May 2012




Cataract tips from the teachers

The heavy hand


Sherleen Chen, M.D.

Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary

Roberto Pineda, M.D.

Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary

While most novice surgeons err on the side of timidity, we occasionally see the opposite tendency toward being overly aggressive during surgery. This may manifest physically as mechanical and manual dexterity issues or cognitively due to limited judgment and awareness. Within the delicate confines of the anterior segment, an overly aggressive approach can be quite problematic. Three of our experienced cataract course instructors offer their advice on maintaining control and safety in this situation.

Finally, starting with this article, we will be changing to a bi-monthly column. We hope that readers will continue to look for more "Cataract tips from the teachers" every other month.

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




Thomas A. Oetting, M.D.

Professor of clinical ophthalmology Director, Ophthalmology Residency Program University of Iowa, Iowa City Chief of Eye Service and deputy director of Surgery Service VAMC Iowa City

First I must thank EyeWorld magazine, Roberto, and Sherleen for bringing visibility to the often secret world of teaching residents. To operate is aggressive and even arrogant in nature. We have to be plenty confident in ourselves to forever modify the eyes trusted to us. However, when we are learning a new procedure or getting started as residents, an overly aggressive approach is not safe. Progression as we learn should be gradual in small steps building on past success. John Sutphin, M.D., chairman, University of Kansas Medical Center, Kansas City, taught me many years ago when I was a new faculty member at Iowa to only change one thing at a time to my routine during a transition. When residents are learning cataract surgery there is a tendency to want to quickly move to the latest and greatest technique. I usually remind overly aggressive resident surgeons that they must build on the basics first. The most common over aggressive move I encounter is the desire of our residents to bring out that chopper when they are not ready. I try to remind them that before chop comes a good groove; before chop comes slick rotation of the lens with the second instrument; before chop comes centration when a second instrument is placed. Overly aggressive actions could be a sign of indifference to the safety of our patients, but most of the time, it is just a sign of passion. The best treatment is to preach patience and give examples of the slow progress of others that residents now respect.

Mark F. Pyfer, M.D.

Clinical attending surgeon Cataract & Primary Eye Care Service Wills Eye Institute Thomas Jefferson University Philadelphia

In my experience, it is unusual to encounter a resident who is overly aggressive in the OR when learning cataract surgery. More commonly, a novice surgeon is somewhat tentative and needs reassurance. However, a few residents I have mentored over the years attempted procedures that were inappropriate or beyond their skill level. Calm but firm guidance and early hands-on attending intervention are required in those cases.

We encourage residents to be confident and learn as much as they can under supervision. In fact, the entire training process rewards those who are self-motivated with a drive to succeed. However, patient safety requires that attendings exert good judgment in our supervisory role. One anecdotal (and possibly apocryphal) example is that of a resident, who had never performed an anterior vitrectomy during cataract surgery, suggesting intentional rupture of the posterior capsule in order to learn the technique. This of course is inexcusable. The dichotomy of resident training is that while we all seek to avoid complications, managing those complications is an important skill that is best learned under expert guidance. That is the most compelling reason to insist that residents in training perform at least 100-150 proctored cataract surgeries. Malcolm Gladwell, author of The Tipping Point, asserts in his recent book Outliers that 10,000 hours of practice are needed before reaching expert status. For eye surgeons, this translates into about 20,000 procedures, a level not attained for most of us until at least several years after residency. Residents near the end of their training will occasionally request to perform a maneuver solely for teaching purposes, such as placing a three-piece lens in the sulcus. Unless necessitated by a compromised zonule or posterior capsule, I do not permit this on an otherwise routine case. Residents who are fortunate (or skilled) enough to complete 100+ phacoemulsification procedures without vitreous loss should have sufficient experience managing ruptured globes, traumatic cataracts, or subluxed intraocular lenses to be comfortable with anterior vitrectomy. We have been using the EyeSi surgical simulator (VRmagic, Mannheim, Germany) for 3 years, and it has been helpful for beginning surgeons. I look forward to expanded capability of the simulator when, just as in pilot training, it will be used to simulate rare events such as suprachoroidal hemorrhage.

Inappropriately aggressive resident behavior is more commonly seen in the clinic when scheduling patients for surgery. Every year, certain senior residents seem to sign up for more surgery or compete for more challenging cases. We have systems in place monitored by our chief residents to assure fairness in surgical numbers. A cooperative spirit is also fostered by the culture of our program, starting from day one, which helps limit aggressive behavior.

Bennie H. Jeng, M.D.

Associate professor of ophthalmology University of California, San Francisco (UCSF) Co-director, UCSF Cornea Service Chief, Department of Ophthalmology, San Francisco General Hospital

Aggressive doesn't always mean bad. Think about aggressive financial investments that people make sometimes they pay off big time. However, there is always risk associated with being aggressive, and sometimes in the financial world, you pay the price dearly. The same situation exists for trainees who are overly aggressive when performing cataract surgery. Sometimes they get away with it and everything turns out great, which unfortunately reinforces that they should continue to do it that way, until one day it completely backfires and there is a huge complication.

The best thing to do is to identify the problem early on. It is infinitely easier to change behavior before it becomes a habit, and it is much harder to deal with a resident who has gotten away with being aggressive for much of his/her training.

Aggressive residents come in two different types: those who have a heavy hand and just "don't know their own strength" and those who perform daring and dangerous maneuvers inside the eye.

For residents who merely seem aggressive because of a heavy hand, I remind them that ocular tissues are delicate. Pushing too hard when making a scleral groove can damage the ciliary body; pushing posteriorly too hard when trying to crack the nucleus can rupture the posterior capsule; and forcing instruments too hard through the main incision can strip Descemet's membrane. If a simple talking to is not effective, a few hours in the wet lab to show them how ocular tissue can behave reasonably with a gentle but firm hand generally does the trick.

The resident who does daring acrobatics during cataract surgery is a different story. This resident has to be distinguished from a resident early in training who is simply unaware that the phaco tip shouldn't be chasing a nuclear fragment deep into the bag, or that he is unknowingly phacoing up against the endothelium. The aggressive resident will purposely do such maneuvers in the name of "efficiency." To that resident, I say that cataract surgery is not a race. There is no reason to risk the patient's outcome for a few minutes less of operating time. With this resident, I will observe carefully for an entire case to see if the perceived aggressiveness is a continuing pattern or just a fluke. If it's a pattern, I will walk though every step at which an aggressive maneuver can be made, such as not regrabbing the capsulorhexis when it would be helpful, risking the tear going radial; using excessive phaco power for a soft lens; and chasing and phacoing nuclear fragments in dangerous places. We'll discuss what can happen in the worst-case scenarios. If aggressive maneuvers are still subsequently being made in the eye, I make the resident stop, and we discuss right then and there the possible ramifications of the maneuvers he or she is doing.

Ultimately, if an aggressive resident chooses to ignore the teachings, actions to protect the patient need to be employed, such as suspending operating privileges until less aggressive actions can be demonstrated in a practice model setting. I've never had to go this far, and I hope never to have to.

Editors' note: Drs. Jeng, Oetting, and Pyfer have no financial interests related to this article.

Contact information

Oetting: 319-384-9958,

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