Improving phaco skills of residents

The subject of residents' surgical skills during phaco are coming under close scrutiny at various institutions. Two of three institutions concluded that the key to improved outcomes is adequate wet-lab training, expert supervision, and increased phaco conferences. The third is developing a valid instrument to evaluate performance during phaco; the results would provide immediate feedback to the resident by the attending surgeon.

Storm Eye Institute

Daniel J. Hu, MD, a resident at the Storm Eye Institute, Medical University of South Carolina, Charleston, and colleagues conducted a study to determine the complication rates in resident-performed phaco from July 2000 to June 2002.

All cases were performed according to a standardized technique using temporal clear corneal incisions, and all patients received a topical fluoroquinolone, non-steroidal anti-inflammatory drug, and steroid postoperatively. Dr. Hu said that 200 consecutive cases performed by residents were reviewed at one surgical location, the Medical University of South Carolina. The overall intraoperative complication rate was 15.4% and an overall postoperative complication rate was 15.9%.

He explained that the vitreous loss occurred as the result of posterior capsular rupture in nine cases, two cases of anterior capsular extension, two cases of zonular dehiscence, and one case from an unknown cause. There were no postoperative complications in five of the nine patients with posterior capsular rupture, three had vitreous in the wound, and one each a wound leak, corneal edema, or cystoid macular edema (CME).

Capsular bag ruptures occurred predominantly in patients with 3+ nuclear sclerotic cataracts, and dense posterior subcapsular cataracts.

In patients with an intraocular complication, the average surgical time increased by about 20 minutes. The visual acuity outcomes in patients with vitreous loss were split. Eight of the 14 patients had visual acuity of 20/40 or better. In the other six patients, who had vision of 20/50 or worse, three had a comorbid ocular disease, two had macular degeneration, and one substantial diabetic retinopathy, Dr. Hu noted.

Postoperatively, the most common complications were CME in 13 patients, corneal edema in 10, vitreous to the wound in seven, wound leak in five, dislocated IOLs in two, acute endophthalmitis in two, and iris prolapse in one.

"The overall rate of CME was 6.4%, of which 23% of the patients had an intraocular complication (posterior capsular rupture with vitreous loss, anterior capsular extension with conversion to extracapsular cataract extraction, and iris trauma)," he said. Thirty-eight percent of patients with CME achieved a final visual acuity of 20/40 or better.

Both patients with endophthalmitis had positive cultures, one with coagulase-negative Staphylococcus and the second Staphylococcus aureus. Neither patient had intraoperative complications and both had surgical times that were shorter than average. One patient had a final visual acuity of 20/25 and the other no light perception.