MAR 2014

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

Issue link: https://digital.eyeworld.org/i/276058

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Page 140 of 210

E W RESIDENTS 138 March 2014 Elementary, my dear Watson! Now ready, aim, fire! Dru Krishnan, MD Assistant professor of ophthalmology, Tufts University School of Medicine Boston My teaching technique I teach capsulotomy in a "plus" pat- tern, with the intersecting lines in t he center of the visual axis. I find this to be the easiest pattern for resi- dents to perform, without causing floaters. The resident starts in the center to prevent a capsulotomy that's too big or decentered, which can be an issue early in training. In my experience, the main bar- riers to resident performance of YAG capsulotomy are putting the lens on the eye, visualization of the poste- rior capsule, and focusing the aim- ing beam onto the posterior capsule. Some things I do to help maximize resident performance include: • Having residents perform go- nioscopy with a three mirror lens. This improves their ability to control the laser lens when performing capsulotomy (dealing with air bubbles, etc.). • Discussing some of the adjust- ments that I make to improve my visualization—I have found that these adjustments are not intu- itive to beginning residents: –Using the center of the laser lens and tilting it when needed to focus the aiming beam properly –Turning up the light on the aiming beam or turning down slit lamp illumination to better visualize the aiming beam on the posterior capsule –Tilting the illumination arm to the side to reduce glare off the lens surface • Teaching the procedure in a step- wise fashion. This allows residents to perfect the steps leading up to "pushing the button," thus in- creasing their confidence prior to actually performing a capsulo- tomy (which is often their first intraocular procedure). Thoughts on the paper Some of the challenges of perform- ing YAG capsulotomy in humans are difficult to replicate by simulators. The challenge of placing the laser l ens on the eye and positioning the patient are not addressed by this simulator. Focusing the beam on the posterior capsule is addressed. How- ever, the "PCO" in this simulator is much thicker than the natural state. As such, finding and focusing on the "PCO" is likely easier in the simula- tor than in a real patient. This m odel has the potential to teach residents how to focus light on the proper surface (bringing the aiming beam into one point onto the "PCO" as opposed to on the lens), which has significant value. With the low cost and reusability, this simulator would be a welcome addi- tion to my resident capsulotomy training, although I don't think it would completely replace the current approach that I use. Michelle K. Rhee, MD Assistant professor of ophthalmology Mount Sinai School of Medicine, New York N d:YAG posterior capsulotomy is one of the earliest procedures a beginning resident learns because of its low risk benefit ratio. Despite this favorable ratio, visually significant sequelae can occur including IOL damage and dislocation, uveitis, and retinal detachment. In addition to this, the climate of increasing pa- tient expectations and use of ad- v anced technology IOLs demand that we perform an effective and elegant capsulotomy. Although simulation for pha- coemulsification via animal eyes as well as the Kitaro Kit and Gulden Ophthalmics Phaco Practice Patient are well established for resident training, there is a dearth of such r esources for YAG capsulotomy. Moisseiev and Michaeli attempt to address this gap by modifying a Gulden Ophthalmics plastic eye by inserting an IOL with a PCO created by artificial sweetener paste. Prior to their model, the literature shows just one other eye simulator where the PCO was made of cardboard or plastic sheet, far from physiologic. Although YAG capsulotomies are in a lower risk category than intraocular surgery, practice outside of the clinic is essential for patient safety and resident confidence building. The model presented by Moisseiev and Michaeli has great potential because of its more realis- tic PCO simulation, 200 um by OCT. Furthermore, its use of an existing teaching platform and inexpensive method of artificial PCO creation N d:YAG posterior capsulotomy is perhaps the most basic and com- mon of laser procedures performed in ophthalmology. While relatively straight- forward, there is still a learning curve and nuances to teaching and learning the procedure. We asked three Harvard Cataract Course instructors to share their thoughts and impressions on a new posterior capsu- lotomy simulator described in the February issue of the Journal of Cataract & Refractive Surgery. In addition, they discuss their pearls and advice for teaching YAG posterior capsulotomy to trainee surgeons. Sherleen Chen, MD, and Roberto Pineda, MD S herleen Chen, MD Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Roberto Pineda, MD Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary Cataract tips from the teachers Simulation of neodymium: YAG posterior capsulotomy for ophthalmologists in training Elad Moisseiev, MD, Adi Michaeli, MD J Cataract Refract Surg (Feb) 2014; 40: 175–178 W e describe a new method for training ophthalmologists to perform a neodymium:YAG (Nd:YAG) posterior capsulotomy. Our model con- sists of an arti.cial anterior chamber that can be adjusted to .t any laser instrument and houses an intraocular lens (IOL). The posterior surface of the IOL is coated with a crust simulating posterior capsule opaci.cation (PCO). This model PCO reacts similarly to real PCO when the Nd:YAG laser is applied to it. It creates conditions simulating near-real posterior capsulotomy and has been used successfully to train three novice residents who had not performed the procedure. The model is simple, reusable, and inexpensive. We believe it may be a valuable tool in training ophthalmologists to perform an Nd:YAG posterior capsulotomy. Financial disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. 138-143 Residents_EW March 2014-DL2_Layout 1 3/6/14 4:16 PM Page 138

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