Case selection for transitioning from divide and conquer to phaco chop

Dear friends, lets get back to ophthalmology! I’d like to share an interesting compilation of facts regarding selection of cataract cases for the surgeon who wants to change – over from using the ‘divide & conquer’ technique to the ‘chopping’ technique via phacoemulsification.Image

Using torchlight, every ophthalmologist who knows his/their basics would correlate nuclear softness or firmness to the color of the nucleus as it transitions from yellow to gold and then to brown. But at the slit – lamp it is essential to catch another detail – the size of the endonucleus! Is it small, medium, or large? For example, a medium sized nucleus would have a larger endonucleus compared to softer lenses with smaller endonuclei.Image

ESTIMATING THE SIZE OF THE ENDONUCLEUS

*High myopes with oil – droplet nuclear cataracts have only a tiny, central, opalescent endonucleus, with most of the lens being the epinucleus.
* In some nuclear sclerotic cataracts, a golden or brunescent fetal nucleus is visible at the slit – lamp, but the nucleus peripheral and anterior to it is pale yellow. Here, a medium sized endonucleus is surrounded by an epinucleus of similar dimensions.

* Finally there are nuclear sclerotic cataracts in which brunescence extends all the way forward to the anterior lens capsule, indicating huge endonucleus with little or no epinucleus.

IMPORTANCE OF KNOWING THE SIZE OF THE ENDONUCLEUS

* Peripheral and deeper troughs are required to crack larger/denser nuclei when using the ‘divide & conquer’ technique. In chopping, the chopper and phaco tips must penetrate deeper than usual for a larger nucleus unless you want to end up with a superficial chop, resulting in failed division.

* Soft to medium density endonucleus are preferable for those starting out with horizontal chopping technique.

WHEN TO TAKE UP BRUNESCENT CATARACTS WITH LARGE ENDONUCLEUS

Since there is little margin for error, these should not be attempted until one has mastered chopping in less difficult cases.

WHAT TRANSITIONING SURGEONS SHOULD AVOID

Unless the ‘transitioners’ happen to be surgeons with superhuman skills, its best to avoid the following conditions, which have a small chance of being predisposing factors to demolition day:

1. Uncooperative patients

2. One – eyed patients

3. Pseudoexfoliation

4. Loose zonules

5. Excessively deep or shallow anterior chambers

6. Deep – set eyes

7. Small palpebral fissures

8. Small pupils

9. Intraoperative floppy iris syndrome

10. Poor corneal clarity

11. Poor red reflex.

Wow! Ophthalmology can be so attractive and boring at the same time! I don’t know about you guys, but I’m off to bed. Wishes for a happy last day of 2013!

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How to select the ideal running shoe

Before wishing everyone a good night’s sleep or a great day (depending on your time zone), I thought I would enlighten ‘beginning’ runners out there about how to choose footwear which is ideal for their own feet, instead of going by brand names as we are so often mislead.

STEP ONE:
KNOW YOUR FOOT TYPE

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To do this, step into a vessel or bathtub of water, then keep your foot on a dry tile or paper. The resulting outline will let you know your foot type. Wearing footwear that do not go with your foot arch is a HUGE beginner’s mistake and is the major cause for most ankle/knee/shin injuries associated with long – distance – running.

STEP TWO:

KNOW WHETHER YOU ARE A PRONATOR OR SUPINATOR (under – pronator)

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‘Pronation’ is actually better known as inward rolling of the ankle while running (a bit of pronation is normal for most runners), while ‘supination’ is the outward motion of the ankle. Choosing the right shoe for your type of ankle rotation has a huge impact on how long you can run comfortably!

STEP THREE: KNOW YOUR FOOT STRIKE

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There are 3 different ways to land, while running. Landing on the heel, landing on your forefoot, and of course, landing somewhere in – between on your mid foot. If you land on your heel or toes, it would figure to get shoes that provide you more cushioning in those areas. Don’t miss out on this point, just because you want lighter shoes!

STEP FOUR: What kind of running do you do?
The needs of a person who sprints are totally different from those of a long – distance – runner. Or are you a trail runner? A pair of shoes that you use on road, might get slippery over loose debris and rough irregular surfaces. Here are different shoes that you need to know about:

Cushioned Shoes

If you have high foot arches and don’t over-pronate when you run, then cushioned shoes are suitable for you.

Stability Shoes

Offer mild to moderate support to runners who slightly over-pronate and are looking for shoes that provide cushioning and durability. Pronation is a natural inward rolling motion of the foot but many runners will find that they prontate more than normal and therefore need running shoes to help prevent this. Stability shoes are for runners with normal foot arches, who have mild to moderate over-pronation but don’t have any major problems with motion control.

Motion Control Shoes

The most supportive and rigid shoes available with heavy-duty stability and control features. Motion control shoes are designed for people with low arches and moderate to severe over-pronation – runners with excessive inward rolling of the foot. Motion control shoes are also suitable for heavier runners needing high durability in a shoe.

Lightweight Shoes

These shoes can handle faster-paced training and often also the racing involved in longer events such as half and full marathons. They are more responsive than standard shoes but still offer some cushioning and stability features.  Some lightweight shoes are suitable for everyday training for lighter runners.

Racing Shoes

These extremely lightweight shoes come with minimal cushioning & stability features, are designed for fast training sessions and racing shorter distances such as 5km – 10km.  Some light, fast and bio mechanically efficient runners can wear racing shoes for longer races.

Natural Motion Shoes

Promoting a running style similar to running barefoot, these shoes allow the joints and muscles of the foot to move more naturally, encouraging a mid-foot strike.  There are many types of natural motion shoes, some which are very minimal – almost like gloves for the feet. Others look more like a traditional running shoe but with minimal cushioning and greater flexibility.

Trail Shoes

Trail shoes are designed for ‘off-road’ running. They are designed to protect you when running on uneven, rocky and wet terrains by offering increased traction, stability and durability. Some are designed to handle specific conditions such as mud or mountains and others can handle a mix of terrain.

Spikes

There are two types of spiked running shoes; track spikes and cross country spikes.  Track spikes are divided further into sprint spikes, distance spikes and jumping spikes. Cross country spikes are designed to give excellent grip when racing over grass, through mud and on snow. All spikes are lightweight with barely any cushioning and have removable and replaceable spike pins which are available in different lengths.

That’s all for now. I hope my compilation is of help. Take care runners and don’t forget to visit your gym to stay – in – shape!

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Regards,

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My first half – marathon

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As an ophthalmologist, I hardly find time for fitness and my frequent bouts with the same last only one hour a day on alternate days at the gym. It wasn’t until I completed a 10 k marathon at Salem in October, that I rekindled my passion for running. This half marathon at Tanjore in December 2013 would further rejuvenate me for my future runs. It was a cool morning in Tanjore, when my wife and I woke up at Hotel Laxmi at 5 am, to start preparations for the marathon at 6:15 AM. I had hit a lukewarm shower at midnight, gotten up at 3:30 Am for a small snack of two bread slices with peanut butter and 5 ounces of Gatorade. Now, as we prepare to start for the site, we discover our pal Mohan had failed to show up at our place on time. We rush to Ashok Lodge, pick him up, then proceed to the marathon – start. I thanked God for helping us scout the site the previous day, hence helping us reach the place on time. As luck would have it, the start was delayed by half an hour. My wife would be running the 5 km race, while Mohan and I would be running the 21 km half marathon. The event started, and as usual an enthusiastic pack made their way at an incredibly fast pace, only to fall behind after I started picking up speed. I started with an 8kmph speed, then picked up to a steady speed of 11kmph. I grabbed a banana and some electrolytes at the 8 km mark (I saved the banana for later), then met a good runner who was running at my pace, so decided to run by his side, till I realized I would not be able to complete the race if I kept running that way. I eventually slowed down at around the 10 km mark, and let him pass. Two incredibly fit old men passed me on the way. I took in the sights of greenery and encouraging villagers, especially the cute children as I pushed on. I allowed nature to embrace me, enjoying the cool wind brushing my face, helping me forget the harsh sunlight that was now playing everywhere. The fields and water canals gave me some awesome sights to look at and pretty soon, I was back to a speed of 10 kmph passing a professional female athlete, who was running with her trainer. I discovered fatigue slowly setting in at around the 15 km mark, but not before I managed to overtake the over enthusiastic runner who passed me 5 km back and two other youngsters who had resorted to walking. I started nibbling on the banana at the 18 km mark, and settled for a steady speed of 8 kmph. Two young boys probably around nineteen passed me soon after, moving quite fast, probably at around 12 kmph. At this point, it was all about finishing the race. I managed to stick to the pace, ignoring the rubbery feeling in my knees, the burning sensation in my feet and my sweat – drenched clothes. In the last 500 meters, another extremely fit elder tried to pass me. I put on a burst of speed toward the last 100 meters, passing him and finishing the race at exactly 1 hour 59 minutes and 43 seconds (Mohan arrived 20 minutes later) while my better half had completed her 5 k run in 30 minutes and was waiting for me. We enjoyed a good breakfast, got our finishing certificates and medals, replenished ourselves with electrolytes, then made our way back to Tanjore, and from there back to home. Was an awesome experience – looking forward to many more races in the coming future.