EyeWorld India March 2014 Issue

28 EWAP CAtArACt/IOL March 2014 Take it to the limit: A surgical training cataract dilemma Geoffrey Broocker, MD Walthour- DeLaPerriere Professor of Ophthalmology Chief of service, Grady Memorial Hospital, Atlanta, Ga., U.S . The study by Meeks et al. addresses the issue of initiating phaco training with ophthalmology residents earlier in their training and without antecedent manual ECCE procedures being performed. Although the study demonstrated little significant difference in outcomes between the two groups (with a single attending surgeon), the study did not indicate the degree or types of cataracts and how they were randomized (if at all) to the two groups. An early nuclear or mostly soft cortical cataract responds easily to phaco even in a novice’s hands. A mature (brick) brunescent cataract in an elderly patient may not do quite so well. Skill sets require hands-on training. Virtual training and wet labs are helpful and currently necessary in most training programs. Manual cataract skill sets are necessary when a surgeon is confronted with phaco machine breakdown or dysfunction and most often during complicated phacoemulsification. I still get at least two or three calls a year from former trainees thanking me for providing these skill sets to them Judith Mohay, MD Associate professor, Department of Ophthalmology & Visual Sciences University of Louisville, Louisville, Ky., U.S. The information provided by this study will help to improve our methods of surgical training for beginning resident surgeons. As such, it is truly welcome and much needed. The aim of this study is to help to decide which surgical technique (ECCE or phacoemulsification) is preferable for beginning ophthalmology residents. The review is a retrospective cohort study. The study identified a large enough sample size of patients/resident surgeons for meaningful statistical analysis. The surgical environment and the level of training was the same for both groups and this was a great advantage for the validity of the outcome. The authors and the University of Texas Southwestern Medical Center residency training program should be congratulated for the excellent surgical outcomes and for the low rate of complications. Although the complication rates were higher for ECCE patients compared to those who underwent phacoemulsification (4.1% versus 2.5%, respectively), this difference could have partially been the result of selection bias. Patients who need ECCE tend to have more advanced cataracts, a higher number of comorbidities, lower socioeconomic status, and altogether higher chances for complications. The selection bias may have affected Roberto Pineda, MD Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary Sherleen Chen, MD Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary In this month’s column, our faculty discusses an article on learning traditional extracapsular cataract surgery and phacoemulsification during residency. They discuss their experience and tips for teaching and acquiring manual extracapsular cataract skills in conjunction with learning phacoemulsification. What should our educational priorities be for assuring adequate manual cataract skills while acquiring competency in phacoemulsification? reference Meeks L, Blomquist P, Sullivan B. Outcomes of Manual Extracapsular Versus Phacoemulsification Cataract Extraction by Beginner Resident Surgeons. J Cataract Refract Surg. 2013; 39:1698-1701. during moments of crisis in the operating room. I liken the situation to general surgery’s laparoscopic cholecystectomy. Within the last 15 years, the vast majority of gall bladder removals have been laparoscopic. In the recent years, the residents have had little or no experience in open cholecystectomies (gall bladders are being removed a lot earlier, easier, and with less morbidity— sound familiar?) or common bile duct exploration. I asked one of my “older” general surgeons at Emory/Grady about this. He said that younger community physicians urgently call older, more experienced surgeons on staff or their mentors in training. A quote I love from two Ohio surgical educators (M.C. O’Bryan and J. Dutro) is: “The emergence of more and more minimally invasive technologies requires planning and vigilance on the part of surgical educators to ensure that the basic tenets of more traditional operations are not neglected.” Unfortunately, there are a growing number of ophthalmic educators who were not taught or minimally taught many of these skill sets and hence cannot teach it themselves. I agree that phaco can be taught earlier in residency training without antecedent ECCE experience. Our own program offers both procedures in the second year, phaco in the second half. The future of U.S. healthcare might include the necessity to perform low-cost self-sealing ECCE. continued on page 30 by Sherleen Chen, MD, and roberto Pineda, MD