!. With juvenile cataracts be careful with capsulectomy/ capsulorrhexis as there is almost no nucleus and therefore no protection / barrier / cushion from the posterior capsule.

 2. With any patient who is a real squeezer --- put in proparacaine or tetracaine  drops several times and then insert a wire lid speculum. Much easier then to use 3 mirror lens, indirect ophthalmoscope, remove sutures or a corneal foreign body, or whatever.

3. Teach epithelial edema diagnosis by looking carefully at the epithelium after applying fluorescein. The characteristic staining pattern ( small dot green and black spots ) often helps you to appreciate early isolated ( sector ) bullous keratopathy which you might otherwise miss. Quite useful when trying to demonstrate early epithelial ( or bullae ) edema.

4. If you want a kinder, gentler, peribulbar block try this : Use 27 G 1 1/4 inch needle ( not a dull Atkinson needle ), inject inferior - laterally ( safer ), use sodium bicarb 8.4% 2 ml per 20 ml of  lidocaine 1 or 2% ( 5 ml per 50 ml ). Good for at least 2 weeks. Put the buffered lidocaine bottle in water in a  tea cup ( ? Chinese ) with a lid and warm the lidocaine bottle ( tea cup ) with a coffee mug warmer. Mr Coffee has one. If you can not find one locally, then the mug warmer can be ordered online from ACE hardware and they will deliver to your local ACE hardware store for under $20 ( see attached photo ). The goal is to warm the lidocaine buffered solution from room temperarture closer to body temp. More comfortable injection. I use a red Iridex diode laser which is more painful than a green wavelength so I frequently use a  peirbulbar injection.

5. If using a serrated forceps ( Kansas, Alfonso , etc. ) to remove nucleus ( MSICS ), be careful. Can tear iris ( iridodialsis ) with serrated forceps as well as irrigating vectis ( loop ) resulting in iridodialysis. First get the nucleus fragments lined up ( positioned ) with A.C. cannula on viscoelastic before entering A.C. with serrated forceps or irrigating vectis.

6. If you want to enlarge ( center, over the visual axis ) an eccentric pupil in the case of an updrawn pupil or adherent leucoma then the first step is to but in pilocarpine 2% every 5 - 10 minutes for three dosages. Then use an Abraham lens ( after proparacaine) to make a radial laser incision toward the visual axis. I often give them 600 mg of ibuprofen one hour earlier. The parameters I use are ( continuous wave ) 1200 - 1400 mW, 100-500 msec ( ? 150 ), 200 um, intervals every 50msec. If you are not " getting anywhere" increase the parameters. You only need a " cut " of a few millimeters. The difficulty is " cutting " through the iris sphincter muscle near the pupil. You will see pigment dispersion. Usually I finish up using the Yag laser. Diode ( argon ) first to prevent bleeding. Can give them oral Diamox ( acetazolamide ) 500 mg immediately, and Alpha Gan ( brimonidine ) and prednisolone acetate 1% drops for one week post op. If you haven't been successful in getting a full thickness cut ( opening ) you can repeat in a few weeks. Some times see a dramatic improvement in vision depending on pre-op pupil appearance and vision. Try to make sure pre - op that the patient has the potential for seeing better after the laser sphinotomy / pupilloplasty. Check color red perception and also light projection. Sometimes light projection is poor initially due to small eccentric pupil.

7. If you are doing laser treatment for any reason, then you should tell the patient you are doing laser surgery. Whether you are using carbon blade, or a diamond blade or a laser light ( beam ), it's still surgery. For a lot of reasons, ophthalmic surgeons should tell all their patients that. Tell it like it is.
8. As a general rule, It is not appropriate to come single - handedly to a developing world country, in order to learn ( practice ) a new surgical procedure. This is true for general surgeons, plastic surgeons, ophthalmologists, or optometrists wanting to do ( learn ) laser surgery.

                                                                         Peace, Baxter

Baxter McLendon