I am a resident and the amount of passion and work i put in is extraordinary, i wont tell where i am from but here the residency is about doing our attending's duties while they enjoy different stupid holidays. And when the attending finally comes he/she does there cases not letting any resident touch it and thats how it is going since 3 years. We cant build surgical experience with this, the other problem is that there are no other options in this country but to graduate with this poor residency where the seniors care less about what will happen to us. I can only watch your videos in awe of performing the techniques you taught but we dont have anyone to help us here

i learnt a lot just from watching this video and reading all the constructive comments from others. thank you everyone.

By now, anyone submitting a video to Cataractcoach with exposed eyelashes should know they will get roasted in the first 10 seconds, so I applaud this resident for the courage to submit this. Dr Devgan’s criticism is on point, and in my training, I remember it was these kinds of professors whose lessons stuck with me the most. Improving the hands comes with practice, and now improving the mind comes so much easier with cataract coach videos. Go watch all the early videos of residents getting into trouble and how the cases were saved. Watch the whole curriculum series. It shortened my learning curve by what feels like light years. This was a tough case, but you must always start with the fundamentals: draping, head position, eye in primary. One trick is to increase the zoom in the scope so you are forced to work in a smaller area view. When something goes wrong like the iris prolapse take a breath and think first. Finally, plan for the patients second eye and know what you are going to do different. Building a surgical plan for every case is a skill built by experience in difficult cases like this one.

Great video Dr, I really felt those words as if I was the fellow doing the surgery, I've improved my technique from constantly watching your videos...

Totally agree with the surgical pearls discussed but I would say many residents graduate with ok/ mediocre surgical skills these days. Who knows if the resident just did their 80th case? Lots to learn but no need to shame them here. I would keep it positive and encourage them to watch more of your videos. They can become great surgeons with more effort and practice, as you mention. Remember that many of these "kids" look up to you- keep them motivated to do better not quit.

This is a tough case even for an experienced surgeon. Looks like small eye with shallow AC and some posterior pressure. As you gain experience, you will learn to notice these things before and at beginning of case, and adjust your technique accordingly. I move my primary incision a bit more anterior in these scenarios, particularly if I notice IFIS when injecting local through sideport at beginning of the case. The short, posterior wound complicated this case further. More gentle hydrodissection would have been better with smaller aliquots given the shallow AC and moderate pupil. Make sure to not overfill these eyes with visco, and have phaco/ IA on position zero with irrigation OFF and even slightly decompress the eye to reduce pressure gradient prior to withdrawal of phaco/IA to reduce Iris prolapse. I like the pressure to be ZERO before removing the phaco/IA. If there is a pressure gradient with rapid removal of IA handpiece as was done in this case, the Iris will follow. Congrats to this resident for keeping composed and completing this challenging case without significant complications.

It appears to me that the attending doesn't even know how to handle the situation. I am 100% certain the top new side port was made by the attending and the viscoat was injected by the attending. Previously during my training, a simple case a iris prolapse, i reposited the iris using repositor, opened iris hooks and about to put in a subincisional hook to prevent further prolapse. My attending asked me what are you doing (she doesn't know why), and insisted on taking over the case. putting in more viscoat. Ended up prolapsing the iris straightaway, and kept on shoving the iris with viscoat canula to the point that she had to cut the prolapsed iris. She sutured the wound with iris incarcerated within it and went for a superior wound. Overall it was just a mess. In this case the resident doesn't have very good surgical technique. Aggressive 2nd round of hydrodissection without tapping down the nucleus after first round. However it do feel the attending made the situation worse.

This looks like a tricky case and well done for resident submitting it. I think a block may have helped here and I do agree that many aspects of the surgery could be improved - it does look like a very shallow AC and possible +vitreous pressure - we all learn from each other and hopefully if comments accepted in the right way the resident would manage the next case in a different way - keep going

The only comments I'd add are: 1. Fairly anterior entry in a shallow AC case 2. I put at least three clock hours between my tunnel and my port. We see how the resident struggled to get the angle to reposit the iris internally, a wider port spacing would make this easier. Visco plus sweep the iris back in. The port at 180 from the wound is way too far around, you can inject visco but not as easy an angle to do the sweep-back. 3. Shallow AC: add an extra pad of dense visco near the wound to help tamponade the iris, and hydrodissect *slowly and gently* Tough case, good on the resident for putting it up, I feel your pain!

Another tip with iris prolapse during hydrodissection is to stick 1 iris hook in posterior to main incision and voila- problem solved! But should have handled releasing the pressure gradient better, and needs to work on phaco in primary…

This video serves as a good reminder to residents AND those teaching residents (including seniors!) to take time to review “game film” and take each subsequent surgical encounter as an opportunity to improve on deficiencies we notice. Each step builds on itself, so work on doing the early steps (including draping) to an excellent standard. I think “tough love” and honest review of surgical videos is important, but I’m not sure publishing the critique on KZfaq is the most appropriate way to go about things. Reviewing these videos and sending back critiques to the original sender may be a better approach.

Some of the more unsavory/hurtful criticism heard in residency can leave indelible memories that we learn from, even if the mentor could have stated it in a better way. That’s just the nature of high-stakes surgery. Some learn from kindness/softness, and others learn from harshness. Better to be able to learn from both. Eye in primary position would make surgeon’s life easier, and shouldn’t be too difficult to do with a second instrument. Sweeping iris back into the eye through a side port instrument instead of trying to reposit through the main incision (where pressure gradient is already working against you) would have expedited that step and minimize cheese-wiring or pigment loss that can occur from trying to push it back in with a cannula. Could argue either way as far as mentor assistance. On one hand, definitely could have helped more to teach resident and achieve better outcome for patient. But I could understand the thought process of letting resident struggle and face reality before being completely on his/her own.

I don like it when my seniors giving me the feedback in indirect soft way " don worry" " it's ok" and then i have to rethink what does he mean, am i good or should i work on myself? What did i do wrong?... i think Dr. Devgan really cares about this surgeon. I like your old school style in teaching Dr. Devgan. Your videos are priceless ❤

Constructive criticism always ❤let’s give it to surgeon for completing the case without any casualties Thanks to cataract coach my 9 year old knows steps of a Phaco coz I have watched it way too many times with her 😂 now she demands a dummy eyeball to practice

It is possible that the case is a high hypermetrope in which vitreous upthrust is a known thing.There could be a fluid misdirection during hydro procedure. Eye not staying in primary position could be a grossly uncooperative patient. I am sure this is not a representative surgery of this surgeon.

How hard / firm should be the eyeball after hydration of wound ? What is the end point ?

I'm just a 1st year resident so my opinion is less important but here are my thoughts: Use tegaderms over the lashes if your initial draping was suboptimal, or just redrape. Perhaps ballot the nucleus with each fluid wave during hydrodissection to prevent a big iris-prolapse-inducing pressure gradient. Drop your hands a bit or raise the bed height a bit so you're not saying hello to the medial canthus quite so much. 🤞🏾

I know topical phaco is the norm in a lot of places but why not peribulbar block for atleast such not so straight forward cases. Makes life a lot more easier during the learning phase.

So the point of this video is to help residents learn (like all your other videos) or to shame and disgrace this resident? I did not understand why it goes on and on about how awful this resident is…

One reason the view is bad is oblique illumination appears to be turned off. Looking at the cornea, there are only the two circular lights. These are the coaxial lights. There is no boat-shaped light (oblique). Depending on your microscope it can be really hard to figure out how to turn those on and off, but this is a really easy thing for immediate improvement!

Congratulations on the music, I loved it!!! For me, it was very interesting. The eyelash issue is relative and can be corrected with a lot of iodine as they will stay in place post-surgery. In my opinion, the surgery went very well, although obviously the end does not justify the means. Perhaps many would have ended up with half an iris in their hand or maybe would not have continued with the surgery, or others would have loosened the blepharostat. I have been performing many surgeries for a long time, but I keep learning, especially from the videos of @UdayDevgan!!!

Sir, what is the important factors to maintain primary position?

●The magnification of the microscope is too low. Beginners should train using higher magnification to prevent eye movement during surgery. Operating with a wider field of view at low magnification can make it difficult to notice eye movements. Higher magnification will help in controlling the eye movement and improve precision. ●Distance Between Side Port and Main Port The gap between the side port and main port is too narrow. This narrow distance forces the surgeon to operate in an awkward and cramped position, potentially causing unnatural hand movements. It can also lead to incorrect insertion angles of the instruments, putting stress on the ports and causing the eye to move. Pay more attention to the placement of the ports to ensure a comfortable working space. ●Length of the Main Port The main port is too short. The insertion angle of the slit knife is too horizontal, which affects the control over the length of the main port. Insert the knife at a slightly upward angle to create a tunnel at least twice as long as the current one before leveling the blade. This technique is especially important for patients with poor dilation and shallow anterior chambers, as it helps prevent iris prolapse. ●Handling Iris Prolapse There is inadequate management of iris prolapse. Advice: The first step is to lower the intraocular pressure by gently releasing a small amount of fluid through the side port. Use a MQA or a cotton swab to gently press the conjunctiva and reposition the iris. Follow the advice given in the video regarding suturing and other corrective measures.

God bless everyone & happiness to all Just a few thoughts 1. With due respect, I can definitely understand what the surgeon is going through & yes I do believe he/she may be having remorse bcz of how far he/she has reached in life & to experience this. 2. Of course I am a big fan of Dr Devgan but I feel if this video wud have the same voice inputs that u usually give then maybe it wud be more helpful for everyone including the operating surgeon 3. And finally being an eye surgeon myself, I can say with full confidence that I wud definitely have no fear of getting operated by this surgeon, everyone starts somewhere, so many people take the risk of being operated by a trainee knowingly or unknowingly I will surely take that risk But no offense to anyone, I think this surgeon will also improve over time & work hard on skills and also I am still a fan of Dr Devgan for the valuable inputs Love & Happiness to all

I don't think this resident has 200 cases, there are residencies which doctors graduate with less then 20 cases. The stress and pressure of surgery can make you forget/ignore things you already know, but by seeing cataractcoach and studying material that is freely available everyday it helps on doing things right. I have experience in teaching residents and know that what you have done (exposing the truth) is the only way this resident will learn that even if this case was successful (if you can call it that), he/she has still a lot to leaen. I agree that this surgeon must do better!

We do not know how the residency is in his/her country, but besides what you correctly pointed out I think the mentor should also bear responsability. He should not have the surgery proceed without the eye and microscope ready. The second paracentesis was clearly for the mentor to manipulate with viscoat and as you said it is not the best way to deal with the iris. However, I have seen many surgeons advocating for the use of viscoelastic between the iris and the cornea (probably more than those who do it the "correct" way). Seeing how he managed the rhexis and the phaco I would say the resident already has some skills but probably has to study more outside the center of residency and improve the technique by him/herself.

This gives me a heart attack! Thank you for sharing so we don't make the same mistake.

Dear colleagues, this resident operates under the guidance of his/her mentor. Yes, most of difficulties are because of his/her actions. But the role of the mentor is to teach how to avoid problems and how to solve them. By the way, the year of residency doesn't play a lot. The number of cases does. That resident may have 20 cases during 4 years. Who knows. I want to say, that if the mentor sits near you, he must guide you to prevent the problems.

This doctor is not ready to do private pracrice cataract surgery. When I started private practice a few years ago, I realized that real world surgery is much tougher. Less time, more cases, demanding patients, and overhead cost to worry about. I was told that I'm the best surgeon in residency class and had so much pride, but transitioning to 20 cases per week was incredibly tough. This should be a routine case, even if patient is uncooperative and eye might be hyperopic. Realistically this doctor cannot start general opthalmology practice focused on cataract. Spend a lot of time in the lab with pig and fake eyes focusing on basic pivoting, then do a course somewhere. Intraocular surgery is technically challenging and unique so it requires dedicated learning. Another option is to give up intraocular surgery and only do pterygium, corneal debridement, bleph, ectropion/entropions that in my opinion are much easier.

It’s good to know that when I need my own surgery, it is likely to be done by an Optometrist who went to a weekend wetlab. And I get so aggravated when patients think the whole surgery depends on the type of IOL inserted alone. What we do is HARD, and the surgeon is the principle factor that makes the difference between a good case and disaster. These patients who patronize to me because they want “the best lens” insult us and our dedication. I wave such “healthcare consumers” on to find some other doctor. It’s almost as if we’ve done our profession a disservice by providing such good care, and now we are held hostage to the high standard we’ve set.

At least he finished his surgery, not all man is able to do good surgery every time, especially under the pressure of taking video which is to present to professor like you. Be kind and encourging him instead of saying sharp words here.

So, my take depends on whether this is a "typical" case by this resident or if this is just one of those nightmares. If the latter, then it's tough to know. But assuming the former, here's my take going chronologically roughly. Eyelashes are sub-optimal. Trim or re-drape Incisions are acceptable. Rhexis is acceptable but needs improvement--need to get a better pivot. Hydrodissectioni: be gentle with it. especially on these "at-risk" irides Managing iris prolapse: needs improvement. Get the lens up or learn to sweep the iris back. But the solution is not through the main wound Nucleus disassembly: adequate; different techniques are very attending dependent. I did just under 200 phacos during training and only learned stop-and-chop for my last ~60. About 50% of our staff were pure D&C. Only 1 would attempt phaco chop (honestly he wasn't great at it) and he definitely wasn't going to teach a resident. The rest were all S&C. Also, if you are good at the other techniques, it doesn't take long to learn direct chop. Not keeping eye in primary: honestly, this is my biggest issure with this case because if you can't see well, the likelihood of complications is going to go through the roof.

This is a very important case showing the consequences of failing to give our learners truthful feedback, and failing to fail them (hold them back, remediate them) when they are not performing at the appropriate level. This is an issue throughout medical training and across disciplines. The TRUELY KIND preceptor is the one who gives the learner honest and constructive feedback (even when it is difficult to hear, and is not taken as kind in the moment by the learner), as Dr. Devgan has in this video.

The music😅

I find it funny you posted this video after coming to the romanian cataract society congress 😂

Dear Uday, We all know how much efforts you do to teach the residents. I used to " when I was a resident" and I am still watching your video's even when I became a surgeon with a good number of surgeries. I would definitely take it as a constructive criticism especially from you because we know you. BTW my wife tells me " you listen to this man more than listening to me" she is probably angry of you, I will not show her this video 😄

This not an easy case, keep up the good work

This resident should read cataract coach’s free pdf

I see this resident needs only some guidance and tips for draping, maintaining eye in primary position and pivoting while manipulating and dealing with prolpased iris better, he will be much better as a trainee.

There are no excuses today as knowledge is readily and freely available unlike 10 years ago.

A Difficult case even to 2000cases surgeons.

just burp a bunch of visco before hydrodissection. The attending didnt help at all here - kept pushing more visco when they should have been decompressing the AC once the iris prolapsed.

A pity we cannot hear audio comments now. Although I do agree that primary eye position is a must, the real necessity of a "proper draping" is not yet clear for me. Apart from it looking nicer and a surgeon feeling better, I am not sure that it adds to the safety of the patient. At least, I do not remember any evidence of it, it may be there. P.S. It is ok to become critic. Only if you does not produce anything, you will not become criticesed.

I think the surgeon is stressed during the surgery as the microscope is never put to the primary and the patient is not the usual cooperative one. The draping technique though has a lot to improve. May be the senior could have taken the case over sooner and taught the junior a lesson!

I taught eye surgery for 10 years. I see I was much more involved. I would switch seats during the case with the resident a few times if necessary to show exactly what I wanted the resident to do. I would tell them to look away from the scope and look at my hands so they can hopefully copy what I am doing. I would never let the resident make the same error over and over- if they couldn’t do what I wanted after switching seats with me a couple of times, I would take over that particular part of the case, then let the resident continue. I would show how just rotating my wrists downward - maybe lower the seat?- would stop the pushing of the eye away from the surgeon. If the draping was no good- I would do it again. I never raised my voice or insulted the resident but I made clear after the case what had to be fixed. In my 10 years there were, however, a handful who were just awful surgeons who made little progress and they should probably give that up. I had discussions with the program director about testing dexterity for applicants like they do in japan. Test scores and intelligence are useless in eye surgery and those who have very poor dexterity should not be accepted.

Im not a fan of unbeveled one step keratome wounds. Langerman incision is my favorite.

Shallow AC with mid dilated pupil. Tough case for a resident with 200 case experience.

This resident should be given constructive and specific feedback on how to improve their techniques. This video does not contribute to anyone’s learning. He or she is doing well in that they sent the video looking for feedback and ways to get better. Would you rather have that or an optometrist who went to a weekend certification course?? KZfaq videos where we undermine our own residency training are not helpful to anyone.

Hard to watch

The video doesnt explain the resident s skills,few decision making issues 1)longer and anterior tunnel in a shallow ac case 2)always eye in primary position,block if necessary Phaco can be hell if the ports are not in right place,and the phaco probe is not held correctly to maintain primary position.

It takes month of ur life performing one surgery.

Learning curve is different among the residents. I think with more practice he can do better. I honestly do not like seniors who talk with residents like you did in this video. You could have encouraged him to do better instead of blaming him all the video. Not all seniors are good mentors.

I would suggest to this young fellow to ignore the idiotic comments made by “professoroids” here and focus only on the things he needs to learn to get better. Dont worry. Time will make u better, if u can endure pain and vitreous. I would only suggest not to do cataract surgery with topical anesthesia until u become a morr effective problem solver surgeon.

With all respect, there is an option to stay as a medical ophthalmologist. You may keep the surgical part for those who can master it.