This article is more than 5 years old. Information may no longer be current.
Case selection important when learning new techniques, trying novel devices
Inexperienced residents and seasoned surgeons need a variety of cases as part of their learning process.
Click Here to Manage Email Alerts
There is a range of difficulty that we encounter during cataract surgery, with some cases being significantly more difficult than others. At the beginning of our careers when we are learning the basics, it is important to select patients who are anticipated to have a straightforward surgery so that we can hone our skills while minimizing complications. Because surgery constantly evolves, learning is a life-long pursuit for experienced surgeons as well, with new techniques, devices and instrumentation coming every year. When trying these new ideas for the first time, we must choose appropriate cases so that we can learn while maintaining a margin of safety for our patients.
An easy phaco case vs. a difficult case is usually determined by a few key factors: patient cooperation, exposure to the cataract, density of the nucleus, condition of ocular structures and patient healing ability. A softer nucleus in a younger patient with great dilation tends to be easier to perform than a dense nucleus in an older patient with poor dilation.
Key factors of surgery
Patient cooperation means ability to tolerate the surgical procedure as well as the willingness of the patient to accept the risks of surgeries and to have reasonable expectations. A patient with ocular comorbidities must understand that the cataract surgery may only correct part of the vision, that the rate of complications is higher and that another surgery may be needed. In addition, the patient should be able to lie flat and endure the procedure while holding still under light sedation. Patients with orthopnea or spinal lordosis may be mentally cooperative but physically unable to lie flat and therefore pose additional challenges.
Figure 1.This patient has a moderate degree of central nuclear sclerosis and would be a good choice for a beginning resident to learn nucleofractis techniques such as phaco chop.
Figure 2. This patient has a very dense cataract and would pose significant challenges to beginning surgeons. More experienced surgeons, however, may see this as a reasonable patient in which to try a new technology or technique because the preoperative vision is so poor that anything would be an improvement.
Source: Devgan U
Exposure to the cataract is important for safe and comfortable surgery. A patient with a prominent brow or a tight pupillary fissure makes it difficult to access the eye during surgery, particularly from a superior approach. Within the eye, a poorly dilating eye makes access to the cataract more difficult and may necessitate the use of hooks or rings to provide further exposure.
The condition of ocular structures relates to the health and stability of the cornea, iris, capsular bag and zonular apparatus. A patient with a weak or irregular cornea, particularly one with a low endothelial cell count, is more likely to have postoperative complications from surgery. If the iris musculature has been adversely affected by drugs such as tamsulosin, it is more likely to be floppy and prolapse during cataract surgery. The capsular bag and zonular structures are critical to hold the nucleus in place during phacoemulsification as well as to accept the IOL.
The condition of ocular structures also relates to the posterior segment of the eye. The vision in patients with retinal disease or optic nerve pathology will be limited, and cataract surgery alone may not improve their vision sufficiently enough. Patients with retinal breaks or weakness may be more prone to developing a retinal detachment after an uneventful cataract surgery. And those with advanced glaucomatous damage to the optic nerve can experience irreversible damage from the phaco surgery.
Patient healing relates to the ability to recover good vision quickly after surgery with an uneventful postop period. Patients with concomitant health issues such as diabetes can have poor wound healing, worsening of their retinopathy and cystoid macular edema after even a well-performed cataract surgery. Patients with a history of uveitis can have a prolonged course of inflammation and more potential complications than others. Even compliance with postoperative eye drops plays a role in the patient’s healing process.
Learning for residents, experienced surgeons
For a resident who is just starting to perform cataract surgery and has done fewer than 10 cases, I prefer a softer posterior subcapsular cataract in a relatively young patient. In this case, I will prolapse the nucleus into the anterior chamber where the resident can safely aspirate it while keeping away from the capsular bag. The goal of these initial cataract surgeries is for the resident to learn to work inside the confined space of the anterior segment and to understand the foot pedal settings.
For a resident who is learning nucleofractis, we want a case in which there is a sufficient degree of nuclear sclerosis (2+ to 3+) so that techniques such as divide-and-conquer and phaco chop can be learned. A soft nucleus would be difficult to crack or chop, and a very dense nucleus may have posterior fibrous connections that would prevent separation of nuclear fragments. The goal of these cases is to learn to break up a lens nucleus.
For experienced surgeons, when trying a new technique or technology, it is easier to change just one aspect of the surgery at a time. For example, if using a new type of IOL, keep the rest of the surgery the same. For a surgeon who wants to try a new phacoemulsification platform, keep the same surgical technique and IOL until the new fluidic and power settings are honed.
Finally, keep patients involved and let them know that you have many years of experience but will be using a new device in order to improve their outcome. Select patients who will appreciate that you have their best interests at heart and that you are keeping up with the newest technologies.
For more information:
Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.DevganEye.com.Disclosure: Devgan reports no relevant financial disclosures.