JAN 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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52 EW RESIDENTS January 2014 Cataract tips from the teachers Take it to the limit: A surgical training cataract dilemma the recent years, the residents have had little or no experience in open cholecystectomies (gall bladders are being removed a lot earlier, easier, and with less morbidity—sound familiar?) or common bile duct exploration. I asked one of my "older" general surgeons at Emory/Grady about this. He said that younger community physicians urgently call older, more experienced surgeons on staff or their mentors in training. A quote I love from two Ohio surgical educators (M.C. O'Bryan and J. Dutro) is: "The emergence of more and more minimally invasive technologies requires planning Sherleen Chen, MD Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary and vigilance on the part of surgical educators to ensure that the basic tenets of more traditional operations are not neglected." Unfortunately, there are a growing number of ophthalmic educators who were not taught or minimally taught many of these skill sets and hence cannot teach it themselves. I agree that phaco can be taught earlier in residency training without antecedent ECCE experience. Our own program offers both procedures in the second year, phaco in the second half. The future of U.S. healthcare might include the necessity to perform low-cost self-sealing ECCE. Geoffrey Broocker, MD Walthour-DeLaPerriere Professor of Ophthalmology Chief of service, Grady Memorial Hospital Atlanta Roberto Pineda, MD Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary I n this month's column, our faculty discusses an article on learning traditional extracapsular cataract surgery and phacoemulsification during residency. They discuss their experience and tips for teaching and acquiring manual extracapsular cataract skills in conjunction with learning phacoemulsification. What should our educational priorities be for assuring adequate manual cataract skills while acquiring competency in phacoemulsification? Reference Meeks, L, Blomquist, P, Sullivan, B. Outcomes of Manual Extracapsular Versus Phacoemulsification Cataract Extraction by Beginner Resident Surgeons. J Cataract Refract Surg 2013; 39:1698-1701. Sherleen Chen, MD, and Roberto Pineda, MD The study by Meeks et al addresses the issue of initiating phaco training with ophthalmology residents earlier in their training and without antecedent manual ECCE procedures being performed. Although the study demonstrated little significant difference in outcomes between the two groups (with a single attending surgeon), the study did not indicate the degree or types of cataracts and how they were randomized (if at all) to the two groups. An early nuclear or mostly soft cortical cataract responds easily to phaco even in a novice's hands. A mature (brick) brunescent cataract in an elderly patient may not do quite so well. Skill sets require hands-on training. Virtual training and wet labs are helpful and currently necessary in most training programs. Manual cataract skill sets are necessary when a surgeon is confronted with phaco machine breakdown or dysfunction and most often during complicated phacoemulsification. I still get at least two or three calls a year from former trainees thanking me for providing these skill sets to them during moments of crisis in the operating room. I liken the situation to general surgery's laparoscopic cholecystectomy. Within the last 15 years, the vast majority of gall bladder removals have been laparoscopic. In Outcomes of manual extracapsular versus phacoemulsification cataract extraction by beginner resident surgeons Landen A. Meeks, MD, Preston H. Blomquist, MD, Brian R. Sullivan, MD J Cataract Refract Surg 2013; 39:1698–1701 Purpose: To evaluate the safety and efficacy of phacoemulsification cataract extraction and manual extracapsular cataract extraction (ECCE) performed by beginning resident surgeons. Setting: Dallas Veterans Affairs Medical Center, Dallas, Texas, USA. Design: Retrospective cohort study. Methods: A review was performed of each resident's series of initial cataract surgery procedures as a late first-year or second-year resident. Data were collected for cases performed over almost a 6-year period during which initially the first primary surgeon cases were ECCE and later, the first primary surgeon cases were phacoemulsification. For each case, the following data were gathered: technique of cataract extraction, laterality, resident, vitreous loss or dropped nucleus, placement of posterior chamber intraocular lens (IOL), and need for reoperation within 90 days of surgery. Results: Complications occurred in 6 (2.5%) of 244 cases in which phacoemulsification was performed by a beginner resident primary surgeon and in 7 (4.1%) of 172 cases in which ECCE was used (P=.40). Posterior chamber IOLs were placed in all but 2 phacoemulsification cases and 4 ECCE cases (P=.24). Moreover, 3 cases in the phacoemulsification group and 1 case in the ECCE group required a reoperation within 90 days (P=.65). Conclusion: Phacoemulsification cataract extraction can be taught safely and effectively to residents with no cataract surgery experience as a primary surgeon. Financial disclosure: No author has a financial or proprietary interest in any material or method mentioned.

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