PRACTICE IS KEY

There is no royal road to learning the skills involved in cataract surgery. Instead, expertise can only be gained through the assiduous practice of techniques learned from highly experienced surgeons, according to Larry Benjamin FRCS, Stoke Mandeville Hospital, Aylesbury, UK. “If you want to become an expert in virtually anything it takes 10,000 hours of practice. That's been shown for a number of activities, from music, to sport and to surgery. That’s about five hours a day for 10 years, taking weekends off, before you’re an expert,†Dr Benjamin told the attendees at the Young Ophthalmologists Symposium at the 17th ESCRS Winter Meeting.

He noted that prior to participating in surgery; trainee ophthalmic surgeons must first become familiar with the basic principles of cataract surgery. In the UK that begins with a mandatory three-day microsurgical skills course. For the first two days of their course trainees learn how to perform basic incisions, sutures and suture knots. On the third day, trainees learn about phacoemulsification, how to use the machine and the basic phacoemulsification techniques. They then progress to the wet lab for further training and practice.

Wet labs and simulation
A good wet lab has fairly simple requirements and, with a little ingenuity, trainee surgeons can enhance their practice with inexpensive and easily acquired materials, Dr Benjamin noted. In the microsurgical course, trainees also learn simpler things like draping the eye for surgery, using a pig’s eyelid and a pig’s eyeball on a plastic head. “Even learning to drape correctly takes practice and it’s one of those simple basic things that if you don't get right you can spoil the whole operation,†he said.

The college skills board enables trainees to practise suturing and capsulorhexis techniques. It also enables them to practise more advanced techniques like suturing muscles onto eyeballs. The basic setup of the skills board is very inexpensive, costing only about ₤200.00 (€230.00). “It’s a good investment. If you have one of these, you can practise forever. Even practising simple suturing techniques for an hour once a week will make you much better at suturing than most trainee surgeons in the country.

There are many types of devices available for practising surgery in simulation. They include artificial heads that can be fitted with pigs’ eyes or with artificial eyes containing artificial cataracts. The types of simulation vary in terms of their similarity to real surgical conditions, however, all can provide trainees with an enhancement of their surgical skills.

He added that he and his associates designed a plastic head that trainees can use to practise their surgical technique from a superior or temporal position. The model has replaceable plastic eyes, including one type designed for suturing and wound construction and another type that has a synthetic cataract and is designed for practising capsulorhexis and phacoemulsification, and costs around ₤400.00 (€460.00). “They are a really good investment, the eyes are not cheap but there are alternatives around, but if you can get the use of one of these heads, one of these skills boards with each unit in the country you're set up for the next 20 years,†Dr Benjamin noted.

There are also more technologically advanced systems like the Eyesi® simulator (VRmagic GmbH), which enables surgeons to perform every part of surgery in a kind of virtual environment. Another option is the Kitaro artificial eye system, which can be used for practising capsulorhexis, and phacoemulsification,†he said. “I think it's very important to use not only the high-tech simulator but also an ordinary microscope with the suture pad, using plastic or pigs’ eyes. Having access to both of these is going to be an advantage to the trainee surgeon,†he added.

Moving on to patients
Dr Benjamin said that bringing trainee surgeons to the point where they can complete a cataract procedure on their own takes several stages. In the first stage, the teaching surgeon must determine their students’ knowledge of the surgical process and have them agree to a contract as to what they will achieve in their three months of training.

Following that, the teaching surgeon should have the trainee perform parts of the surgery in his first actual cases. For example, the trainee could begin the procedure but after a pre-agreed length of time hand the case over to the teaching surgeon. Similarly, the teaching surgeon might perform the beginning of the procedure and let the trainee finish the operation. The trainee’s first cases should be fairly straightforward, involving cooperative patients with grade II cataracts and well-dilated pupils.

Also, because procedures are often performed under local anaesthesia trainees and trainers should agree to a code so if something untoward should occur, the patient will not become overly alarmed when the teaching surgeon needs to take over. “In summary, you need to structure the training, to supervise it carefully, it’s hard work. Practice needs to be regular and frequent, simulation is very useful and should be undertaken to prepare you for your first supervised cataract procedures in actual patients,†Dr Benjamin concluded.