|Year : 2023 | Volume
| Issue : 1 | Page : 59-63
Cataract surgery training: Report of a trainee's experience
Matteo Ripa1, Atef Sherif2
1 Ophthalmology Unit, “Fondazione Policlinico Universitario A. Gemelli IRCCS”; Ophthalmology Unit, Catholic University “Sacro Cuore”, Rome, Italy
2 Ophthalmology Unit, Al Matarya Teaching Hospital, Cairo, Egypt
|Date of Submission||12-May-2022|
|Date of Decision||09-Aug-2022|
|Date of Acceptance||02-Dec-2022|
|Date of Web Publication||21-Feb-2023|
Largo A Gemelli, 8-00168 Rome
Source of Support: None, Conflict of Interest: None
| Abstract|| |
BACKGROUND: To report a trainee's experience gained in the cataract extraction training program after the COVID-19 pandemic.
METHODS: An ophthalmologist was trained in phacoemulsification and intraocular lens (IOL) implantation in the ETAPE foundation, Eye Center, Cairo for a period of 4 weeks by three expert cataract surgeons. The training was tailored to the previous trainee's experience according to his residency logbook and supervised by one expert cataract surgeon. The training included didactic lectures, clinical observations, and hands-on practical experience. In addition, the trainee was provided with a logbook to record details of patients operated on and procedures observed.
RESULTS: The trainee performed 58 phacoemulsification surgery with IOL implantation and two extracapsular cataract extraction over the 4 weeks. Seven patients underwent intraoperative complications. Surgical time (ST) improved from 48.77 ± 9.65 min in the 1st week to 19.34 ± 1.31 min during the last week of training (P = 0.046). Poisson regression showed that patients affected by less severe cataracts were more likely to exhibit a lower incidence of complications than patients affected by more severe cataracts. In addition, patients operated on during the 1st week were more likely to show a higher incidence of complications than those operated on during the last week.
CONCLUSIONS: The 4-week surgical training effectively improved surgical confidence and micro incisional skills according to ST reduction and complication rate occurrence. Ophthalmologists benefit from enhancing their cataract skills in a short time following a well-structured cataract extraction course. This could undoubtedly lead to improved surgical outcomes for patients undergoing cataract extraction.
Keywords: Cataract surgery, COVID-19, ophthalmic surgery, surgical training
|How to cite this article:|
Ripa M, Sherif A. Cataract surgery training: Report of a trainee's experience. Oman J Ophthalmol 2023;16:59-63
| Introduction|| |
Cataract surgery is the most widely performed surgical procedure worldwide, with about 60,000 cataract procedures daily. Affecting almost 95 million people worldwide, cataract remains the leading cause of blindness in the middle- and low-income countries.
To face the burden of cataract blindness, structured hands-on cataract surgery training is provided by each residency program to build and update trainees' surgical skills.
Despite this commitment, there are many reports of inadequate surgical exposure for trainee ophthalmologists. In 2019, a survey conducted by AlEnezi et al. reported that only 10% of respondents had performed 80 or more phacoemulsification cases (although 43% of respondents were still in training at the time of the survey), thus failing to achieve the required numbers according to the Saudi Commission for Health Specialties which had previously set a required minimum number for each surgical procedure at the time of graduation.
Furthermore, the recent COVID-19 pandemic has impacted ophthalmic practice and training as many trainees have been redeployed to emergency departments or intensive care units, suspending their ophthalmic training. During the pandemic outbreak, outpatient ophthalmological visits drastically dropped, and elective cataract surgery was significantly curtailed. This led to an attenuation of microsurgical skills, especially in less experienced trainees when returning to surgery after the hiatus.
Although the number of cases needed for a resident to achieve competency remains unknown, practising phacoemulsification requires exposure to high-volume surgery, with at least 86 up to 150 cases, to be a competent cataract surgeon and provide patients with the best affordable quality eye care.
The ETAPE foundation, Eye Center, Cairo offers structured courses in both extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens implant surgery, small incision sutureless cataract surgery (SICS), and phacoemulsification, helping trainees to develop the necessary cataract surgical skills.
This is a report of a 4-week ophthalmologist's microsurgery training experience at the ETAPE foundation, Eye Center, Cairo and its implication for ophthalmological training.
| Material and Methods|| |
For 4 weeks, three expert cataract surgeons trained an ophthalmologist in phacoemulsification and intraocular lens (IOL) implantation in the ETAPE foundation, Eye Center, Cairo. The training was tailored to the previous trainee's experience according to his residency logbook, and the trainee was assigned to and supervised by one of the expert cataract surgeons. The training included didactic lectures, clinical observations, and hands-on practical experience. In addition, the trainee was provided with a logbook to record details of patients operated on (such as age, gender, axial length, and cataract severity according to severity grade World Health Organization 2002 classification) and procedures observed and performed.
The 48-h workweek consisted of didactic lectures, surgical observation, hands-on practice, and postoperative examination. The didactic lectures included a revision of the basic surgical anatomy of the eye and lens pathophysiology, operating microscope and phacoemulsification machine parameters alongside phacodynamics and fluidics, introduction to the instrumentation of cataract microsurgery, preoperative patient management, phacoemulsification techniques (phaco-chop, divide-and-conquer, and stop-and-chop), postoperative management and approach to cataract complications.
The trainee was asked to observe at least five cataract extractions either by conventional ECCE, SICS, or phacoemulsification (using the observer's eyepiece on the microscope or a closed-circuit TV) before the hands-on surgical training for each day. According to case difficulty and skills, the trainee was asked to perform at least two cataract surgeries daily using either the Leica M620 F20 (Leica AG, Heerbrugg, Switzerland) or the Zeiss Lumera 700 (Carl Zeiss Meditec AG, Jena, Germany) operating microscope. Phacoemulsification was performed using either the Centurion or the Infiniti Phacoemulsification system (Alcon Laboratories, Inc.). The assigned supervisor was scrubbed during each procedure and took over from the trainee when needed during challenging surgical steps or intraoperative complications. Practical management of postoperative complications was done with the supervisor. All the procedures were video recorded to allow the trainee to watch the surgery again and learn from his previous mistakes. Documented sheets for each surgery were also available for trainees to review their surgeries and discuss with their supervisors.
Daily postoperative examination of previously operated patients was performed before the work began to evaluate the anatomical and visual outcomes of the patients operated on the day before. For more experienced trainees, complex cases, including poor dilating pupil suitable for iris hooks insertion, zonulysis for capsule tension ring usage, dense mature and whitish cataracts, and cloudy cornea, were chosen. At the end of the course, trainees received a signed and stamped certificate indicating the number of surgeries performed, a logbook, and a Phaco book about procedures, steps, and diagnoses.
All data were collected in the surgical logbook, including details of patients operated on and procedures observed and performed, and all statistical analyses were performed using the 27th version of SPSS (IBM-SPSS, Chicago, IL, USA). Descriptive statistics techniques summarised all variables included in the study. In-depth, qualitative variables were expressed as absolute and percentage frequency. As for quantitative variables, we performed the Shapiro–Wilk test to assess their distribution. Then, if normally distributed, they were described as mean and standard deviation. Differences for each parameter considered were evaluated between groups as qualitative variables, either by the Fisher's Exact test or the Chi-square test, with Yates correction, as appropriate. Quantitative variables were instead assessed by one-way ANOVA or Student t-test if normally distributed; otherwise, either the Mann–Whitney U-test or the Kruskal–Wallis test was applied. Poisson and multiple regression investigated the effects of covariates of interest on the complication rate and surgical time (ST), respectively. A value of P < 0.05 was considered statistically significant.
| Results|| |
The trainee observed 243 phacoemulsifications with IOL implantation, 96 ECCE, 41 anterior vitrectomies due to posterior capsular rent, and subsequent vitreous loss in the anterior chamber (AC), three pars plana vitrectomies for lens material removal due to posterior capsular rent and dropped nucleus.
Over the 4 weeks of training, the trainee performed 58 phacoemulsification surgeries with IOL implantation and two ECCE. The baseline and surgical features are highlighted in [Table 1].
Seven patients underwent intraoperative complications (five patients had posterior capsular rupture without dropped nucleus for which anterior vitrectomy with IOL sulcus lens implantation was performed, and two iris bleedings during IOL implantation, which were well controlled by hyaluronic acid (HA) injection). Although 11 challenging cases were selected during the last week of training (four highly myopic eyes, three poor dilating pupil eyes with iris hooks insertion, two haze cornea eyes, and two high severity grade cataracts), the complication rate was higher during the 1st week of training and decreased all over the training (1st-week of training complication = four-2nd-week of training complication = one; 3rd-week of training complication = one; 4th-week complication = one, P = 0.05).
The baseline characteristic and complication features of the patients who underwent complications are summarized in [Table 2]. During the whole training, ST decreased. During the 1st week, ST improved from 48.77 ± 9.65 min to 19.34 ± 1.31 min during the last week of training (P = 0.046). Multiple regression was run to predict ST from the axial length, complication (yes/no), cataract severity, and week of training. These variables statistically significantly predicted ST, F = 45.76, P < 0.0005, R2=0.88. Complication (yes/no), surgical week of training, and cataract severity variables added statistically significantly to the prediction, P = 0.03, whereas axial length did not affect the prediction (P = 0.3) [Figure 1]. Poisson regression was run to predict the number of complications based on the experience of the week of training and cataract severity. The regression coefficient of cataract severity was negative, suggesting that patients affected by less severe cataracts (NS 1+, CS 1+) were more likely to exhibit lower complications than patients affected by more severe cataracts (NS 4+, CS 4+). The incidence ratio (IRR) indicated that for everyone's unite increase of complication, the predicted incidence rate changed by a factor of 0.23 (P = 0.03). The regression coefficient for the week of surgery was positive, suggesting that patients operated on during the 1st week were more likely to exhibit a higher incidence of complications than those operated on during the last week. The IRR indicated that for everyone's unite increase of complication, the predicted incidence rate changed by a factor of 1.2 (P = 0.03).
|Table 2: Baseline and surgical features of patients who underwent intraoperative complications|
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|Figure 1: Scatter plot of multiple regression analysis of surgical time during the whole training in the function of cataract severity grade. WHO: World health organisation|
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| Discussion|| |
Cataract extraction is one of the most crucial surgical skills ophthalmologists need to master during their residency and careers.
However, due to the recent COVID-19 pandemic, ophthalmology residency programs (ORPs) failed to provide adequate surgical training. As a result, many elective procedures were stopped, and many ophthalmologists were redeployed to deal with the pandemic. Hence, many surgeons stopped performing ordinary microsurgery for several months. Furthermore, many residents enrolled in some ORPs fail to achieve the required numbers to be independent surgeons due to inadequate surgical training programs.
Many centers around the world provide surgical courses to enhance surgical skills. The ETAPE foundation, Eye Center, Cairo is one of many centers with structured training programs in ophthalmic surgical subspecialties tailored to the trainee's previous experience. The trainees are exposed to didactic lectures and hands-on training under supervision.
Here, we report a trainee's 4-week surgical experience in cataract extraction.
Similarly to any educational process, surgical teaching has followed a specific methodology as the trainee was first exposed to the theoretical principles of cataract extraction and phacodynamics and, soon after, led to the operating room to observe both highly experienced surgeons and more skilled surgeons trainees in surgical settings and live surgery. During the entire training, the trainee was assisted by a professional instructor ready to identify and prevent high-risk situations, and each procedure was fully video recorded for further review.
The trainee performed 60 cataract extractions (58 phacoemulsifications with IOL implantation and two ECCE). Operative ST was strictly related to the week of training, cataract severity, and complication rate, as shown by multiple regression. Indeed, during the 1st week of surgery, it was longer than the last week (48.77 ± 9.65–19.34 ± 1.31, P = 0.046). This might be due to the stress of the first cases he encountered in a new operating environment. In addition, his lesser microsurgical experience was exacerbated by the presentation of more advanced cases with more mature cataracts.
Nevertheless, only four complications occurred over the first surgical week. They consisted of three posterior capsular ruptures (PCR) and one iris bleeding. They happened during nucleus sculpture and due to inappropriate surgical maneuvers during IOL implantation in a hyperopic eye, respectively. As demonstrated by Poisson regression, the complication rate was related to the cataract severity and the week of training. Indeed, the higher complication rate occurred in the 1st week (four complications in the 1st week and one complication in the 2nd, 3rd and 4th week of training, respectively) as the trainee's surgical confidence were still under the average level, and he was less skilled. As cataract severity could highly impact the complication rate, it gradually increased according to the previous surgical experience and improvements.
Although PCR incidence in phacoemulsification for experienced surgeons is 0.45%–3.6%, the trainee PCR incidence was 8.3%, in accordance with residents' PCR rates that are between 0.8% and 8.9%. In addition, most PCRs occurred during the 1st week of training.
The supervisor promptly took over from him to deal with the complications, performing anterior vitrectomy and IOL sulcus implantation in the first three PCRs and then guiding the trainee over the two following cases at the end of the 2nd and 3rd week. Due to the floppy iris syndrome, two iris bleeding occurred. The trainee well managed them with HA injection with the supervisor's guidance.
Despite no statistical significance, higher and lower axial length eyes (Highly myopic and hypermetropic eyes, respectively) required more time than those with standard axial length. Indeed, while hyperopic eyes are shorter than standard eyes and have less “working room,” myopic eyes are usually longer than standard eyes and often become challenging due to the increased depth of the AC, floppy and large capsular bag, and zonular weakness in some cases.
As ST and complication rate showed a remarkable improvement over the training, the trainee was asked to perform more challenging cases. Four highly myopic eyes, three poor dilating pupil eyes, two cloudy cornea eyes, and two high-severity grade cataracts were chosen for the last week of training. Despite the greater difficulty, the trainee performed them without any intraoperative complications. However, poor dilating eyes required more time as the trainee had been guided to iris hooks insertion.
Despite the results, this report has many limitations. First, the trainee did not record any further additional challenging features such as the history of glaucoma, uveitis, trauma, frontal bossing, or sunken globe. Second, according to the trainee's previous experience, a few complex cases, including whitish and dense mature cataracts, were performed. Third, all surgeries were performed under local anesthesia (peribulbar anesthesia). Therefore, more complex surgical cases are required to describe the effectiveness of well-structured surgical training in developing microincisional surgical skills.
| Conclusion|| |
The 4-week surgical training effectively improved surgical confidence and micro incisional skills according to ST reduction and complication rate occurrence.
Ophthalmologists benefit from improving their cataract skills following a well-structured cataract extraction course. This could eventually lead to improved surgical outcomes for patients. It is hoped the findings from this report will be helpful for those who require enhancing surgical skills in this crucial surgery.
Financial support and sponsorship
Conflicts of interest
We wish to confirm that Matteo Ripa has no conflicts of interest associated with this publication whereas Atef Sherif is employed in ETAPE foundation, Eye Center, Cairo and receive a salary for this work.
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[Table 1], [Table 2]