CATARACT/ IOL

Is backwards better?

by Daniela Gemperli

Dr. Daniela Gemperli comes from a family of physicians in Campo Grande, Brazil. Her mother, Dr Lizabel Gemperli, has a clinic with her own ambulatory and surgery centre, where the full spectrum of ophthalmic surgical procedures are performed. Following the completion of her own residency, Daniela took a year of fellowship in cornea surgery and research. She is currently a fellow with Drs. Fine, Hoffman, and Packer in Eugene, Ore., concentrating on advanced surgical techniques on cataracts and cornea. Her concept of how cataract surgery should be trained was completely new to me and, at the same time, a refreshing surprise. The readers of this month column, especially those of us who teach cataract surgery, will find this technique very thought provoking.

I. Howard Fine, MD, Column Editor

Drs. Fine and Gemperli in surgery Source: I. Howard Fine, M.D.

The principle surgical experience that residents obtain during their training in the developing world is phacoemulsification of cataracts. This is not surprising, since cataract surgery will be the most common surgical procedure they will perform as they enter practice and for the foreseeable future. However, the past has a major impact on this learning experience because, traditionally, we learn how to perform cataract surgery from the initial steps of the procedure forward to the final steps on the operation. I finished my own residency at the Santa Casa Hospital in Sao Paulo, Brazil, in January 2008. At that time, I began my cornea fellowship and also continued training residents in cataract surgery. My own training was in a traditional method, performing surgery commencing with the incision and ending with viscoelastic removal and incision closure. My experience, like so many other surgeons in training, was made difficult because mistakes made at the onset of the operation, making all of the sequential steps more difficult. For instance, an improperly constructed incision, perhaps too large, too small or architecturally improper, can plague the surgeon throughout the entire rest of the operation. An improperly constructed capsulorrhexis may create obstacles that are very difficult to overcome and may, in fact, prejudice the outcome. As I was beginning my own activities as a teacher of cataract surgery, Dr. Jonathan Lake, who was chief of the Cataract Surgery Section at our hospital at that time, in conjunction to others in Brazil, instituted a new system for training residents in phacoemulsification of cataracts. The new system involved residents performing the final steps of the operation as the first intraocular maneuvers they were trained in, and, with increasing experience, going backwards sequentially to learn and master each of the preceding steps. So, the initial cataract surgical maneuver performed by the residents was removal of residual viscoelastic. Once they were experts at that, they were taught how to implant the intraocular lens. After they master that, they start to perform cortical clean-up. The initial nuclear removal technique they learned was the mobilization of the second and third quadrants; then, removal of the first quadrant and finally removal of the last quadrant, perhaps the most dangerous part of quadrant removal, because of the exposed posterior capsule. After they were experts at quadrant removal, they would learn how to groove and crack nuclei and only then would be taught how to chop nuclei. By this time, the residents were quite capable of performing nuclear disassembly and phacoemulsification of segments. Now, they were ready to learn hydrodissection and hydrodelineation, capsulorrhexis and incision construction. With this system, mistakes made by the inexperienced residents, in his or her initial intraocular maneuvers, were unlikely to undo the case or create a disasterous complication. With increasing experience, going backwards in the steps, their intraocular maneuvers became more skilled and more precise, so that by the time they were doing the initial steps of the surgery, they had adequate dexterity to avoid problems that could plague them from the rest of the case. It has frequently been stated that in teaching the teacher learns more than the student. I found that in teaching each of these steps, I was highly focused on the subtle maneuvers that allow precision and accuracy, and I became a better surgeon myself in the process.

I found it easier to both learn and teach using this method. It became obvious to me that the learning curve was shorter and less traumatic. Complications were fewer, more easily compensated for, resulting in greater patient’s safety. We all know that the phacoemulsification is step-dependent and that an early error is more likely to result in a less than perfect outcome. It seems to me that all training programs should give this system a trial, to enhance resident training and patient outcomes.