Figure 1

Performing surgery outside of one's familiar surroundings—especially outside of one's own country—creates challenges of personality and purpose. I have had the opportunity several times now, in various locales, to perform live surgery at international congresses and operate using new technology not yet available in the United States. I've successfully completed cataract surgery in India, Malaysia, Germany, Mexico, Brazil (twice) and Italy (twice). Every time I do it I learn more about surgery and more about myself.

Most recently I had the opportunity to perform cataract surgery in Sao Paulo, Brazil. I had already done so once before—in December, 2001, at the Instituto de Catarata, Departmento de Oftalmologia, Universidade Federal de São Paulo—as part of a symposium presentation. This time I was asked by one of the intraocular implant manufacturers to gain experience with some of their newer products.

I am a creature of surgical habit and punctilious protocol. At my own surgery centre I insist on every little thing being just so, from the position of the microscope foot pedal to the size of each cannula. I have my own special diamond knives and a special relationship with each of my microforceps. I'm very nice, and my staff would say that I'm a lot of fun in the O.R., but I'm also quite demanding. I have a huge stake in the outcome of every procedure, and I am always striving for perfection.

Arriving at the eye clinic in Sao Paulo to perform surgery, I had no instruments of my own (my luggage had been temporarily delayed back in the United States). As I observed the resident surgeon's technique, I decided on the spot to completely adopt his approach rather than try to explain my own technique and try to adapt the Brazilian operating room to my accustomed behavior. I decided it would be easier to just go with what was going on.

I was aware that this would mean a large change for me. For example, I sit at the side of the patient when operating; the Brazilian surgeon sat at the head. I use two 1.3 mm temporal clear corneal incisions to extract a cataract; he used one 2.2 mm incision to the right (nasal in a left eye, temporal in a right eye) and one 1.0 mm incision to the left (temporal in a left eye, nasal in a right eye). I separate inflow and outflow—irrigation and aspiration—via my two symmetric incisions; he used an irrigation sleeve on his aspiration needle so inflow and outflow occurred through the same incision. I use a microforceps to perform the most delicate part of the operation—the capsulorhexis; he used a unique and relatively large forceps, the jaws of which actually open rather than close when firmly squeezed. I use an irrigating chopper to divide up the cataract; he used a small curved rod known as a Sinskey hook. Really, except in the broadest sense, we perform two very different operations. The only gross similarity is the use of phacoemulsification, ultrasound, to break up the cataract. At least he did have state of the art phaco machines, and I am familiar with those.

I reassured myself that the principles of phacoemulsification are the same no matter the specific techniques. We construct a self-sealing corneal incision, open the lens capsule, divide up the cataract, remove the pieces, leave the lens capsule intact and clean, and place an intraocular lens in the capsule where the cataract used to be. Sounds simple, but there are a lot of details, and, as I said, I am a creature of habit. I was extraordinarily nervous about following what I nevertheless was certain was the right course.

When I sat down in those unfamiliar surroundings I realized that the view through the microscope was also entirely different from what I was used to. At that moment I was incredibly relieved and thankful that my assistant scrub nurse was actually an eye surgeon herself and a rather good English speaker. Her voice and confidence reassured me, and I got the attitude of success. I knew I could make it right. Despite a pretty shaky hand and a lot of second-guessing, I did in fact persevere and accomplished two cataract cases without complication.

The next day, both of those patients were able to read the 20/20 line on the eye chart without correction, and I had learned a valuable lesson. It is the skill of the surgeon that makes the surgery. We possess great technology and brilliant techniques—and we should not allow them to possess us. Finding challenges that force us to adapt to different methods and think through the fundamentals of what we do leads us to greater self-confidence and ultimately makes us better surgeons.