Our first day of operating has just come to a close and nine new patients are lying in their beds with patches over one eye. For some it's their only eye, so they're not interacting much with the other patients. Most of the others are chatting while they finish dinner. This trip is my fourth one to Clinica Ezell, so I've been able to get back into the groove a little quicker than last time We unpacked yesterday and this had to be the most well-supplied I've ever been. We were able to do three cases last night before bed so today wasn't nearly as long as it could have been. The toughest thing about coming back is actually getting used to the idea that each eye is not going to look perfect. Going from doing cataract extractions with no blood loss, perfect corneas, and lightning-fast recovery to manhandling these cataracts out with all the grace of a can opener is tough mentally. Making a 12 millimeter incision on an eye when your're used to getting the job done through 2.8 is a bit overwhelming. My technique has gotten much better over the few years I've been coming here, which wouldn't have been difficult since I had only done a handful of this type of extracapsular cataract surgery during residency. You just don't see these types of cataracts in the states. There was one today that we could have given to the kids of the village for their marble collection. I used the same technique today that I did last time on a trip with Larry Patterson, an ophthalmologist from Tennessee. We watched a DVD that some eye surgeons in Nepal had produced that showed their suture-less extracap surgery. Suture-less extracap! The term makes about as much sense as "suture-less C-section." But it works. I wouldn't have believed it, but it does. I did nine of them today, carefully dissecting a tissue plane through the sclera to the cornea that would seal shut on its own. And not a single suture placed. Unbelievable! There were only two times when cases didn't go entirely as planned today and vitrectomies had to be done. Both were on cataracts where the dense nucleus was firmly adherent to the underlying capsule and the delivery of the former included the latter. Those are the ones that start to get you down because you wish their eye had been healthier, that you could have gotten to them sooner before the outcome was so inevitable. But then you see them the next day and they can count your two fingers in front of their face when yesterday they had to be led into the room by a nurse. And that "dos" you hear is what stays in your head the rest of the week reminding you that you're leaving things better than you left.

Lee Coleman, MD