Good quality training leads to good quality cataract surgery

By Roibeard O'hÉineacháin

NICE - Modern training in cataract surgery should reflect the changing nature of the practice and instil trainee surgeons with strong sensibilities in their roles as healthcare physicians, according to a Swedish ophthalmologist.
"The aim of the training is to educate eye surgeons who can serve the patients in our community in the best possible way.

"Then we have to provide the surgeons with a good basis for continued education because there is such a tremendous speed of change in our field," Bo Philipson MD, PhD said.
As part of their training, cataract surgeons should learn all aspects of anterior segment surgery.

They also need to gain a good grasp of traumatology and an understanding of how wound healing can affect the visual outcome.
Furthermore, while much of the training of surgical techniques will involve phacoemulsification, students should also have some knowledge of both intracapsular and extracapsular methods, he said.
Prior to treating humans, students should practice on pig eyes under supervision. The progression to living patients requires a closely supervised step-by-step approach, Dr Philipson said.

Those involved in the training of surgeons should take these opportunities to identify those individuals whose talents may lie elsewhere.
"One important thing is that you must have the ability to discourage unsuited surgeons. I know that in some countries that is legally impossible.

"Some of my friends in the US can be sued if they discourage somebody from training to become a surgeon but there must be the possibility of doing so," he said.
In order to take full advantage of cataract surgery as a refractive technique, surgeons in training need to be thoroughly knowledgeable of the various methods for IOL power calculation.

They should also have a good understanding of the theories of accommodation and the optics of the eye in general, including lens aberrations and wavefront aberration.
"We need more and more to have good knowledge of the optics of the eye. In the old days, 50 or 60 years ago, optics was a very important part of practice.
"But then ophthalmologists came to think that optics was something for other personnel to take care of. Now it's certainly coming into our field again," Dr Philipson said.

He emphasised that surgeons should never forget that their responsibility to their patients neither begins nor ends on the operating table. Surgeons should be involved in the examination of the patient and in imparting information to the patient prior to surgery.

They should also be involved in the postoperative examinations during the first two days after surgery and at the final examination some weeks later.
"I really think we should stop the trend towards cataract surgery technicians where the surgeons perform their surgery and then run away as quickly as possible without taking care of complications and so on.

"The worst examples are surgeons who only operate on simple cases. When it's something complicated then they like to send it away to somebody else.
"We need to have surgeons with a thorough knowledge of all aspects of anterior segment surgery. They should be taking care of the patient and not play the technician role," Dr Philipson stressed.

The accurate recording of patient outcomes should become a feature of standard practice and therefore also of standard training in ophthalmic surgery, he continued.
Outcome measures to be recorded should include patients' final refraction and the incidence of complications such as endophthalmitis, dropped nuclei, capsular breaks and corneal trauma.

"Surgical outcome is extremely important to follow. I think that has been neglected a lot up until now. Most surgeons don't have a good follow-up. They claim they have a very low complication rate but they don't have the data.

"It's extremely important to have computerised systems to collect the data from the surgery. I think that in the future you will be expected to be able to show the rates of complications and successes," he said.

Dr Philipson noted the training of surgeons is not completed upon graduation but continues for the duration of their careers.
To that end it is important they be encouraged to participate in the exchange of knowledge by attending ophthalmic societies' conferences and reading ophthalmic journals.

"I think we can be very proud of our cataract surgery today. We have a high quality surgery with a very low complication rate. Most surgeons have a very high ethical standard. It is certainly one of the most cost-effective procedures for the community, patient and surgeon.

"However, we should always have a policy of exchanging our knowledge. Its important to have good leadership and most important of all to have good patient care," Dr Philipson remarked.

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