EyeWorld Asia-Pacific March 2012 Issue

30 EW CATARACT/IOL March 2012 I n October last year, EyeWorld asked Ayman Naseri, MD, director, University of California, San Francisco (UCSF) residency program, to summarize a study on complication rates of phaco vs. manual ECCE conducted at their institution. In that study, Dr. Naseri and his colleagues found comparable complication rates between ECCE and the first 10 phaco cases performed by first year residents. The study was published in the June 2011 issue of Ophthalmology; Dr. Naseri’s summary can be found in the October 2011 issue of EyeWorld Magazine (“Part I: Complication rates of phaco vs. manual ECCE among initial surgical traineeds at UCSF”, p. 76). EyeWorld then asked experts in training residents in cataract surgery Rosa Braga-Mele, MD, Devin Gattey, MD, Lisa Park, MD, and Jack Dodick, MD, to comment on the study and its publications. Here we publish their responses, along with the perspectives of two experts from the Asia-Pacific region, Pannet Pangputhipong, MD, and Sanduk Ruit, MD. What is your opinion of and take-home conclusion from the UCSF study data? Dr. Braga-Mele: The UCSF study is a very interesting study that looks at complication rates of residents performing ECCE or phacoemulsification. The data revealed that the complication rates were about the same with respect to vitreous loss and similar with respect to reoperation rates (but perhaps for different reasons). However, the study failed to look at post-op outcomes such as visual acuity, astigmatism, and corneal endothelial stability. It also showed that there was a lower rate of PCIOL implantation in the ECCE group, which makes one assume that ACIOLs were used and they inherently have a longer-term complication issue. The conclusion that the author states of further studies needing to be done to weigh the educational benefits of teaching ECCE is a valid one; however, one must question the ethics of subjecting live patients to ECCE when phacoemulsification can likely be performed with relatively good results. Dr. Gattey: I applaud Dr. Naseri and his group for their thoughtful analysis of this dilemma. The primary outcome of vitreous loss rate is an important one, but more germane to the patients receiving the procedures is final uncorrected and best corrected visual acuity. ECCE induces substantially more astigmatism than phacoemulsification, leading, presumably, to worse uncorrected visual acuity. This alone makes ECCE less ethical in my mind even if all other outcomes are equal. Another interesting result was the high rate of vitreous loss (17% for ECCE and 16.9% for phaco) for beginning surgeons. This points to a need for better cataract surgery training models, perhaps with more time spent on wet lab practice or the use of surgery simulators. Drs. Park and Dodick: We agree with the overall conclusion that it is acceptable to teach phaco first as a primary cataract extraction technique. When we trained, residents were required to perform 10 ECCEs before moving to phaco. We don’t believe this is necessary or desirable, and this policy is no longer the case in our training program. The techniques are not dependent on one another, and with the judicious use of the wet lab and surgical simulation as introductory exercises, we feel comfortable starting a novice surgeon with phaco techniques. It would appear that the take-home conclusion from the UCSF study data is that there is no significant difference in patient outcomes between ECCE vs. phaco in the hands of a novice surgeon. We are pleased to see that they found the rate of vitreous loss to be the same in the two groups. But what would ultimately be more important to know is the final visual acuity in order to show that it is ethical for patients to receive ECCE. Dr. Pangputhipong: During the early phase of phaco training in Thailand, we found that the rate of vitreous lost among experienced cataract surgeons and residents trained under close supervision were 2.06% and 6.93%, respectively. (Tayanithi, Will ECCE become a vanishing art? Pakitti; Pungpapong, Keerati; Siramput, Patharaporn. Journal of the Medical Association of Thailand 2005;88(Suppl. 9):S89-S93) These rates were comparable to those from ECCE and within acceptable range. Dr. Ruit: Cataract surgical training is an important and integral part of the residency training in ophthalmology. We expect the residents to be safe and good cataract surgeons in the community they are working in. Though the surgical technique to start in training (ECCE or phaco) is highly debatable, we strongly feel that they should start with ECCE and learn phaco afterwards. Manual small incision cataract surgery (MSICS) has evolved in the last 15 years to be highly safe and provide excellent visual outcome. This surgery has allowed us to bring in a large target group within the reach of the surgery (affordable and accessible). When you routinely encounter cataract patients with more than three fourths of them being blind, the technique of phacoemulsification becomes practically an impossible endeavor. The UCSF study comparing the complication rates of phaco vs. manual ECCE among residents is quite interesting and highlights the debate further even in countries like the United States of America. I believe if the residents have the skills of MSICS with phaco, they will be able to convert safely from any point of complication during phaco surgery, thus, providing much less chance of resurgery. Finding a tutor and trainer with the skills of manual ECCE in Western countries could possibly prove to be difficult at times. For residents who have interests in international ophthalmology, it is mandatory that they learn both techniques. How important is it for phaco surgeons to know how to do a manual ECCE? Dr. Braga-Mele: It is important for phaco surgeons to feel comfortable with ECCE to be able to convert a difficult or challenging case. However, unless one keeps the skills in tune, even some of the best phaco surgeons (that may have been ECCE trained) have a difficult time feeling comfortable with conversion to ECCE. Luckily, there are not many cases in this day and age, in the U.S. or Canada, that require conversion to ECCE. Many of these cases get referred to surgeons who tend to do the more challenging cases and because of this, these surgeons keep their skills honed. It is also difficult to say at what point in one’s career that ECCE needs to be taught or whether it should be in a wet lab situation or on live patients. Dr. Gattey : A previous paper by Dr. Naseri’s group noted that the two highest risk factors for a major intraoperative complication during resident- performed phacoemulsification cataract surgery were mature 4+ nuclear sclerosis cataract and zonular pathology. These cases are often “converted” to ECCE after complications ensue, necessitating that expert surgeons eventually acquire the skill to perform an ECCE under challenging circumstances. Planned ECCE is often the best choice for these cataracts. Manual small incision cataract extraction (MSICS) is a variation of ECCE that is even better suited for these potentially complicated surgeries. Its benefits include the possibility of a sutureless procedure and the induction of less astigmatism than traditional ECCE. Used extensively in South Asia, this procedure has a proven track record for routine and difficult cataracts and, in experienced hands, can be performed as quickly as phaco. Drs. Park and Dodick: We believe it is still critical to teach ECCE as a technique and for cataract surgeons to feel comfortable handling an open eye. In our training program at NYU, which includes a Level 1 Trauma Center and coverage of the New York correctional system, we often encounter cases necessitating conversion to ECCE or ICCE. Additionally, 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 patient post-op. With the technological advancements of our phacoemulsification equipment, even a novice surgeon can achieve