September 2011




Cataract tips from the teachers

by Michelle Dalton EyeWorld Contributing Editor

Sherleen Chen, M.D.

Instructor in Ophthalmology, Harvard Medical School and Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary

The Harvard Intensive Cataract Surgical Training Course was founded in 2005 by Bonnie Henderson, M.D., at the Massachusetts Eye and Ear Infirmary (MEEI). This annual weekend course draws second year residents from across the country and features lectures and wet lab training in basic cataract surgical techniques. What is unique is that the faculty consists of surgical instructors from residency programs across the country who voluntarily travel to Boston to teach in the course. All of the faculty members are selected by their respective department chairs as the best resident surgical attending from that program. Because many of us teach residents and because many readers are in (or are not that far removed from) their own residencies, I thought that EyeWorld should have a regular column dealing with tips for helping less experienced cataract surgeons. Our trade journals and meeting programs tend to highlight cataract experts discussing the most complex cases and techniques (e.g., Rich Hoffman's Tips and techniques column). In contrast, this column will focus on more basic surgical pearls and problems. To lead this effort, I have tapped two talented MEEI faculty members, Sherleen Chen, M.D., and Roberto Pineda, M.D., who along with Bonnie are co-directors of the Harvard cataract surgery course. In this ongoing column, they will feature the talent and advice from these Harvard course faculty members who have been designated as the "best of the best" at training residents. This new EyeWorld columnCataract tips from the teachersdebuts this month.

David F. Chang, M.D., chief medical editor

Roberto Pineda, M.D. Assistant Professor of Ophthalmology Harvard Medical School and Director of Refractive Surgery Massachusetts Eye and Ear Infirmary

Earlier this year, Dr. Chang approached us about a column focused on cataract surgery pearls based on the Harvard Intensive Cataract Surgical Training Course for young cataract surgeons and for those teaching surgeons-in-training. We planned a series of articles focused on helping teachers and students glean the most from their cataract learning experiences. Since the beginning of the academic year is often very stressful for both residents and their instructors, we thought it might be useful to start by sharing our faculty's tips and pearls for new cataract instructors. Residents rely on their teachers to take them successfully through a case. These teaching skills are unique from those we learn in training, and most instructors don't receive formal training as educators. For those of you who have taught residents for some time, these themes may resonate with you. We have asked Drs. Borboli, Greenstein, and Kloek to share their insights into "at the microscope" cataract training for new teachers.

Sherleen Chen, M.D., and Roberto Pineda, M.D.


Sheila Borboli, M.D., Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston

The following tips can be helpful in efficiently teaching phacoemulsification to a beginning ophthalmic surgeon. These pearls can minimize complications encountered during surgery and reduce the stress and anxiety for both the preceptor and the resident.

1. Case selection: Residents enjoy a challenge, but don't "overchallenge" them in the beginning. Avoid involving the resident in cases such as overtly dense nuclei, small pupils, pseudoexfoliation, or patients with compromised corneal endothelium. The increased risk of adverse events adds to the stress in such a setting. The traumatic experience of an intraoperative complication can be intimidating to a beginner surgeon. Success is a more potent confidence builder than failure.

2. Divide the early cataract cases into steps and have the resident focus on one step at a time: This is an extremely helpful strategy in teaching phacoemulsification. The steps are introduced in order of difficulty, with the easier steps, e.g., IOL insertion and viscoelastic removal, introduced first. The most difficult and critical steps, e.g., capsulorhexis or nucleus removal, are only attempted when the other steps have been successfully performed on a number of cases. This method allows the resident to build confidence in his/her skills. Have the resident practice working under the microscope and become familiar with the surgical instruments. This gives the preceptor an opportunity to observe the resident's skill level, identify weaknesses, and intervene to correct technique errors. Using this approach, there is a clear understanding of what the expectations areof the resident for each case. Over a relatively short period of time, residents are able to perform entire cases by building every week on skills acquired during the previous weeks. This has the advantage of putting less pressure on the attendings to turn over entire cases and reduces the burden on the operating room schedule. All parties leave satisfied.

3. Communication: Instill in the residents the notion that treating cataracts is not a procedure performed exclusively in the operating room. Engage them in surgical planning, biometry evaluation, and IOL selection. Discuss phacoemulsification machine parameters and reasons for modifications, the preferred technique, instruments, and method of nucleus disassembly. Following each case, discuss with the residents in a calm and friendlysetting technique errors, intraoperative events, errors in recognition, or other observations you made in regard to their performance.

4. Simulation: Use a wet lab if available. It is a stress-free environment where techniques can be demonstrated and the resident can practice on pig eyes steps such as wound creation and suturing. If the eyes are in good condition with a clear cornea, capsulorhexis and nucleus removal can be practiced. A surgical simulator is particularly helpful, especially for certain steps, e.g., capsulorhexis. The software allows performance measures to be evaluated. Encourage the residents to use it as much as possible prior to attempting this step in the operating room.

Scott H. Greenstein, M.D., F.A.C.S., Massachusetts Eye & Ear Infirmary, Harvard Medical School

For anyone teaching either a resident or another practitioner a new surgical procedure, there are several key points to bear in mind. Some may seem obvious, but unless you find yourself in the gratifying position of teaching surgery (which I do after 20 years of private practice), these may not all be apparent.

1. Scrutinize every step: As a teacher, you cannot look away from the microscope for even a second. The 20 major steps of cataract surgery have multiple technical and judgment components.

2. Prevent complications: Know when to switch seats and take over. While it may be useful in horseback riding to get back in the saddle after a fall, we cannot afford to let the procedure progress to a point where it becomes irretrievable.

3. "The enemy of good is perfect" does not apply to cataract surgery: Our patients expect perfection today, and the results of the trainee must equal that of the attending.

4. Repetition is good and essential: Try to have the resident do multiple consecutive cases, early on in training emphasizing certain aspects of the procedure (such as incision creation or capsulorhexis).

5. Ask the resident for his/her opinion: For example, "Do you think we need to use trypan blue?," "Do we need iris hooks?," "Are we looking at cortex or capsule?," "Do we need a suture?"

6. Don't go after a tiny piece of residual, far-peripheral cortex.

7. Be patient at all times: While you may have performed ten thousand of these as an attending, the resident has done maybe a dozen or two. Never lose your cool. This sets a good example for the resident to maintain composure and logical thinking if a complication does arise.

8. Communicate: Do this in soft tones, respectful of the patient who may be able to understand the nature of what is being said. Try to give a full commentary on every step you go through on the first case of the day, before the resident starts. General anesthesia cases obviously enable maximum verbal input.

9. Utilize positive reinforcement: In many ways, you are acting as a coach.

10. Instill confidence: "You can do this."

11. Avoid all distractions in the room: Pagers should be given to the circulating nurse, rather than being worn by the resident. There should be no unnecessary conversations in the room. Music should be played at low volume and only if the trainee agrees to this.

12. Overcome your fears: See numbers 1 and 2.

13. Remember, there's a patient under there: R.P.E. (Respect, Protect, Experience)

14. Reinforce particularly challenging steps by working in the wet lab or on a surgical simulator.

I hope these recommendations contribute to a better learning experience. There is something to learn, both by the instructor and the trainee, in every case.

Carolyn Kloek, M.D., Massachusetts Eye and Ear Infirmary, Harvard Medical School

Teaching cataract surgery is gratifying but challenging. A few basic steps that are summarized below can make the experience more successful and rewarding for both the attending surgeon and the trainee.

1. Practice with trainees in the wet lab before the operating room: Spending time with a trainee in the wet lab prior to working with him or her in the operating room not only gives the attending surgeon a sense of the trainee's skill level, but also gets both the attending and trainee comfortable working and communicating with one another prior to the operating room.

2. Make sure the trainee is in a comfortable position at the operating microscope before beginning the surgery: Appropriate positioning at the operating microscope (making sure the trainee isn't hunched over, making sure the shoulders are relaxed, and ensuring appropriate hand position and stabilization) is essential prior to beginning a teaching case. Awkward positioning makes the surgery more arduous for the trainee and can potentiate a nervous tremor. Often the beginning resident doesn't have enough experience to recognize awkward positioning and needs to be instructed.

3. Switch seats frequently: The attending surgeon should have a low threshold to switch seats with the trainee if he or she appears to be struggling with a particular step of surgery, visualization is poor through the side scope, or if the attending gets that sinking feeling that a step of the surgery just doesn't look quite right. I switch frequently with trainees in any of the above situations, and once I have moved the case beyond the point at which the trainee was struggling and/or ensured there are no complications, I hand the case back over to the trainee.

4. Introduce cataract surgery in a stepwise manner: Performing an entire cataract surgery from start to finish can be overwhelming for residents early in their cataract surgery training. At the Harvard Ophthalmology Residency we introduce cataract surgery to residents in a stepwise manner. This approach to teaching surgery allows the trainee to focus on one step of surgery for a series of cases before progressing to entire cases.

5. Take time after each case to discuss every step of the surgery with the trainee in detail: Ideally surgical videos of the trainee's cases are available for the attending and trainee to review together, but in the absence of this technology, simply talking through the steps of surgery after each case is helpful. There are often many teaching points that can be highlighted when reviewing the cases in this step-by-step manner, even when a case goes smoothly.

Contact information

Borboli: sheila_borboli-gerogiannis@
Greenstein: Scott_greenstein@meei.harvard. edu

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