EyeWorld Asia-Pacific March 2014 Issue

29 EWAP CAtArACt/IOL March 2014 Myoung Joon KIM, MD Associate Professor, Asan Medical Center 88, Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea Tel. no. +82-2-3010-3975 Fax no. +82-2-470-6440 mjmjkim@gmail.com M eeks et al. proposed that phacoemulsification cataract surgery can be taught safely and effectively to residents with no manual ECCE experience. Although the complication rate of phacoemulsification (2.5%) was lower than ECCE (4.1%) in the study, it has generally been accepted that ECCE is a safer procedure than phacoemulsification in challenging cataract cases performed by less experienced surgeons. However, in Korea, most institutions have chosen phacoemulsification without antecedent manual ECCE in resident training programs, and our center also does it that way. The reasons for initiating cataract surgery with phacoemulsification are as follows: First, mature (hard nuclear) cataracts, in which manual ECCE can be chosen preferably, have become rare recently in Korea. Second, patients have expectations of fast visual recovery after cataract surgery. The annual number of cataract surgeries performed in Korea is now over 300,000 cases in a population of 50 million. Many patients are knowledgeable on modern cataract surgery and would therefore not accept an initial manual ECCE procedure. Third, technologies for phacoemulsification have developed incredibly. Examples are modulation of ultrasound energy, improved fluidics, stable maintenance of the anterior chamber, quality viscoelastics, and so on. Advances in technology allow residents to perform phacoemulsification more safely under the supervision of experienced surgeons. Fourth, many know-hows for phacoemulsification training have been accumulated. For example, intensive modular training has been adopted in training courses operated by the Korean Society of Cataract and Refractive Surgery (KSCRS). Fifth, even experienced surgeons do not prefer manual ECCE because of the long operation time, postoperative astigmatism, and late visual recovery. Although primary phacoemulsification cataract surgery for resident training is the general trend, there is no doubt that manual ECCE is an essential procedure for cataract surgeons. Therefore, some situations involving complications can be great opportunities to train manual ECCE techniques. An example is a posterior capsular rupture in the early steps of phacoemulsification. As such, our institution recommends limbal incisions for resident surgeons instead of clear corneal incisions, because limbal incisions allow the procedure to be easily switched to manual ECCE. In conclusion, I agree that phacoemulsification cataract surgery can be taught safely and effectively to residents with no manual ECCE experience. However, it should not overlook the fact that manual ECCE is an essential procedure for cataract surgeons. Editors’ note: Prof. Kim has no financial interests related to his comments. YAO Ke, MD Professor, Eye Institute of Zhejiang University Eye Center, SecondAffiliated Hospital of Zhejiang University, College of Medicine, China 88 Jiefang Road, Hangzhou, 310009, China Tel. no. +86-571-87783897 Fax no. +86-571-87783897 xlren@zju.edu.cn N owadays, in China, phacoemulsification is performed on about 55% of cataract patients, the remaining 45% patients receiving ECCE. In our eye center, we only perform ECCE in cataract patients with very hard nucleus; so ECCE is performed much less frequently than phacoemulsification (5% vs. 95%). For the last 5 years, we have had a systemic training project for cataract surgery at our eye center. All the residents begin their cataract surgery training with preclinical study which is composed of surgery-related knowledge learning and surgery simulation. Surgery simulation is through cataract surgery simulators and animal models. Residents should complete at least 10 cataract surgeries on surgery simulator or pig’s eye, respectively. After that, residents could get opportunities to begin clinical study. Before they operate on cataract patients, they need to complete at least 20 procedures as the cataract surgery assistant. Then they are allowed to perform surgery on cataract patients step by step, such as the clear corneal incision, capsulorhexis, phacoemulsification, I/A procedures and IOL implantation. One attending doctor is specifically responsible for clinical training according to arrangement. Residents should learn surgery skills progressively until they complete 15 cataract surgeries under the direction of the attending. Furthermore, we provide intensive phacoemulsification training. Residents in the final year have a 3-month intensive surgery training. In this period, he or she could perform two or three phacoemulsification surgeries under the supervision of an attending every day, so he or she could have significant improvement in surgery skills. At any other time outside these 3 months, the residents could have training once a week. Because ECCE only accounts for 5% of cataract surgeries in our center, we provide the opportunity of ECCE training to residents in our Mobile Eye Hospital. We go to the poor areas to give free of charge cataract surgeries at least 4 times every year. Each time we would arrange three attendings and three residents to perform ECCE surgeries. Under the premise of patients’ safety, residents learn the surgery skills under the supervision of senior doctors. On average, there are 200 to 400 ECCE surgeries every year. Editors’ note: Prof. Yao has no financial interests related to his comments. Views from Asia-Pacific