ON MY OWN

My back was soaked in perspiration. Drenched, really. The only thing that stood between my wet forehead and a salty drop of sweat stinging my eye was the surgical cap. 
I had never sweated as much in the operating room as today; this was the second time Koorosh Faridpooya, one of my mentors in vitreoretinal surgery, let me perform a vitrectomy. 
During my first vitrectomy, Dr Faridpooya had gone easy on me, but this time was different. Dr Faridpooya is razor sharp, and he expects his trainees to be sharp too. Despite the sweat, I felt like I had it all under control, but this was just wishful thinking – an illusion. 
I had seen Dr Faridpooya perform about 100 procedures, so I knew in my mind’s eye how it was all supposed to happen. But doing it myself was a different story. 
First of all, the vitreous cutter was in my right hand. Was it in the correct location? Were the motions properly directed and sufficiently fluid to avoid generating traction on the vitreous base, which can induce retinal tears? Was I actually cutting any vitreous, or was I simply re-aspirating the infusion fluid? It didn’t seem like much was happening. 
Secondly, the illumination was in my left hand, which my consciousness seemed to have been neglecting. Instead of tangentially illuminating the vitreous, like a lighthouse beam in a fog, it was pointed straight down, needlessly illuminating the macula like a searchlight. I corrected its position and immediately felt better about myself. But this nice feeling wouldn’t last long.

PAY ATTENTION!
“What’s your cut rate?” asked Dr Faridpooya from somewhere behind me, where he was monitoring my “progress” on the flat-screen on the wall. I didn’t dare take my eyes away from the microscope to check the cut rate on the vitrectomy machine’s own screen. Before I could admit not knowing, he answered his own question. “You’re in vitreous shave mode at 5,000 cuts per minute (cpm) instead of vitreous core mode at 3,000cpm. At this rate we’ll be here all day and night. Pay attention!” 
There were so many things that needed attention: 1. Right hand, 2. Left hand, 3. Right foot, 4. Left foot, 5. Eye, 6. Ears, and, most importantly, 7. Mind. How would I ever learn to pay attention to all seven components, much less do it well? So I focused even more. Besides my hands, I concentrated on the five other components. 
I paid attention to my feet: below my right foot was the vitrectomy control pedal, which works much like the pedal of a phaco machine. Below my left foot was the microscope’s foot pedal, which unlike phaco surgery, is continually, actively following the motion of the eye to maintain visibility. 
Besides my hands and feet I had to remember to look! This entails monitoring half a dozen factors just to maintain a clear view of the posterior segment (microscope + posterior segment biome + cornea + anterior segment + lens + anterior vitreous), each of which can get cloudy. This particular patient was pseduophakic, so at least I didn’t have to worry about lens touch and the near-instant cataract that can cause. But I struggled to maintain an overview of the fundus while making sure not to cut into the retina. 
Then there’s the auditory component, which, like during cataract surgery, provides feedback about what the machine is doing. Lastly, the most important bit, there’s the thought process, which has to plan and execute the whole ordeal. 
The intellectual component of VR surgery was the most unexpected element, the one that surprised me the most. My mentors are all so experienced that it always seemed as though they didn’t need to plan what they were doing, as though it was all reflex, all automatic. Not so. 
Unexpected things are happening all the time, and they need to be dealt with immediately. The induction of a PVD can cause a retinal tear anywhere, which can, within just a few minutes, lead to a retinal detachment. 
What to do? Laser now, so I don’t forget, or laser later, after properly shaving the periphery? Should I laser the whole periphery, or just around the retinal tear? Should I use kenakort to be sure the periphery is totally clean? Or should I trust my own inexperienced judgment, and start peeling the ILM before the crystalline lens gets cloudy and makes a peel too difficult?
Meanwhile, I was making progress and Dr Faridpooya was satisfied, for the moment. I was focused and the seven components were all under control. I was in shave mode, indenting the periphery and trimming the vitreous base at 5,000cpm. So far so good!
Dr Faridpooya was satisfied for the moment.