softwares confirming better outcomes, has it helped a surgeon to perform better or has it become a bane because there is no room for improvisation?

Uday Devgan: There will always be room to become better and provide better outcomes. Remember that in cataract surgery, we still have a long way to go. While I can achieve plano +/- 0.5 diopters in 98% of LASIK patients, when it comes to cataract surgery, even the world's best surgeons cannot produce outcomes that tight.

eOphtha: When compared to SICS, phacoemulsification does have an advantage of early recovery of patient and somewhat better astigmatic control.  However, the yawning difference in the surgical cost does not justify that.  Your comments please.

Uday Devgan: Surgeons should be able to perform both SICS as well as phaco. I made sure that every one of my 100 residents learned both the manual extra-capsular technique as well as phaco. If have a patient with a dense, truly brunescent cataract in the presence of a weak corneal endothelium, then SICS will likely produce a better outcome and faster recovery than phaco. Our center in Beverly Hills just purchased a femtosecond laser for cataract surgery, but still less than 1% of ophthalmologists in the USA have access to this technology. Does that mean that their surgeries aren’t as good? Of course not. Remember that master carpenters can build incredible things with the simplest of tools. Surgeons are similar.

eOphtha: What are your favorite settings for soft and hard cataracts? Can these settings be useful for other surgeons in a general way or is it that you find your skills to be aptly suited to these settings?

 

Uday Devgan: There are no magic settings. It makes no sense for me to tell you specific numbers for aspiration or vacuum if you do not know the size of my phaco needle, the type of patient I have, or the technique that I use. More importantly, surgeons should understand fluidics and then make adjustments on the fly as needed. What if you decide to go from a 2.8 mm phaco incision to a 2.0 mm incision with the new micro tip? Will your setting be the same? Of course not: you will have to use a higher bottle height to get more infusion pressure to achieve a reasonable level of inflow through the smaller phaco sleeve, you will need a higher vacuum to be able to aspirate the cataract fragments down a narrower needle, and you will likely set a lower flow rate to optimize the fluidic balance. Phaco is a thinking man’s game, not a memorizing man’s game.

eOphtha: Lastly, is it possible to devise a system by which a sensor attached to the phacoprobe can automatically correct the settings depending upon the activities in the anterior chamber, like change in flow, IOP, volume etc.

Uday Devgan: Yes, you can create sensors which monitor some of your settings and this may help to reduce surge. Look at the new vitrectomy machines for retinal surgeons and many of these features are already built in. To adapt it to cataract surgery we may need to create a water-tight environment and stop incision leakage while being careful to avoid phaco burns. But no matter the machine, remember that you’ll still need to have the wisdom, judgment, and reactions of an experienced surgeon – because that simply cannot be programmed into a machine.

 

Special thanks to Dr Kundan Karan