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| BRIEF REPORT |
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| Year : 2004 | Volume
: 52
| Issue : 3 | Page : 233-4 |
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Learning phacoemulsification. Results of different teaching methods.
A Hennig, B Schroeder, J Kumar
Sagarmatha Choudhary Eye Hospital, Lahan, Nepal
| Date of Submission | 11-Feb-2003 |
| Date of Acceptance | 20-May-2003 |
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Correspondence Address:
A Hennig
Sagarmatha Choudhary Eye Hospital, Lahan
Nepal
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 15510464 
We report the learning curves of three eye surgeons converting from sutureless extracapsular cataract extraction to phacoemulsification using different teaching methods. Posterior capsule rupture (PCR) as a per-operative complication and visual outcome of the first 100 operations were analysed. The PCR rate was 4% and 15% in supervised and unsupervised surgery respectively. Likewise, an uncorrected visual acuity of > or = 6/18 on the first postoperative day was seen in 62 (62%) of patients and in 22 (22%) in supervised and unsupervised surgery respectively. Keywords: Phacoemulsification, monitoring cataract surgical outcome, surgical training, learning curve
How to cite this article:
Hennig A, Schroeder B, Kumar J. Learning phacoemulsification. Results of different teaching methods. Indian J Ophthalmol 2004;52:233 |
Phacoemulsification for cataract extraction has become increasingly popular in developing countries. Many experienced eye surgeons who are familiar with extracapsular cataract extraction plan to learn phacoemulsification. We report the results of three surgeons' learning curves with different teaching methods, using a simplified evaluation system for monitoring cataract surgical outcome.[1]
| Materials and Methods | |  |
The learning curves of three experienced surgeons converting from sutureless non-phaco ECCE/PC-IOL technique to phacoemulsification were analysed retrospectively, comparing the first with the second 50 cases of each surgeon. Posterior capsule rupture (PCR) during surgery and uncorrected visual acuity (VA) on the first postoperative day were recorded. VA was graded according to WHO definitions into good (ž6/18), borderline (<6/18 - 6/60) and poor (<6/60) outcome. All patients were examined on slitlamp and reasons for uncorrected VA <6/60 were analysed. During a one-month training period, each surgeon performed 100 phacoemulsification operations using the identical surgical set-up. The "stop and chop" technique, involving longitudinal groove, breaking of the nucleus and phaco-chop was taught. All patients received a PC-IOL according to biometry findings. Three teaching methods were evaluated as follows:
1. No formal training: Surgeon A had no formal training. He performed phacoemulsification without supervision according to instructions from video teaching material and instructions by the company representative who had installed the phaco machine. Patients with all grades of nuclear cataract[2] were included and only those with white, mature cataracts were excluded.
2. Formal training: Surgeon B performed phacoemulsifi-cation under the guidance of an experienced phaco-surgeon but did all the steps of the surgery by himself. Only if surgical complications occurred, the teaching surgeon took over to continue with the operation. Patients with nuclear cataract grade NUC-1 and 2[2] were included, those with grade NUC-3 as well as patients with white, mature cataracts were excluded.
3. Stepwise formal training: Surgeon C learned phacoemulsification stepwise and was taught by an experienced phaco-surgeon. Surgery was divided into three major steps. Step 1 : Self-sealing incision and capsulorhexis. Step 2 : Hydrodissection and phaco-emulsification. Step 3 : Bimanual irrigation/aspiration and IOL implantation. At the beginning of the training, only step 3 was taught, whereas the teaching surgeon did steps 1 and 2. Once step 3 was mastered, the trainee learned steps 2 and 3 of the surgery, while the teaching surgeon was still doing step 1. After 30 surgeries, Surgeon C was instructed to do all steps of the surgery independently. Only patients with nuclear cataract grade NUC-1[2] were operated, others with more dense or mature cataracts were excluded.
| Results | | |
First day uncorrected VA and PCR rate significantly improved during the learning process with all training methods [Table - 1].
PCR occurred in 4 (4%) of operations with stepwise (Surgeon C) and in 10 (10%) with formal training (Surgeon B). An even higher PCR rate of 15 (15%) cases was observed, if no formal training was used (Surgeon A). Patients operated by Surgeons B and C had 65 (65%) and 62 (62%) "good" uncorrected VA on the first postoperative day, whereas Surgeon A achieved only 22 (22%) "good" VA results. Likewise, patients with "poor" VA on the first postoperative day were less common in the series of Surgeons B and C [4 (4%) and 9 (9%)] than in the series of Surgeon A [16 (16%)]. Corneal pathology related to surgery was the reason for "poor" VA in 3 patients of Surgeon C, 4 of Surgeon B and 11 of Surgeon A [Table - 2]. Other major surgical complications, such as posterior dislocation of lens fragments or wound leakage due to incisional burn did not occur with all three surgeons.
| Discussion | | |
Most earlier studies on learning phacoemulsification have analysed the learning curves of junior surgeons during their residency period. [3],[4],[5] Likewise, senior surgeons, well experienced in ECCE, should expect a significant number of complications when converting to phacoemulsification.[6]
In a survey performed in England between 1996 and 1997, only 46% (6 of 14) of the participating consultant ophthalmologists had performed phacoemulsification under supervision before "going solo".[7] However, learning without formal training may lead to a high number of major surgical complications especially during the first 50 surgeries, with PCR occurring in up to 20% of the cases.[6]
We were able to demonstrate that these problems can be minimised if the phaco-training is done stepwise, under the supervision of an experienced phaco-surgeon and on carefully selected patients with immature cataracts and less hard nuclei.
Monitoring cataract surgical outcome gives the surgeon useful information about the quality and what he may need to improve. As shown in our study, this may require only a few parameters such as PCR, uncorrected VA on the first postoperative day and analysing reasons for VA less than 6/60. These data can easily be obtained from all patients undergoing cataract surgery.
Monitoring surgical outcome will help improve surgical results and thus reduce unnecessary blindness related to cataract surgery.[1],[8]
| References | | |
| 1. | Pararajasegaram R, Limburg H, Cook C, Yorston D, Chirambo M. Monitoring cataract surgical outcome. J Community Eye Health 2002;15:49-59.  |
| 2. | WHO Cataract Grading Group. A simplified cataract grading system. Geneva: WHO Publication 01.81; 2002. pp 3-6. |
| 3. | Sharma N, Bhartiya P, Sinha R, Vajpayee RB. Trypan blue assisted phacoemulsification by residents in training. Clin Exp Ophthalmol 2002;30:386-87. |
| 4. | Thomas R, Naveen S, Jacob A, Braganza A. Visual outcome and complications of residents learning phacoemulsification. Indian J Ophthalmol 1997;45:215-19. [ PUBMED] |
| 5. | Cruz OA, Wallace GW, Gay CA, Matoba AY, Koch DD. Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. Ophthalmology 1992;99:448-52. [ PUBMED] |
| 6. | Martin KR, Burton RL. The phacoemulsification learning curve: Per-operative complications in the first 3000 cases of an experienced surgeon. Eye 2000;14:190-95. [ PUBMED] |
| 7. | Gonglore B, Smith R. Extracapsular cataract extraction to phacoemulsification: Why and how? Eye 1998;12:976-82. [ PUBMED] |
| 8. | Dandona L, Dandona R, Anand R, Srinivas M, Rajashekar V. Outcome and number of cataract surgeries in India: policy issues for blindness control. Clin Exp Ophthalmology 2003;31:23-31. [ PUBMED] [ FULLTEXT] |
[Table - 1], [Table - 2]
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