EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/233841
January 2014 Judith Mohay, MD Associate professor, Department of Ophthalmology & Visual Sciences University of Louisville, Louisville, Ky. The information provided by this study will help to improve our methods of surgical training for beginning resident surgeons. As such, it is truly welcome and much needed. The aim of this study is to help to decide which surgical technique (ECCE or phacoemulsification) is preferable for beginning ophthalmology residents. The review is a retrospective cohort study. The study identified a large enough sample size of patients/resident surgeons for meaningful statistical analysis. The surgical environment and the level of training was the same for both groups and this was a great advantage for the validity of the outcome. The authors and the University of Texas Southwestern Medical Center residency training program should be congratulated for the excellent surgical outcomes and for the low rate of complications. Although the complication rates were higher for ECCE patients compared to those who underwent phacoemulsification (4.1% versus 2.5%, respectively), this difference could have partially been the result of selection bias. Patients who need ECCE tend to have more advanced cataracts, a higher number of comorbidities, lower socioeconomic status, and altogether higher chances for complications. The selection bias may have affected the outcome of this retrospective cohort study by biasing away from the null, therefore at least in part explaining the higher observed complication rate in the ECCE group. Although phacoemulsification itself can be safely taught to beginning resident surgeons, the two procedures can be combined effectively for a "first-ever performed" cataract surgery. A 12 o'clock approach, preparing for standard ECCE but actually proceeding with phaco (as far as the resident can safely go) would allow us to teach key points of both procedures and is much safer for the patient. I also believe that it is crucial to select appropriate cases for beginning cataract surgeons—irrespective of the type of procedure. Securing success with surgery early on has a tremendous positive psychological effect for young eye surgeons and it can affect their whole career. The suggested steps to improve the success of surgical training including the microsurgical curriculum with a mandatory checklist of laboratory skills are very important and well adopted in our residency program as well. We were able to improve surgical outcomes for our residents with few other steps: • Video recording and analyzing resident surgeries with an attending present in surgical outcome conferences • Encouraging participation of second-year residents in intensive cataract courses with wet lab experience • Promoting modular phacoemulsification training for junior residents Michele Bloomer, MD Associate professor, Department of Ophthalmology University of California, San Francisco This article represents one of the largest studies comparing two methods of cataract extraction performed in the hands of early resident surgeons and validates the training methods used in the majority of residency programs in the United States today. Economic realities and increased patient expectations have driven a major shift in resident surgical training, and it is reassuring to find that this has not lead to unacceptable surgical complication rates. The methods used in this study are particularly interesting. Having the cases attended by "a dedicated senior faculty member" supports what we have found to work best at our institution. Identification of experienced core faculty to guide residents through their initial year of cataract surgery has helped to decrease complications and build resident surgical skills faster. Complications encountered early on in training can lead to loss of self confidence making it more difficult to advance on to more challenging cases. Use of a well-defined microsurgical curriculum prior to the first patient experience is also something that we have found critical. We employ a standardized virtual surgery simula- EW RESIDENTS 53 tor program in addition to the tactics outlined in the article. While the simulator has some limitations, it has proved to be a valuable adjunct to the wet lab. One of the key takehome points of this article is the importance of a well-structured approach with early surgical trainees that will allow them to succeed with either technique. The role of ECCE in residency training remains a major source of debate as more programs abandon the tradition of teaching ECCE prior to phacoemulsification. This study highlights the dilemma of how this skill is to be transmitted to trainees if more programs abandon teaching it. While phacoemulsification is essential and can be learned without prior ECCE experience, there is still a need to teach ECCE skills.1 Many argue that a technique cannot be mastered by performing a handful of cases, especially done only in early residency, so a change in traditional training curriculum is warranted. A comprehensive ophthalmology education should involve a similar approach to ECCE training that is taken with phacoemulsification. A structured curriculum, as outlined in the article, used throughout all years of residency would provide trainees with a more complete armamentarium to handle the full spectrum of cases that they will encounter during their careers in ophthalmology. It will be interesting to see how this educational paradox plays out in the future. EW Reference 1. Pershing S, Kumar A. Phacoemulsification versus extracapsular cataract extraction: where do we stand? Curr Opin Ophthalmol. 2011 Jan;22(1):37-42. Editors' note: The physicians have no financial interests related to this article. Contact information Bloomer: bloomerm@vision.ucsf.edu Broocker: ophtgb@emory.edu Mohay: jmambr01@louisville.edu