Eyeworld

34 | EYEWORLD | JUNE 2019 ATARACT C YES CONNECT Contact information Devgan: devgan@gmail.com Rao: naveen.k.rao@lahey.org by Liz Hillman EyeWorld Senior Staff Writer "Residencies and fellowships will span the spectrum with some providing much more sur- gical experience than others," Dr. Devgan said. "Ultimately, the surgeon in training reaps what he sows, and those who work hard and hunt for good cases from which to learn will do best." Even if experience with these devices in training is limited, knowledge in how to use them is important. Skills transfer sessions at conferences are a great way to gain experience, Dr. Rao said, as is working under direct su- pervision of an experienced surgeon who can provide pearls. "Watching YouTube videos is also helpful, but especially with capsular tension segments, there is a steep learning curve," Dr. Rao said. "It helps to understand how to position the segment in the Z-axis, and this is only possible when looking through an operating microscope. Three-dimensional video recording is now pos- sible with Alcon's NGENUITY device, so this could be a promising new way for experienced surgeons to teach these techniques to surgeons who can't join them in the operating room or in the wet lab." Dr. Devgan advised finding a mentor in your area, asking them for advice often, and even considering working with a more experi- enced surgeon on more complicated surgeries. How to manage only a small amount of zonular dialysis versus global zonular weak- ness varies. When there is only 1 clock hour of zonular dialysis, Dr. Rao prefers placing a three-piece IOL with the haptics oriented in the direction of the missing zonules. Dr. Devgan said he will do the same thing, provided the zonular laxity is not expected to progress. When there are 3–4 clock hours of zonular dehiscence, which occurs frequently, Dr. Rao said he places a capsular tension ring followed by a single-piece or three-piece IOL in the capsular bag. In cases of diffuse zonular weakness (more than 4 clock hours), if he thinks the bag can withstand manipulation, Dr. Rao said he places one or two capsular tension segments sutured to the sclera, then uses a capsular tension ring to expand the bag, and places a single- or three- According to the results of the 2018 ASCRS Clinical Survey, the majority of ophthalmologists in residency training report that they are not comfortable managing a case with zonulopathy. Many report not having used tools such as capsular tension rings or hooks during their training. This seems to change in fellowship and the first 5 years in practice, but the question remains: Should we be preparing our resident surgeons to deal with zonular deficiency during their residency training? If so, how much training is appropriate? In this month's YES Connect column, we interview two attending surgeons who routinely train resident cataract surgeons and have significant experience dealing with zonular issues. —Samuel Lee, MD, YES Connect co-editor Gaining experience to manage zonulopathy R esidents should be able to place iris hooks and pupil expansion rings by the end of their training, said Naveen Rao, MD. "I'd consider these to be part of the basic skill set for a competent cat- aract surgeon," he added. "Capsular hooks, capsular tension segments, and capsular tension rings are a different story, though, since their use is much less common." In general, the 2018 ASCRS Clinical Survey reflects this sentiment. It found that 59% of residents had not used hooks, rings, or segments. In fact, only 14% of residents reported being confident in managing zonulop- athy. Fellows were more confident (32% were confident in managing zonulopathy), and nearly half (49%) of those within their first 5 years of practice were confident in management of loose zonules. The use of rings, hooks, and pupil expansion devices among fellows and those in their early years of practice was more common than that reported by residents. Uday Devgan, MD, said that residents should be exposed to a wide range of cataract cases in training, including those where cap- sular support hooks or tension rings are used. A sewn-in capsular segment is something that could be handled by a senior resident under the guidance of a more senior-level ophthalmolo- gist, he said. About the doctors Uday Devgan, MD Clinical professor of ophthalmology Jules Stein Eye Institute University of California, Los Angeles Naveen Rao, MD Lahey Hospital and Medical Center Burlington, Massachusetts Financial interests Devgan: CataractCoach.com Rao: None Samuel Lee, MD

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