Eyeworld

EW CATARACT 76 October 2011 by Ayman Naseri, M.D. Part I: Complication rates of phaco vs. manual ECCE among initial surgical trainees at UCSF A ll ophthalmology resi- dency programs in the United States must teach cataract surgery in order to maintain accreditation, but each program makes its own choices as to how to best train young surgeons. Although most training is focused on teaching pha- coemulsification techniques, some believe that extracapsular cataract extraction (ECCE) is an important part of surgical education in cataract removal. Some educators argue that ECCE experience imparts basic surgical skills such as suturing and wound construction that are essential to the beginning ophthalmology resident. 1 Others contend that ECCE is the standard "fall back" technique in the event of certain phacoemulsifi- cation complications and therefore should be learned prior to pha- coemulsification. 2 But many believe that ECCE is an outdated method and that training residents in ECCE prior to phacoemulsification is un- necessary. 3 Still others argue that ECCE should be taught, but not as an introductory technique for begin- ning surgeons. A report at the 2009 meeting of the Association of Uni- versity Professors of Ophthalmology showed that in 2002, 73% of U.S. ophthalmology residents began learning cataract extraction with ECCE, 4 whereas by 2009 only 55% of residents began with ECCE (Ta, Chris. Do Residents Still Perform ECCE? Lecture presented at: Associa- tion of University Professors of Oph- thalmology, 43rd Annual Meeting, Jan 29, 2009; Indian Wells, Calif.). This trend suggests a shift away from teaching ECCE to ophthalmology residents in the U.S. At UCSF, we continue to train our first-year residents in ECCE prior to teaching phacoemulsification. Through reviewing surgical compli- cations at our weekly morbidity and mortality conference, we realized that we needed to ask a more funda- mental question: Are we putting pa- tients at risk for complications by using one technique over another? Few studies have compared out- comes of the two surgical techniques at the earliest stage in resident expe- rience, when the surgeon learning curve is steepest. We recognized that, because of pre-op differences in case selection between ECCE and phacoemulsifica- tion, a true comparison is difficult in a retrospective study. For example, patients with denser cataracts might be more likely to be scheduled for ECCE because of the difficulty of L ast year, I received an urgent phone call from a Bay Area sur- geon who had paused during cataract surgery on a pseu- doexfoliation patient when it became apparent that the zonules were extremely deficient. The lens was so mo- bile that it was hard to complete the cap- sulorhexis and the nucleus was very brunescent. With the patient still on the table, my advice was to convert to a man- ual ECCE. However, the surgeon volun- teered that she had never performed or been trained in manual ECCE and as a re- sult preferred to abort the operation and refer the patient to me. The question of whether manual ECCE could become a vanishing art is an important one as increasing numbers of residency programs reduce or eliminate this component of cataract surgical train- ing. I asked our UCSF residency program director, Ayman Naseri, M.D., to summa- rize his recent study regarding complica- tion rates of phaco vs. manual ECCE among initial surgical trainees at UCSF. The study was published in the June issue of Ophthalmology. Ayman was an unusually precocious and gifted surgeon as a UCSF resident, where I was one of his early phaco attendings. Now that he oversees cataract surgical training for UCSF resi- dents, it is wonderful to see him apply his teaching skills and outstanding analytical insights to this important and often chal- lenging endeavor. I then asked Rosa Braga-Mele, M.D., Devin Gattey, M.D., Lisa Park, M.D., and Jack Dodick, M.D., to comment on the study and the implications. All four are noted experts in training residents in cataract surgery and shared their insights and experiences from the University of Toronto, Oregon Health & Science Univer- sity, and NYU School of Medicine (Manhat- tan Eye and Ear Infirmary), respectively. David F. Chang, M.D., chief medical editor Chief medical editor's corner of the world Ayman Naseri, M.D., UCSF residency program director Pursuing the Next Level of Outcomes in Customized Laser Refractive and Cataract Surgery Supported by an educational grant from Abbott Medical Optics Inc. Rosen Centre Hotel – Junior Ballroom 9840 International Drive (adjacent to the Orange County Convention Center) Monday, October 24, 2011 ORLANDO 2011 Registration now open! www.EyeWorld.org Check online for program updates. Register Now! 76-83 Cataract_EW October 2011-DL2_Layout 1 9/29/11 5:26 PM Page 76

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