EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78712
66 EW RESIDENT April 2012 Cataract tips from the teachers Treading too lightly Sherleen Chen, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Natalie Afshari, M.D. Director, Cornea and Refractive Surgery Fellowship Program Assistant professor, Department of Ophthalmology Duke University, Durham, N.C. T Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary ometimes when beginning some- thing new, there is a tendency to be overly cautious. This may create in- effectiveness or even make achieving goals more difficult. Such is the situation that can occur with beginning phaco surgeons, who may be too timid and slow with their instru- mentation, resulting in inefficient pha- coemulsification, with the potential for additional collateral damage. This month, three faculty members share their experience in helping early phaco sur- geons progress past their timid tendencies to become safer and more effective cataract surgeons. S Sherleen Chen, M.D., and Roberto Pineda, M.D. here are several ways to help the overly timid resi- dent gain confidence in learning cataract surgery. First, you need to make sure that the groundwork has been set prior to stepping into the OR. This can be done by ensuring proper wet lab practice has been accomplished (ideally with you at the resident's side), by reviewing cataract videos and discussing them with the resident, or by having the resident discuss with you the steps of the surgery, including how to manage any common difficulties. When you are comfortable that the basic pre-surgical training and preparation have been undertaken, it's very important to make the OR environment as comfortable as pos- sible for the resident. The timid resi- dent is already quite nervous and anxious, and anything that you can do to ease the tension will help. Start by ensuring the surgical sched- uling is set to allow sufficient time so the resident doesn't feel rushed or hurried. Also, consider having the timid resident start by only doing a few steps of the surgery at first—he or she may gain much-needed confi- dence by only having a small por- tion of the surgery to focus on and master. At the time of surgery, establish- ing a calm OR atmosphere is crucial. Take a few moments to again review the surgical steps prior to beginning. During the surgery itself, remain calm, cool, and collected. Don't try to convert residents to your tech- nique even if it's more efficient— allow them to proceed in the way they are most comfortable. As resi- dents gain more experience and are less timid, specific teaching on tech- niques is more appropriate and better received. Be supportive and Douglas M. Blackmon, M.D. Assistant professor, Department of Ophthalmology Emory University, Atlanta Director, Corneal and Refractive Surgery Veterans Affairs Medical Center, Atlanta I teach a lot of residents in the oper- ating room, so I encounter a variety Casey Eye continued from page 65 continue to encourage regular evalu- ation and management of their neo- vascular AMD perioperatively. EW References 1. Tabandeh H, Chaudhry NA, Boyer DS, Kon-Jara VA, Flynn HW. Outcomes of cataract surgery in patients with neovascular age- related macular degeneration in the era of anti-vascular endothelial growth factor therapy. J Cataract Refract Surg. 2012 April; 38:677-682. 2. Fung AE, Lalwani GA, Rosenfeld PJ, Dubovy SR, Michels S, Feuer WJ, Puliafito CA, Davis JL, Flynn HW Jr., Esquiabro M. An optical coherence tomography-guided, variable dosing regimen with intravitreal ranibizumab (Lucentis) for neovascular age-related macular degeneration. Am J Ophthalmol. 2007; 143:566-583. 3. Fletcher RH, Fletcher SW. Clinical research in general medical journals: a 30-year perspective. N Engl J Med. 1979; 301(4):180- 183. 4. Rosenfeld PJ, Shapiro H, Ehrlich JS, Wong P; MARINA and ANCHOR Study Groups. Cataract surgery in ranibizumab-treated patients with neovascular age-related macular degeneration from the phase 3 ANCHOR and MARINA trials. Am J Ophthalmol. 2011 Nov; 152(5):793-8. 5. Klein BEK. Is the risk of incidence or pro- gression of age-related macular degeneration increased after cataract surgery? [editorial] Arch Ophthalmol. 2009; 127:1528-1529. 6. Dong LM, Stark WJ, Jefferys JL, Al-Hazzaa S, Bressler SB, Solomon SD, Bressler NM. Progression of age-related macular degeneration after cataract surgery. Arch Ophthalmol. 2009; 127:1412-1419. 7. Hooper CY, Lamoureux EL, Lim L, Fraser- Bell S, Yeoh J, Harper CA, Keeffe JE, Guymer RH. Cataract surgery in high-risk age-related macular degeneration: a randomized controlled trial. Clin Exp Ophthalmol. 2009; 37:570-576. 8. Chew EY, Sperduto RD, Milton RC, Clemons TE, Gensler GR, Bressler SB, Klein R, Klein BEK, Ferris FL III. Risk of advanced age- related macular degeneration after cataract surgery in the Age-Related Eye Disease Study; AREDS report 25. Ophthalmology. 2009; 116:297-303. Contact information Lauer: lauera@ohsu.edu affirmative, and avoid criticism or negative feedback during the sur- gery. While critical evaluation of surgical technique is important, for the timid resident this may be more effective if undertaken while review- ing videos or discussing performance after the surgery. By ensuring proper preparation, maintaining a calm and comfortable OR environment, and giving posi- tive feedback intraoperatively, timid residents can gain the confidence needed to improve their OR skills. of personalities. Some residents ap- pear confident and have steady hands, some actually may be aggres- sive or seem hurried. However, it is common to have young surgeons at the other end of the spectrum be tentative, whether trying to avoid missteps or complications, or maybe because of their inexperience. Surgeons, among other things, need to be confident in their abili- ties, acknowledge potential limita- tions, and be efficient. Being timid interferes with all of those character- istics. To overcome this potential obstacle to successful surgery, you must identify its cause. Most often, being timid is sim- ply due to inexperience. To avoid its interfering with successful surgery, the resident should start preparing well in advance. Residents should: 1) Read books and watch videos to understand the procedure and the instruments involved. 2) Familiarize themselves with upcoming patients by reviewing their charts. 3) Discuss and listen to fellow residents and other surgeons talk about their sur- geries. 4) Talk to the actual attend- ing surgeon they will be working with, if possible. Residents can be- continued on page 68