PASSING THE TORCH

Leigh Spielberg during an operation. Courtesy Leigh Spielberg

More than a generation has passed since phacoemulsification and intraocular lens (IOL) implantation became the standard treatment for cataracts in the developed world. The current generation of trainee cataract surgeons therefore have a great advantage over the previous generation, who had to develop their techniques almost from scratch with a lot of trial and error.

Moreover, the advent of the Internet, and YouTube and the proliferation of courses and wetlabs at meetings have increased the availability of relevant knowledge for trainees.

“When I started my cataract surgery as a resident there were no videos, no VHS, no videotaping. The only way you could learn was to stand beside the surgeon and learn the technique from the operating microscope. Now the spread of knowledge is much quicker,” Roberto Bellucci MD, University Hospital Verona, Italy, told EuroTimes.

“Teaching surgery has also become a little bit less surgical and a little bit more technical. Now it is mandatory to teach how phacoemulsification machines work and how to get the best out of them. Now you need to be a little bit like plumbers to understand fluidics, tubing and the general mechanics of phacoemulsification,” he added.

The wide adoption of sutureless surgery has had a dramatic effect on the way cataract surgery is taught, somewhat to the detriment of ophthalmic surgery as a whole, Dr Bellucci said.

“Before the advent of sutureless surgery, cataract surgery was more similar to the other types of surgery because it involved incisions that had to be sutured. Now there is no need to learn how to close the eye. So the transition to other types of ophthalmic surgery, like corneal transplants, either deep anterior lamellar or penetrating keratoplasty is now much more difficult for young ophthalmologists than it was before.”

He added that the ESCRS is trying to remedy that by introducing specific courses dedicated to teaching young surgeons procedures involving the suturing of large incisions. “The ESCRS has undertaken a major role in ophthalmic education, with the purpose to fill the gap between university teaching and everyday life,” he added.

STARTING WITH A GOOD FOUNDATION

As with any new undertaking, learning how to perform cataract surgery involves first finding out as much as possible about the nature of the task and the skills involved, said Oliver Findl MD, Hanusch Hospital, Vienna, Austria.

“First of all, I want my trainees to have a good medical knowledge, which they can obtain by watching videos and reading books. We have a syllabus for students. In addition, the ESCRS has the iLearn programme. That gives them the opportunity to obtain all the medical knowledge they need on their computers and tablets. If possible they will go to one or two courses at the international meetings, for example the ESCRS Congress and the cataract didactic courses at the ESCRS Winter Meeting, and I have them go to wetlabs,” he said.

Surgical simulators like the EyeSi system can also be very helpful, Dr Findl noted. There have been a couple of studies published in peer-reviewed journals, showing that they do improve skills and knowledge, he said.

“One of the advantages of simulators is that they allow you to practise for a long time and simulators also give you direct feedback on your microsurgical technique. I don’t have one myself in my unit because they’re pretty expensive. They are not a must, but I think simulators are nice to have,” he added.

BECOMING ACQUAINTED WITH THE EQUIPMENT

Before trainees actually takes part in a surgical procedure, they should become well-accustomed to using the equipment involved, such as the surgical microscope, the knives and forceps and the phacoemulsification machine they are going to use, Dr Findl said.

“After the operating list is finished, I tell my trainee to go to the operating theatre in the afternoon or evening and place a tennis ball on the operating table and practise using the pedals of the microscope. After a while they become very comfortable doing this and they don't have to think about the pedals of the microscope anymore.

“Then I ask them to practise on the tennis ball using the surgical instruments, including the phaco handpieces, with a gloved hand. I also have a representative from the company who manufactures the phaco machine come in and explain how it works from A to Z. Usually these reps have a lot of technical knowledge and will show
all the features of the machine to the trainee.

LEARNING FROM END TO BEGINNING

Dr Findl noted that that the older, beginning-to-end, step-by-step approach to teaching cataract surgery was correct about teaching each part of the procedure in individual steps, but simply put things in the wrong order.

“When I learned, back in the old days, I would start the surgery at the beginning and see how far I could go before the surgeon took over. That is not a good way of doing it for several reasons. First, the earliest parts of the procedure are also the most difficult and most dangerous. Second, complications occurring during incision creation or capsulorhexis are much more difficult to remedy than are the final steps of the procedure.

“That is why I do it from the last step to the beginning - so reverse. First, I have them take the viscoelastic out of the eye, then when they have done that five or 10 times and are confident in their performance, the next step is to learn how to place the lens in the eye, and then later how to perform irrigation and aspiration, remove nuclear fragments, how to perform nuclear fragmentation, hydrodissection, capsulorhexis until the last step of performing the initial incisions,” Dr Findl said.

OPERATING TABLE-SIDE MANNER

One thing trainee surgeons should keep in mind from the beginning is the patient attached to the eye on which they are operating, Dr Findl noted. “I think it is very important to talk with the patient during surgery. Most of the procedures are done under local anaesthesia and patients do feel some discomfort during surgery once in a while. Usually the junior surgeon is too stressed to talk to the patient during the procedure. I'm looking through the microscope as well and I comment as I would if I were doing the surgery.”

THE VIDEO REVOLUTION

Soosan Jacob FRCS noted that surgical videos help fill in the gaps of knowledge that can remain even after intensive study and observing surgery first-hand.

“Watching a senior or mentor performing is a great technique, because they will explain the many nuances that are difficult to explain without a visual demonstration. But sometimes what happens is that there is a pressure of time on the surgeon or the trainee may be hesitant to ask questions,” said Dr Jacob, Dr Agarwal's Group of Eye Hospitals, Chennai, India, in an interview.

“Watching a surgical video where every point is being explained is a very different situation. Now the surgeon can explain each and every step much better. Furthermore, if there’s something of particular interest that occurs during the procedure like a complication, the trainee can actually stop, rewind, go back and watch it again until they are sure they understand,” she added.

Dr Jacob said that combining written explanations with video illustration provides the best of both worlds. She therefore makes videos for her YouTube channel that provide a visual demonstration for many of the techniques she describes in her columns in EuroTimes.

She noted that making a good instructional video involves time and effort - making sure the lighting is optimum, the microscope is focused and aligned well and that all the steps are shown clearly in a manner understandable to the viewer. This is followed by editing the presentation in such a way that the key points are clearly illustrated and explained. “Making a good video tends to be time-consuming, but the beauty is that when you do this you are also becoming a better and better surgeon and a better communicator,” Dr Jacob said.

SURGICAL MENTORS

EuroTimes columnist Leigh Spielberg MD, FEBO was recently granted permission to perform his first series of independent, unsupervised cataract procedures, which he has described in his column in the September issue. He noted in an interview that very focused observation of his surgical mentors early in his training was among the most essential parts of his learning experience.

“Before you’re actually doing surgery, a good understanding of the anatomy of the anterior segment is crucial. Paying very close attention to the procedures performed by the mentor, not just passively watching but really paying attention to each step as it is performed, is an excellent way to learn it,” said Dr Spielberg, Rotterdam Eye Hospital,
the Netherlands.

Dr Spielberg added that he found preoperative preparation to be very useful, including screening each patient’s medical file and taking note of any surgical risk factors, such as use of tamsulosin, prior retinal tears or pseudoexfoliation. This also shows your surgical mentor that you have done your homework and are interested in learning, he said. He noted that assisting surgery before participating in the actual surgery itself further enhanced his training.

“In my hospital, residents serve as first assistants during most cataract surgeries. This involves handing each instrument to the surgeon throughout the procedure, which requires you to always anticipate the next move and keeps very alert,” Dr Spielberg said.

Once you’re performing procedures, there are several important milestones on the road to achieving the confidence necessary to perform cataract surgery without supervision, he noted.

“The first intraocular steps are intense, because you’re initially a bit unsure of what you're doing, but each successfully completed step generates a giant boost in terms of confidence. The first time you’re alone at the operating table, with your mentor in the OR but not scrubbed in, that's a big deal. And if your mentor happens to leave during a cataract operation, that's a push towards independence, and it made a big impression on me that someone was willing to entrust their patient to my hands,” he said.

Yet regardless of a surgeon’s experience, that confidence must be tempered with modesty and respect for the eye, he stressed. “Even the best ophthalmologist is never completely confident in his or her skills. Everyone has to maintain a sense of humility and a degree of caution during every procedure, because even those who have done tens of thousands of procedures can still encounter a complication.”

Roberto Bellucci: robbell@tin.it

Oliver Findl: oliver@findl.at

Soosan Jacob: Dr_soosanj@hotmail.com

Leigh Spielberg: leigh.spielberg@gmail.com