Surgical outcomes, complications and learning curve of glued intraocular lens of a vitreo retinal fellow in training.

Purpose: To evaluate surgical outcomes, complications and learning curve of glued intraocular lens surgery by a vitreoretinal (VR) fellow in training. Methods: Analysis of 50 eyes requiring glued intraocular lens (GIOL) surgery for various indications was done. Both the consultant VR surgeon (Group 1) and VR fellow in training (Group 2) operated 25 eyes each. The primary outcome measures were visual acuity at 3 months, and time taken for completion of surgery. Secondary outcome measures were refractive correction, intraocular pressure and intraoperative or postoperative complications. Results: The uncorrected visual acuity (UCVA) improved from log MAR 1.54±0.56 (Snellen 20/693) to 0.45±0.26 (Snellen 20/56) and from 1.64±0.53 (Snellen 20/873) to 0.56±0.45 (Snellen 20/72) in group 1 and 2, respectively. The best corrected visual acuity (BCVA) improved from log MAR 0.74±0.61 (Snellen 20/109) to 0.33±0.26 (Snellen 20/42) and from 1±0.68 (Snellen 20/200) to 0.40±0.50 (Snellen 20/50) in group 1 and 2, respectively (P > 0.05). The surgical time was significantly less in group 1 when compared to that of group 2 (64.26 vs 107.16 minutes) P value <0.05). The mean time taken for the initial 10 cases and later 15 cases in group 2 were 131.9 and 91.2 minutes, which was statistically significant. The complication rates in both groups were comparable. Transient hypotony (IOP < 11) was seen in 56% (14/25) of eyes in group 2 and 44% (11/25) in group 1 (P = 0.39). Conclusion: The study results are encouraging for a VR fellow with good short-term visual outcomes and comparable surgical complications. The procedure gives promising results and the learning curve is overcome by a desire to learn and with increasing number of procedures done under supervision.

Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study.

PURPOSE: To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons. SETTING: Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA. DESIGN: Retrospective chart review. METHODS: All cases of cataract extraction by phacoemulsification with intraocular lens implantation, performed by comprehensive ophthalmologists between January 1 and December 31, 2014, were reviewed. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome, were included for analysis. Visual outcomes and the rate of perioperative adverse events were compared between resident and attending surgeon cases. Factors predicting adverse events were also assessed. RESULTS: In total, 1931 eye cases of 1434 patients were reviewed, and 65 resident cases and 168 attending surgeon cases were included. The mean logarithm of the minimum angle of resolution corrected distance visual acuity was better in the resident group 1 month after surgery (0.051 ± 0.10 [SD] versus 0.132 ± 0.30, P = .03); however, the difference was eliminated when controlling for macular disease. The mean operative time was 43.8 ± 26.5 minutes and 30.9 ± 12.6 minutes for cases performed by resident surgeons and attending surgeons, respectively (P  .0001). Residents utilized supplemental pharmacologic dilation or retraction more frequently than attending surgeons (98% versus 87% of cases, P = .008). The overall rate of adverse events was no different between residents and attending surgeons (P = 0.16). Dense nuclear sclerosis predicted adverse events in cataract cases with iris challenges (adjusted odds ratio, 1.86; 95% confidence interval, 1.17-2.94; P = .001). CONCLUSION: Although requiring longer operative times and more surgical manipulation, residents who performed cataract surgeries with iris challenges achieved outcomes comparable to those performed by attending surgeons, and residents should be given the opportunity to operate on these eyes.

Results and safety profile of trainee cataract surgeons in a community setting in East Africa.

PURPOSE: To evaluate the results and safety profile of assistant medical officer ophthalmologists (AMO-O) performing cataract surgery in the last stage of their surgical training, before their appointment to local communities. METHODS: We retrospectively analyzed the records of patients who underwent cataract surgery by AMO-Os at Dar es Salaam, Comprehensive Community Based Rehabilitation for Tanzania Disability Hospital between September 2008 and June 2011. Surgical options were either extracapsular cataract extraction (ECCE) or manual small incision cataract surgery (MSICS), both with polymethylmethacrylate intraocular lens implantation. RESULTS: Four hundred and fourteen patients were included in the study. Two hundred and twenty-five (54%) underwent ECCE and 189 had MSICS. Mean logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity (UCVA) improved from 2.4 ± 0.6 preoperatively to 1.3 ± 0.8 1 week postoperatively (t-test, P < 0.001) and to 1.1 ± 0.7 3 months postoperatively (t-test, P < 0.001). Mean logMAR best-corrected visual acuity (BCVA) was 0.7 ± 0.5 1 week postoperatively and 0.6 ± 0.5 3 months postoperatively. There was no significant difference in mean logMAR UCVA (P = 0.7) and BCVA (P = 0.7) postoperatively between ECCE and MSICS. 89.5% achieved BCVA better than 6/60 and 57.3% better than 6/18 with a follow-up of 3 months. Posterior capsule rupture and/or vitreous loss occurred in 34/414 patients (8.2%) and was more frequent (P = 0.047) in patients undergoing ECCE (10.2%) compared with MSICS (5.3%). CONCLUSION: AMO-O cataract surgeons at the end of their training offer significant improvement in the visual acuity of their patients. Continuous monitoring of outcomes will guide further improvements in surgical skills and minimize complications.

Virtual phacoemulsification surgical simulation using visual guidance and performance parameters as a feasible proficiency assessment tool.

BACKGROUND: Computer based surgical training is believed to be capable of providing a controlled virtual environment for medical professionals to conduct standardized training or new experimental procedures on virtual human body parts, which are generated and visualised three-dimensionally on a digital display unit. The main objective of this study was to conduct virtual phacoemulsification cataract surgery to compare performance by users with different proficiency on a virtual reality platform equipped with a visual guidance system and a set of performance parameters. METHODS: Ten experienced ophthalmologists and six medical residents were invited to perform the virtual surgery of the four main phacoemulsification cataract surgery procedures - 1) corneal incision (CI), 2) capsulorhexis (C), 3) phacoemulsification (P), and 4) intraocular lens implantation (IOL). Each participant was required to perform the complete phacoemulsification cataract surgery using the simulator for three consecutive trials (a standardized 30-min session). The performance of the participants during the three trials was supported using a visual guidance system and evaluated by referring to a set of parameters that was implemented in the performance evaluation system of the simulator. RESULTS: Subjects with greater experience obtained significantly higher scores in all four main procedures - CI1 (ρ = 0.038), CI2 (ρ = 0.041), C1 (ρ = 0.032), P2 (ρ = 0.035) and IOL1 (ρ = 0.011). It was also found that experience improved the completion times in all modules - CI4 (ρ = 0.026), C4 (ρ = 0.018), P6 (ρ = 0.028) and IOL4 (ρ = 0.029). Positive correlation was observed between experience and anti-tremor - C2 (ρ = 0.026), P3 (ρ = 0.015), P4 (ρ = 0.042) and IOL2 (ρ = 0.048) and similarly with anti-rupture - CI3 (ρ = 0.013), C3 (ρ = 0.027), P5 (ρ = 0.021) and IOL3 (ρ = 0.041). No significant difference was observed between the groups with regards to P1 (ρ = 0.077). CONCLUSIONS: Statistical analysis of the results obtained from repetitive trials between two groups of users reveal that augmented virtual reality (VR) simulators have the potential and capability to be used as a feasible proficiency assessment tool for the complete four main procedures of phacoemulsification cataract surgery (ρ < 0.05), indicating the construct validity of the modules simulated with augmented visual guidance and assessed through performance parameters.

Confidence of ophthalmology specialist trainees in the management of posterior capsule rupture and vitreous loss.

PurposeTo ascertain ophthalmology trainee confidence in managing posterior capsule rupture (PCR) and vitreous loss.MethodsAn electronic survey was distributed to ophthalmology trainees in a single UK postgraduate training Deanery. Data collected included the stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs personally managed by the trainee, previous vitrectomy experience during vitreoretinal rotations, and attendance at advanced phacoemulsification courses. Trainees self-evaluated their confidence in managing PCR with vitreous loss, including the management of specific aspects of the procedure.ResultsAcross training grades, only 9.1% (2/22) felt confident managing PCR without senior support. Respondents were most confident with fluidic parameters and IOL considerations, but 77.3% (17/22) lacked confidence in avoiding a dropped nucleus. Eleven respondents had completed >350 cases (mean 576; range 383-1087). In this subgroup, mean cumulative PCR rate was 2.1% (range 0.9-4.9%), and trainees personally managed a mean 3.5 cases of PCR (range 1-7). Only 18.2% felt they could manage PCR and vitreous loss without senior support, and 45.5% stated they were not confident in avoiding a dropped nucleus. The most experienced trainee (1087 cases) had personally managed PCR just six times, and three trainees with >350 cases had only managed PCR once each.ConclusionsThe Royal College of Ophthalmologists' requirement of 350 completed cases appears insufficient for independent cataract surgery, as opportunities to manage complications as a trainee are scarce. A competency-based assessment framework may be preferable, with a more targeted approach to training incorporating surgical simulation within the formal curriculum.

Outcomes of manual extracapsular versus phacoemulsification cataract extraction by beginner resident surgeons.

PURPOSE: To evaluate the safety and efficacy of phacoemulsification cataract extraction and manual extracapsular cataract extraction (ECCE) performed by beginning resident surgeons. SETTING: Dallas Veterans Affairs Medical Center, Dallas, Texas, USA. DESIGN: Retrospective cohort study. METHODS: A review was performed of each resident's series of initial cataract surgery procedures as a late first-year or second-year resident. Data were collected for cases performed over almost a 6-year period during which initially the first primary surgeon cases were ECCE and later, the first primary surgeon cases were phacoemulsification. For each case, the following data were gathered: technique of cataract extraction, laterality, resident, vitreous loss or dropped nucleus, placement of posterior chamber intraocular lens (IOL), and need for reoperation within 90 days of surgery. RESULTS: Complications occurred in 6 (2.5%) of 244 cases in which phacoemulsification was performed by a beginner resident primary surgeon and in 7 (4.1%) of 172 cases in which ECCE was used (P=.40). Posterior chamber IOLs were placed in all but 2 phacoemulsification cases and 4 ECCE cases (P=.24). Moreover, 3 cases in the phacoemulsification group and 1 case in the ECCE group required a reoperation within 90 days (P=.65). CONCLUSION: Phacoemulsification cataract extraction can be taught safely and effectively to residents with no cataract surgery experience as a primary surgeon.

Resident experience with toric and multifocal intraocular lenses in a public county hospital system.

PURPOSE: To study the outcomes of toric and multifocal intraocular lens (IOL) implantation performed by resident surgeons. SETTING: Parkland Health and Hospital System, Dallas, Texas, USA. DESIGN: Case series. METHODS: Patients seen between July 2008 and May 2011 and meeting inclusion criteria (including >1.0 diopter [D] of astigmatism in toric group and <0.75 D astigmatism in multifocal group) were offered implantation of the study IOLs. Major outcomes were uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) and, for the multifocal IOL, near visual acuity. Residents were surveyed about their knowledge regarding these IOLs. RESULTS: Seventy-nine eyes of 60 patients received an Alcon Acrysof toric IOL. Eighteen eyes of 10 patients received an Alcon Acrysof Restor IOL. In the toric group, 57% of eyes achieved a postoperative UDVA of 20/25 or better and 90% achieved 20/40 or better. The CDVA was 20/25 or better in 92% of eyes. The mean refractive cylinder was 1.69 D preoperatively and 0.38 D postoperatively. In the multifocal group, 78% of patients achieved a UDVA of 20/25 or better and 94% achieved 20/40 or better. All patients had a CDVA of 20/25 or better. Near vision was Jaeger 3 or better in 94%. The survey showed that residents have a strong comfort level with preoperative and surgical techniques for premium IOLs after their experience in the residency setting. CONCLUSION: Residents in public county hospitals can be taught to use premium IOLs with good success rates, comparable to those in other published studies. FINANCIAL DISCLOSURE: Dr. McCulley is a consultant to Alcon Laboratories, Inc., and Dr. Aggarwal is on the speaker's bureau for Alcon Laboratories, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Structured extracapsular cataract extraction-intraocular lens microsurgical training: report of a trainee's experience.

AIM: The aim was to report the experience an ophthalmologist gained in a structured intraocular lens (IOL) microsurgery training program for the information and benefit of colleagues in ophthalmology training institutions. MATERIALS AND METHODS: An ophthalmologist was trained in extracapsular cataract extraction (ECCE)-IOL implant in Aravind Eye Hospital (AEH), Madurai, for a period of 8 weeks. Details of patients operated on, procedures observed, and conferences attended were prospectively recorded in a log book. RESULTS: Training was available in conventional ECCE with posterior chamber IOL (ECCE-PCIOL), small incision sutureless cataract surgery, and phacoemulsification. During the period, this trainee observed a total of 1527 cataract extractions, administered 528 retrobulbar and 1047 facial blocks, and also operated on 75 patients. The trainee gained experience and confidence to perform high-quality, low-cost cataract surgery. CONCLUSION: Hands-on experience and competence in quality ECCE-IOL implant microsurgery can be acquired in a short period of time in a high-volume cataract center. Trainees can also be exposed to other techniques of cataract surgery. Ophthalmology training centers with diminishing surgical training opportunities can also benefit from this structured training in a high-volume cataract center like Aravind Eye Hospital.

Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees.

PURPOSE: To measure the relative difficulty of each stage of phacoemulsification surgery performed by basic surgical trainees. SETTING: Mater Misericordiae University Hospital, Dublin, Ireland. METHODS: This prospective study comprised 100 consecutive cases of phacoemulsification performed by 8 trainee surgeons over an 11-month period. The trainees completed a questionnaire at the end of surgery, rating the degree of difficulty of 8 individual stages of phacoemulsification on a 5-point scale from 1 (very easy) to 5 (very difficult). RESULTS: At the start of the study, trainees had spent a mean of 9.4 months training. The mean preoperative best corrected decimal visual acuity was 20/70. The most difficult stages were phacoemulsification and capsulorhexis with the highest mean scores of 3.32 +/- 1.00 (SD) and 3.30 +/- 1.24, respectively and the lowest completion rates of 66.7% and 74.4%, respectively. The first 3 stages of peribulbar blockade (1.72 +/- 0.75), draping the surgical field (1.35 +/- 0.70) and corneal incision (1.97 +/- 0.72) were easiest and had close to a 100% completion rate. Hydrodissection, irrigation/aspiration, and intraocular lens insertion had difficulty rates of 2.42 +/- 0.92, 2.80 +/- 1.10, and 2.58 +/- 1.08, respectively, and completion rates of 92.3%, 78.4%, and 83.1%, respectively. Posterior capsule tear occurred in 9%, including 4% with vitreous loss; there was 1 case of zonular dehiscence. CONCLUSIONS: Trainee surgeons found phacoemulsification and capsulorhexis the most difficult stages of cataract surgery early in the learning curve. More time can be dedicated to mastering these steps in the wet lab.