MAR 2014

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

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E W RESIDENTS 1 39 m akes it a practical and reproducible option. I am curious to know what material IOLs (acrylic or silicone) and laser power settings were used in their study. Until there is an af- fordable, commercially available PCO practice eye, I am interested in trying their recipe for our resident training. Aside from the ability to practice the basics of setup and l aser/tissue feedback, it provides the opportunity to attempt different patterns of capsulotomy and per- haps even inspire creative, novel ones. We teach our residents the following points: • Review charts in advance to confirm the correct procedure, u nderstand why it is indicated, and prepare necessary equipment. • Check laser, lens, settings, and locate the topical anesthetic, bal- anced salt solution rinse, tissues, elbow rests prior to bringing the patient into the room. • Optimize ergonomics for yourself and the patient. • Anesthetize and encourage the patient to open both eyes to in- crease comfort with the Abraham capsulotomy contact lens. • Communicate with the patient during the procedure to enhance cooperation and comfort ("verbal anesthesia"). • Make each laser shot count since the amount of energy used corre- lates to the risk of retinal detach- ment (start at 1 mJ/pulse). • Start lasering at the periphery of the optic so any inadvertent pit- ting will be outside of the visual axis. • Administer an antihypertensive such as an alpha-adrenergic recep- tor agonist one hour prior to and immediately after the laser to blunt any IOP spike. • Check IOP one hour after the procedure and discharge on PF1% qid x one week with a follow-up in one week. S teven Urken, MD Chief of ophthalmology A tlanta Veterans Affairs Medical Center Assistant professor of ophthalmology Emory University School of Medicine I commend the authors for their de- velopment of a capsulotomy simula- tor. Among teaching procedures, I find laser patients the most anxious and hyper-alert to intra-procedure coaching. Therefore, I encourage trainees to choose their words care- fully. A system that can lead to a de- crease in the verbal communication required during the teaching of a laser procedure is a true asset. Practi- cally, I might use this system one time with each new resident incor- porating IOLs with different materi- als. Using this model gives the trainee an opportunity to practice focusing and also a chance to pur- posefully pit the different IOLs so he/she can see the potential damage to different IOL materials caused by this procedure that is often consid- ered harmless and easy. A session with this simulator would allow me to describe my technique while the trainee receives immediate visual feedback. Most importantly, it would greatly decrease the amount of discussion that would take place while I proctored the trainee's first live capsulotomy, thereby alleviating a great deal of the patient's anxiety. I do not believe beginning residents would gain much from using the system on their own or from re- peated practicing with it once they had performed a live procedure. I respectfully disagree when the authors state that their model allows ophthalmologists in training to gain a realistic experience. In my experi- ence, the residents have the most trouble learning how to properly focus the laser's aiming beam in vivo. Their trouble stems from a combination of inexperience with the glare from laser lenses, from patient anatomy, and from patient movements that include normal b reathing patterns. Oftentimes trainees are tilting the laser lens too much and a slight sliding of the lens helps their focusing. Additionally, I start with a posterior offset of 250 microns that can be adjusted to help proper laser application. The au- thors' system cannot provide a real- istic "moving" target. Of course, this is not a limitation unique to their m odel. A laser capsulotomy is one of the least technically demanding pro- cedures we teach trainees. However, I would suggest that it is one of the m ost critical. This is often a resi- dent's first exposure to performing intraocular procedures and first opportunity for many educators to work one-on-one with a resident. Therefore, this is the opportunity to make a lasting "first impression" and impact how trainees approach invasive ocular procedures for the rest of their career. EW Contact information Krishnan: ckrishnan@tuftsmedicalcenter.org Rhee: michelle.rhee@mssm.edu Urken: surken@emory.edu March 2014 Faneuil Hall Marketplace 1 Faneuil Hall Square 617-635-3105 www.faneuilhallmarketplace.com The Shops at Prudential Center 800 Boylston Street 617-236-3100 www.prudentialcenter.com Merry Trading Company 866-367-8208 www.merrytrading.com Revolutionary Boston Museum Store 617-742-4733 www.revolutionaryboston.org Robin's Candy 253 Newbury Street 857-263-7618 robinscandy.com Jonathan Adler 129 Newbury Street 617-437-0018 www.jonathanadler.com Simon Pearce 103 Newbury Street 617-450-8388 www.simonpearce.com Alex and Ani 115 Newbury Street 617-421-0777 www.alexandani.com Boston shopping: Quick guide 138-143 Residents_EW March 2014-DL2_Layout 1 3/6/14 4:16 PM Page 139

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