1. Step by step: Learning Phacoemulsification and MICS for Tremor Surgeons Gede Pardianto Sumatera Eye Hospital Medan - Indonesia

2. Pre-phaco Say NO to Drugs Say NO to Drugs Say NO to Failure Say NO to Failure Patient selection Patient selection –Optical biometry scanned immature cataract

3. Peri-phaco: What must to do Adjust your microscope  reset first Adjust your microscope  reset first Adjust your seat Adjust your seat Adjust your patient’s position Adjust your patient’s position Protect the fellow eye Protect the fellow eye Place your drape properly Place your drape properly Cut to open your drape properly Cut to open your drape properly Place your speculum properly Place your speculum properly Now place your hands gently firm Now place your hands gently firm

4. Microscope: Ensure Your foot please  stay on pedal Your foot please  stay on pedal Pupil Distance Pupil Distance Illumination Illumination Magnification Magnification Focus Focus Reset (again) Reset (again)

5. Incision: Pitfall and how to avoid Early anterior capsule tear  see the edge of knife Early anterior capsule tear  see the edge of knife ‘Not enough’ port ‘Not enough’ port Leaking wound  shallow ACD  use three planned incision Leaking wound  shallow ACD  use three planned incision –Iris prolapse  More limbal  Direct one-planed Post operative astigmatism  position of incision Post operative astigmatism  position of incision

6. CCC: Pitfall and how to prevent Escape Escape Too large Too large Too small Too small Weak Weak Grab the cornea  forceps Grab the cornea  forceps OVD OVD Posteriorly and toward center area Posteriorly and toward center area

7. Hydrodissection: Pitfall and how to prepare Inadequate  little bit more power Inadequate  little bit more power Difficult to rotate  add some Difficult to rotate  add some Early drop nucleus  ensure fluid flow out trough incision  place needle posteriorly on incision  all fluid move out of the chamber Early drop nucleus  ensure fluid flow out trough incision  place needle posteriorly on incision  all fluid move out of the chamber

8. Hydrodelineation: The Need Traumatic cataract Traumatic cataract Posterior pole cataract Posterior pole cataract Post vitrectomy cataract Post vitrectomy cataract Hard brown cataract Hard brown cataract

9. Rotating the nucleus: What’s important Be sure  nucleus  movable Be sure  nucleus  movable Beware of zonular weakness Beware of zonular weakness Use two tools Use two tools Beware of the line of CCC  don’t ever break it Beware of the line of CCC  don’t ever break it

10. Sculpting and Cracking: Must do Nearest area Nearest area Position of phaco tip and tip’s bevel Position of phaco tip and tip’s bevel Position and direction of chopper Position and direction of chopper Make sure those in right handling, right place, right setting, right maneuver of hands and feet Make sure those in right handling, right place, right setting, right maneuver of hands and feet Beware of the edge of CCC Beware of the edge of CCC

11. Segment removal: Must practice Smaller segment  easier to remove Smaller segment  easier to remove Position of phaco tip Position of phaco tip –Center  center of iris plane area –Irrigating controlled Direction of bevel Direction of bevel Mind your foot on pedal Mind your foot on pedal Mind you second instrument Mind you second instrument

12. Last pieces and epinucleus removal Mind your irrigation Mind your irrigation Bevel-up Bevel-up Mind your second instrument Mind your second instrument Mind your foot on pedal Mind your foot on pedal Don’t hesitate to add OVD  lift epinucleus anteriorly Don’t hesitate to add OVD  lift epinucleus anteriorly Don’t to fast move to I/A mode Don’t to fast move to I/A mode

13. Irrigation/Aspiration and Capsule Polish Mind your illumination Mind your illumination Mind the posterior capsule Mind the posterior capsule Always from equator or edge area Always from equator or edge area Venting controlled Venting controlled Stop without move  use OVD Stop without move  use OVD

14. Inserting the IOL Zoom out Zoom out Gently loading IOL from pack to cartridge Gently loading IOL from pack to cartridge Zoom in, focused Zoom in, focused Inserting the IOL Inserting the IOL Mind the edge of CCC ahead Mind the edge of CCC ahead Firm your hand  no retread Firm your hand  no retread Under OVD or hydro-insertion Under OVD or hydro-insertion

15. Wound closure: Pitfall Inadequate Inadequate Loss of fluid Loss of fluid Don’t to fast  Don’t to fast  –overload anterior chamber –Damage corneal structure

16. Tremor surgeons can wave the rule Tremor surgeons can wave the rule Beware because we have tremor Beware because we have tremor But But Be happy because we can perform high value phacoemulsification and MICS Be happy because we can perform high value phacoemulsification and MICS

17. T | H | A | N | K | - | Y | O | U | + | + | + | + Best regards from Indonesia