EyeWorld India March 2012 Issue

31 EW CATARACT/IOL March 2012 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. Pangputhipong: The ability to perform ECCE is an important skill of a competent and independent phaco surgeon. While training residents to perform good phaco without ECCE experience is possible, their future practices may be limited by the need to refer complex cases or when complications occurred. Dr. Ruit: I personally feel it is very important and mandatory for Phaco surgeons to be able to do MSICS. In this part of the world where we often encounter advanced cataracts and other resource constraints, surgeons with the expertise of only phaco will end up with a serious handicap. Some unique features of the challenges of doing cataract surgery in this part of the world are as follows: • Cost and quality of medical consumables • Cost and complexity of equipment (operating microscopes and phaco machine) • Availability of appropriate, simple and safe surgical technique • Advanced cataracts • Engineering backup While operating in a community like ours, a phaco surgeon with skills of MSICS will be able to perform very safe surgery with good visual outcome. This will allow them to handle the complications of surgery very effectively. What is now debatable is whether to teach MSICS or phaco first. I personally feel the residents should start with MSICS or even ECCE. Each step of the surgery is to be learned in parts. This will allow them to get familiar with hand-eye coordination under the microscope, learn the fine art of suturing, get familiar with the wound construction and safe cruising in the anterior chamber. In my opinion, MSICS will teach the dynamics of both horizontal and vertical forces in the eye while phaco is predominantly a vertical force. Surgeons trained in MSICS will have room for deviating safely from the technique of phaco in times of complications such as extension of capsularhexis, rent in the posterior capsule, very large, brown and hard nucleus, morgagnian cataract, pseudo exfoliation syndromes, etc. Good quality expensive microscopes are not available all the time. It is a lot easier to do MSICS than phaco on a simpler operating microscope. The lack of good quality power supply and engineering backup makes phaco surgery very challenging. Surgeons with expertise in both Phaco and MSICS can selectively operate safely in communities particularly when the conditions are challenging and sub optimal. Such a surgeon will be much more versatile in handling the complications very safely and effectively. How are residents instructed 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 Philippine mission with some of our staff to perform cataract surgery, mostly ECCE. Some have done electives in India to learn small incision EC (this is subsidized by our department). It is a shame that they do not learn ECCE or small incision EC directly 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 Institute, 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 expansion 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 zonular pathology. One of the limiting factors of this approach is the difficulty 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, hindering 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 appropriate patients. Earlier in the surgical year, the decision to perform a primary ECCE is made more frequently in the patient with a brunescent cataract than later in the year when the residents become more comfortable with phaco techniques and can be trusted not to use too much energy 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 attempt 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 assessment of the surgical skill of the resident 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 critical point in the case and being able to accurately predict the odds of that particular resident being able to handle the clinical situation at hand. The main obstacles to teaching ECCE include the incidence of appropriately brunescent cataracts that are ideal for this technique. Limited OR time and the desire to do more cases also diminish the incentive for the residents to book an ECCE. Additionally, for many volunteer faculty members who rarely perform ECCE in private practice, it is not uncommon for them to express reluctance in attending these cases, perpetuating the perception that this is an obsolete technique. Another teaching strategy we advocate is the backward step-wise approach to surgery; i.e., allowing the junior residents to participate in parts of a senior resident’s case, starting with viscoelastic removal, inserting the lens, performing I&A, etc. We enjoy having the senior residents supervise their juniors and watching them realize the patience and time it takes to sit at the assistant scope. Dr. Pangputhipong: Residents will observe/assist many ECCE cases as well as attend pig eye wet lab before they start to do surgery under close supervision. After collecting 50 ECCE cases, usually at the end of 2nd year or the beginning of 3rd year of training, they will convert to phaco. Dr. Ruit: In our institution, residents learn to become good MSICS surgeons. In the first year, the residents assist in surgery and perform steps of surgeries in bits and pieces. Initial focus is given on good hand-eye coordination, learning conjunctival peritomy and a good wound construction with the concept of self-sealing wounds. Initially, residents are encouraged to make larger wound sizes, often up to 10 mm in the external wound. Nucleus delivery from the wound through the scleral tunnel is assisted by the use of a corrugated high flowing simco cannula. Cortex aspiration is done by the simco cannula. We never use an anterior chamber maintainer as our infusion aspiration cannula has a special infusion size of 21 G instead of the conventional 23 G. This high flow of infusion helps in maintaining the anterior chamber. The intraocular lens is implanted, the wound integrity is tested and if need be the residents are encouraged to put some stitches at the beginning. At the first post op day, cases are examined under slit lamp and steps of surgery are revisited. Each resident keeps an audit of their surgery. They are assisted in handling complications such as premature entry, irregular tunnel, thin scleral flap and scleral bleeding. The second step is to teach them the anatomy of the anterior capsule and capsulotomy. We constantly remind them that every cataract is different from another. Our residents initially learn to perform a closed wound v-shaped anterior capsulotomy with a straight needle. There are several advantages with this technique; for instance, it creates a closed chamber, is more controlled and can be performed in all types of cataract and capsule. Very often the capsules that we encounter are fibrotic, leathery, thin and tense with fluid, with variable anterior adhesions. The v-capsulotomy allows nuclei of all sizes to be delivered safely into the anterior chamber. For residents who learn phaco after ECCE, the learning curve is less steep. When the residents encounter complications during phaco surgery, such as rupture of the posterior capsule before continued on page 44