EyeWorld Asia-Pacific December 2011 Issue

30 EW CATARACT/IOL December 2011 Cataract tips from the teachers Surgery pearls for new cataract instructors, from members of the faculty of the Harvard Intensive Cataract Surgery Training Course Sheila Borboli, MD, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Mass., USA The following tips can be helpful in efficiently teaching phacoemulsification to a beginning ophthalmic surgeon. These pearls can minimize complications encountered during surgery and reduce the stress and anxiety for both the preceptor and the resident. 1. Case selection: Residents enjoy a challenge, but don’t “overchallenge” them in the beginning. Avoid involving the resident in cases such as overtly dense nuclei, small pupils, pseudoexfoliation, or patients with compromised corneal endothelium. The increased risk of adverse events adds to the stress in such a setting. The traumatic experience of an intraoperative complication can be intimidating to a beginner surgeon. Success is a more potent confidence builder than failure. 2. Divide the early cataract cases into steps and have the resident focus on one step at a time: This is an extremely helpful strategy in teaching phacoemulsification. The steps are introduced in order of difficulty, with the easier steps, e.g., IOL insertion and viscoelastic removal, introduced first. The most difficult and critical steps, e.g., capsulorhexis or nucleus removal, are only attempted when the other steps have been successfully performed on a number of cases. This method allows the resident to build confidence in his/her skills. Have the resident practice working under the microscope and become familiar with the surgical instruments. This gives the preceptor an opportunity to observe the resident’s skill level, identify weaknesses, and intervene to correct technique errors. Using this approach, there is a clear understanding of what the expectations are of the resident for each case. Over a relatively short period of time, residents are able to perform entire cases by building every week on skills acquired during the previous weeks. This has the advantage of putting less pressure on the attendings to turn over entire cases and reduces the burden on the operating room schedule. All parties leave satisfied. 3. Communication: Instill in the residents the notion that treating cataracts is not a procedure performed exclusively in the operating room. Engage them in surgical planning, biometry evaluation, and IOL selection. Discuss phacoemulsification machine parameters and reasons for modifications, the preferred technique, instruments, and method of nucleus disassembly. Following each case, discuss with the residents in a calm and friendly setting technique errors, intraoperative events, errors in recognition, or other observations you made in regard to their performance. 4. Simulation: Use a wet lab if available. It is a stress-free environment where techniques can be demonstrated and the resident can practice on pig eyes steps such as wound creation and suturing. If the eyes are in good condition with a clear cornea, capsulorhexis and nucleus removal can be practiced. A surgical simulator is particularly helpful, especially for certain steps, e.g., capsulorhexis. The software allows performance measures to be evaluated. Encourage the residents to use it as much as possible prior to attempting this step in the operating room. Scott H. Greenstein, MD, FACS, Massachusetts Eye & Ear Infirmary, Harvard Medical School For anyone teaching either a resident or another practitioner a new surgical procedure, there are several key points to bear in mind. Some may seem obvious, but unless you find yourself in the gratifying position of teaching surgery (which I do after 20 years of private practice), these may not all be apparent. 1. Scrutinize every step: As a teacher, you cannot look away from the microscope for even a second. The 20 major steps of cataract surgery have multiple technical and judgment components. 2. Prevent complications: Know when to switch seats and take over. While it may be useful in horseback riding to get back in the saddle after a fall, we cannot afford to let the procedure progress to a point where it becomes irretrievable. 3. “The enemy of good is perfect” does not apply to cataract surgery: Our patients expect perfection today, and the results of the trainee must equal that of the attending. 4. Repetition is good and essential: Try to have the resident do multiple consecutive cases, early on in training emphasizing certain aspects of the procedure (such as incision creation or capsulorhexis). 5. Ask the resident for his/her opinion: For example, “Do you think we need to use trypan blue?,” “Do we need iris hooks?,” “Are we looking at cortex or capsule?,” “Do we need a suture?” 6. Don’t go after a tiny piece of residual, far-peripheral cortex. 7. Be patient at all times: While you may have performed ten thousand of these as an attending, the resident has done maybe a dozen or two. Never lose your cool. This sets a good example for the resident to maintain composure and logical thinking if a complication does arise. 8. Communicate: Do this in soft tones, respectful of the patient who may be able to understand the nature of what is being said. Try to give a full commentary on every step you go through on the first case of the day, before the resident starts. General anesthesia cases obviously enable maximum verbal input. 9. Utilize positive reinforcement: In many ways, you are acting as a coach. 10. Instill confidence: “You can do this.” 11. Avoid all distractions in the room: Pagers should be given to the circulating nurse, rather than being worn by the resident. There should be no unnecessary conversations in the room. Music should be played at low volume and only if the trainee agrees to this. 12. Overcome your fears: See numbers 1 and 2. 13. Remember, there’s a patient under there: R.P.E. (Respect, Protect, Experience) 14. Reinforce particularly challenging steps by working in the wet lab or on a surgical simulator. I hope these recommendations contribute to a better learning experience. There is something to learn, both by the instructor and the trainee, in every case. Carolyn Kloek, MD, Massachusetts Eye and Ear Infirmary, Harvard Medical School Teaching cataract surgery is gratifying but challenging. A few basic steps that are summarized below can make the experience more successful and rewarding for both the attending surgeon and the trainee. 1. Practice with trainees in the wet lab before the operating room: Spending time with a trainee in the wet lab prior to working with him or her in the operating room not only gives the attending surgeon a sense of the trainee’s skill level, but also gets both the attending and trainee comfortable working and communicating with one another prior to the operating room. 2. Make sure the trainee is in a comfortable position at the operating microscope before beginning the surgery: Appropriate positioning at the compiled by Sherleen Chen, MD, and Roberto Pineda, MD