Eyeworld

C M Y CM MY CY CMY K EW CATARACT 80 October 2011 tionally, with the pseudoexfoliation patient as well as the difficult IFIS patient, ECCE remains an important fallback technique in a surgeon's repertoire. Additionally it is important to know how to manage the ECCE pa- tient post-op. With the technologi- cal advancements of our phacoemulsification equipment, even a novice surgeon can achieve clear corneas and be lulled into an expectation of easy outcomes and an ignorance of the normal course of surgical healing. Residents have to be taught that ECCE can result in excellent visual results, but requires a level of vigilance and patience that comes only with experience. In a complicated case, it becomes easy to panic or "throw in the towel" and not work toward the end result that a good ECCE can achieve. Dr. Chang: How are residents in- structed in ECCE at your institution and what are the obstacles? Dr. Braga-Mele: At the University of Toronto, our residents receive ECCE training in a wet lab situation on human cadaver eyes at least two or three times during their residency. They also have the opportunity in their PGY 4 or 5 year to travel on a Philippines mission with some of Will continued from page 79 our staff to perform cataract surgery, mostly ECCE. Some have done elec- tives in India to learn small incision EC (this is subsidized by our depart- ment). It is a shame that they do not learn ECCE or small incision EC di- rectly by our department, but it would be a difficult and challenging ethical decision to take that step backward for our patients. Dr. Gattey: At the Casey Eye Insti- tute, we stopped teaching traditional ECCE several years ago as it is a flawed procedure. With the advent of modern phacoemulsification units, capsule dyes, and pupil expan- sion devices, resident surgeons can handle more difficult cases than ever before utilizing phacoemulsification. However, for reasons stated above, there are still instances when one needs to be able to do an ECCE. We now teach senior residents MSICS, introducing this technique later in their training and employing it on patients with dense nuclei or zonu- lar pathology. One of the limiting factors of this approach is the diffi- culty in predicting which nuclei will be truly dense and therefore less suitable for phacoemulsification. In any case, residents get to perform only a few MSICS surgeries, hinder- ing their chances to gain a lot of skill in this area. Another drawback is the fact that only one faculty member is comfortable teaching this technique currently. Drs. Park and Dodick: Our approach to teaching ECCE at NYU includes, first and foremost, choosing appro- priate patients. Earlier in the surgical year, the decision to perform a pri- mary ECCE is made more frequently in the patient with a brunescent cataract than later in the year when the residents become more comfort- able with phaco techniques and can be trusted not to use too much en- ergy or push hard on the zonules. Often, with a dense lens, we will have the resident start the case as an ECCE, taking down the conjunctiva, creating a 180-degree scleral groove, and tunneling into the cornea. But we will always have the resident enter with a small incision and at- tempt a capsulorhexis first (even in a planned ECCE) rather than a can- opener and decide afterward whether to open the wound for an ECCE or attempt phaco. A large part of that decision rests on our assess- ment of the surgical skill of the resi- dent up until that point in the case. The ability to minimize vitreous loss often lies with the faculty member making the right decision at a criti- continued on page 82 76-83 Cataract_EW October 2011-DL2_Layout 1 9/29/11 5:26 PM Page 80

• Cover