# of Phacos

[Ophthalmology]

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In comparing residency programs, does the number of phacos you do as a resident really matter once you get to a certain level? If so, what is this minimum cutoff?

I am comparing a program where the avg # of phacos is 100 with a program where the average is 170. Is there really going to be a difference in my proficiency depending on which of these programs I would graduate from?

I would really appreciate any comments from fellows or attendings that have recently graduated.

 

[Andrew_Doan]

Hi and welcome to the forum.

In my opinion, 100 good cases are sufficient. It took me 75-100 cases to feel comfortable. I finished with ~150 cases, but the extra 50 didn't add much to my skill. The factor that contributes to surgical skill is how the surgeon handles complications during the cases. Thus, the best time to experience problems is during residency when attendings are present and available to assist/teach/rescue. 😉

Good luck!

 

[NR117]

I would also add that the variety of cases you do is far more important than the total number of your cases. What I mean is, it will serve you far better to do 100 cataracts which include some cases with small pupils, pseudoexfoliation, posterior synechiae, weak zonules, white cataracts etc. than to do 200 mostly straightforward cases. That's why I wouldn't put too much weight into numbers alone.

 

[f_w]

Be careful in comparing the numbers given to you by the programs.

Some of them send their residents to do an overseas rotation at one of the 'cataract camps' in india. It will undoubtedly pad the numbers for their residents and the program. However, this type of developing world practice might not be a reflection of what you can expect in your day to day professional life in the US (yes, you made the blind see, but they have a different set of expectations from the kind of psychos you will encounter in PP here. Cataract surgery in some layers of society is considered an adjunct to your golf-game).

 

[ckyuen]

I agree with Andrew. Different people require a different number of cases to feel comfortable. People may laugh at what I say next. But look for a program that does some planned extracaps. Why? Case in point I am doing a 87 year old male tomorrow with a CF NSC. It's so dark it's almost black. I couldn't even get a view of the fundus, and it's an NSC, not mature or cortical cataract. Many would argue you can phaco it. and with a 1.1 mm tip you probably could, but you may kill his cornea at the same time. In residency you try not to get a complication, but in private practice people want 20/20 and they want it now, as in post op day one. A dense nsc like this will take a month to recover with the swelling you would get from doing a phaco. So I would say if you can find a place where you do 20 extracaps and 100 phacos you'll be ready. I was just reviewing my logs and I did more than this, with about over 30 cases of 66982 or complex cataracts, which will definitely help prepare you for the real world. b/c guess what your partner or boss when you start doesn't want to do the complex cases, where as you will be hungry for any case you can get. So the 4 mm pupils, mature cataracts, pxe, all will be coming to you. Also, try to learn as many techniques for doing phaco as possible, but in my opinion divide and conquer and removing it in the iris plane or lower is best for the eye. guys who flip the nucleus and eat it anteriorly have horrible looking corneas the next day, and chopping saves some phaco time, but is not really faster overall, and pulling the nucleus up to eat it again kills corneal endothelial cells. Really it depends on the surgeon, but I don't think the other techniques are any faster. And the time you waste going b/t cases or making small talk with the or staff will quickly negate any time savings from the procedure.

 

[Visioncam]

Having an excellent cataract teacher is also very important. However, it's nearly impossible for applicants to know who is good. It's likely that the residents will know who the best one in their program is but won't know if that person is really outstanding compared to other programs.

I've had enough attendings to appreciate that "best teacher in my residency" and also the lousy ones that the residents thought was good but really just had good bedside manner (but lousy teaching skills).

 

[schistosomiasis]

I both agree and (humbly) disagree with some of the points made above. Definitely don't agree with not learning anything by extra 50 cases over 100. Just finished my residency in June with 127 class one cases (attendings don't touch clinic patients). The more the better is my philosophy; you can only get better by doing more cases. Even with routine cases- you can work on your time and efficiency. I only felt comfortable after 100 cases (definitely not 75), and started to do the hard cases towards the end (small pupils, PXE; although being in New York we had a lot of dense cataracts even early in the year). I didn't even feel that comfortable with small pupil cases at the end of my residency, but now halfway through my fellowship I am not intimidated. Another argument for more cases- for example, between 100 and 125 I cut down my average operating time from about 25 to 20 minutes. Give me another 25-30 cases, and I could probably cut it down further. Some of the residents in my program who did under 100 didn't even feel comfortable doing cases with topical anesthesia!

When I was a resident one of my fellows did about 200 cases in her residency. She told me, in the first 30-40 you figure out the steps; by 90-100 you feel comfortable; between 100-200 you work on the nuances and speed.

I agree with the statement above that extracaps help. My suturing wasn't that great even at the end of residency, but halfway through a vitreoretinal fellowship- all of those sclerotomies and secondary IOLs have made me quick. I disagree that one technique is better than another. Divide and conquer is certainly important to get good at (probably the most important), but the more in your arsenal, the more options you have- if I had done 170 cases instead of 127 I could have learned quick chop (I do stop and chop on most cases).

Not every program has a teacher like Tom Oetting (I interviewed at Iowa, Andrew! 🙂 ). I basically taught myself how to do cataract surgery. This meant that I needed to get more cases in to be as good as people in other programs. The more cases you do, the more situations you'll be in, and the more comfortable you'll be in any tough situation. Now that I attend resident cases as part of my fellowship, I have to say the more you do the better- someone with 170 will probably be more experienced than someone with 100. Even the "good" residents who have already done 80 cases that I teach still need my help to get out of trouble sometimes.

Having said all of this, do I think that you should pick one residency over another because of 170 vs 100? It definitely shouldn't be the only criteria, but it should certainly be taken into consideration along with everything else (geography, quality of faculty, friendlieness of program, presteige of program, etc). There is also a big variation among residents within one program depending on the aggresiveness, motivation, and skill of the individual resident, the numbers for the people in my class were two about 125, one at 100-110, and the fourth at 85. Would I have felt comfortable going into practice after 127? Absolutely yes, I don't need an attending sitting next to me in order to improve- they don't even scrub when I do the phacos in my retina fellowship. I can improve on my own.

One other thing that I would look at is other types of cases that residents do. For example, I only did three trabs, one corneal transplant, and one vitrectomy (although I did a LOT of plastics). While you won't be doing them on your own as a general ophthalmologist, it certainly can't hurt to get exposure to other subspecialties.

Hope this helps.

 

[mdkurt]

look for a program that does some planned extracaps.

Amen. This is a valuable skill that is being overlooked in some training programs.

 

[rubensan]

one of the reasons i knew that i really wanted to do ophthalmology was after watching one of the residents do phaco for the first time, i thought it was one of the coolest things i had ever seen. i guess i'll learn more about different phaco techniques as i go through residency, but i was curious about the benefit of of flipping the nucleus and then phacoing it from the anterior side? is it easier? quicker?

guys who flip the nucleus and eat it anteriorly have horrible looking corneas the next day, and chopping saves some phaco time, but is not really faster overall, and pulling the nucleus up to eat it again kills corneal endothelial cells. Really it depends on the surgeon, but I don't think the other techniques are any faster. And the time you waste going b/t cases or making small talk with the or staff will quickly negate any time savings from the procedure.

 

[Pastrami King]

You can find a brief introduction to phaco techniques, answers to the questions below, and lots of pretty pictures at the

CRST Virtual Textbook of Cataract Surgery
David F. Chang, MD, Editor
http://www.crstoday.com/Cybertext/Phaco Techniques.html

one of the reasons i knew that i really wanted to do ophthalmology was after watching one of the residents do phaco for the first time, i thought it was one of the coolest things i had ever seen. i guess i'll learn more about different phaco techniques as i go through residency, but i was curious about the benefit of of flipping the nucleus and then phacoing it from the anterior side? is it easier? quicker?

 

[ckyuen]

Yes flipping then eating it anteriorly can be faster. I watched someone who flipped the lens 90 degrees so it looked like a dart board and then ate it. Note it must be a soft lens to do this. Also you can flip it 180 degrees and eat it like an apple so the nucleus spins around like a top. Should have low vacuum b/c don't really want to hold onto the nucleus. and the other way I have seen it is flip it 90 degrees and rotate the nucleus so it looks like a tire about to run over your phaco tip then eat from the edges and let it spin. These techniques work best if you make a huge rhexis and have a soft lens. Otherwise you may be calling retina to fish it out. Remember a 7 minute phaco is not necessarily better than a 10 minute phaco if you kill a lot of endothelial cells and the patient doesn't see well. I'm very hard on myself and I like all of my phaco's with exception of icg and t blue to be better than 20/40 post op day one. A couple of reasons for this. 20/40-1 is considered visually significant so if they are better the first day than going into surgery you will get more patients. I also have optometrists at my practice and if they see your patient 20/20 pod 1 with a pristine cornea they will quickly tell their colleagues about your skills. All that being said. My default technique as I said above is divide and conquer it takes me about 12-13 minutes to do a typical cataract initial cut to patching, so I don't see any need to revert routinely to another method b/c I think spending that couple of extra minutes to polish the capsule even anteriorly and use as little phaco energy as necessary. I use a seibel chopper as my second instrument so if the nucleus is really hard I can just chop it a little in the bag. However, I do stop and chop, of course extra cap, flip if I need to. Remember no matter how fast you are the limiting factor is usually getting the cases, unless you live in a town where you're the only ophtho for miles around. even then if you have two or's and do a phaco in 30 minutes cut to finish and jump room to room in an 8 hour day you can do 16 cases which is a lot of cases. Don't worry about time, just aim for great results. The times I have had a complication are the times I look at the clock during the case. And trying to save a minute here or there but having to do more vitrecotmies or deal with complications quickly will erase that time savings. Also turn over time is usually a limiting factor. The hospitals I'm at take about 20-25 minutes to turn over the room so your speed is not really much of a factor. If you do retrobulbar anesthesia routinely kiss your time savings good bye. But absolutely do it if necessary, ie doing an extracap. Otherwise I usually give sub-tenon's anesthesia on the field if the patient can't hold still. I just finished training this past year, and I do most all of my cases under topical even those needing icg or t blue dye or small pupils or don't speak a language i speak, but I don't ever try to fool myself and let my ego get in the way of having proper anesthesia. I have even put people under general for mature cataracts in a severely ******ed patient, and older demented patients with severe cataracts that could not follow instructions. And you may be surprised by how much their mental status increased when they could see. Also I encourage everyone to learn how to do a scleral tunnel. clear cornea is fine most of the time, but on that ******ed patient I did a tunnel to protect more against rubbing. He seems to love the work as he shakes my hand now when prior to surgery his response was to grunt and say UNNHHH to everything. REMEMBER FIRST AND FOREMOST GET GOOD RESULTS OR DON'T DO THE SURGERY, TREAT EVERYONE AS IF THEY ARE YOUR PARENT OR GRANDPARENT. AND DON'T LET EGO GET IN THE WAY OF DOING THE RIGHT THING. ALSO SUTURE IF IT LEAKS OR YOU HAVE ANY REASON TO SUSPECT IT WILL. Thankfully we did not have single case of endophthalmitis by a resident in my three years, I think our program went about 12000 cases without a case.

 

[ckyuen]

sorry to be so long winded, but one more thing for all begining phaco surgeons the rhexis is the hardest step. make your life easy and try discovisc or use a soft shell technique (viscoat the provisc under it in the a/c , or dispersive on top and cohesive below) it will make doing your rhexis much easier. and if it runs out stop right away and put a cohesive viscoelastic like provisc not viscoat.

 

[rubensan]

no need to be sorry, you're posts are GREAT! i'm getting excited about starting residency! yes, i heard rhexis is the hardest part, although experienced cataract surgeons and residents make it look EASY. many have told me that practicing rhexis in the wet lab on pig eyes is not so helpful. i heard practicing with your loops on boiled cherry tomatoes or parchment paper on-top-of silly putty is pretty good. any thoughts? bottom line, i guess that's why you want to aim for over 100 phacos in residency, right?

also, i hear the terms "it depends on how aggressive you are" thrown around a lot re: # of phacos that residents graduate with. again, i guess i'll find this out in my residency, but what does that mean in ophtho? will i become like my wife who is a GYN resident and believes that EVERYONE (well, not everyone, but you know what i'm saying) could benefit from a TAH or VAG HYS and is constantly calling her patients at home to remind them to come to clinic and to their preop evals? i used to laugh at her obsessiveness, but she keeps telling me "you'll see in 2-3 years how HARD it is to get patients on the table."

sorry to be so long winded, but one more thing for all begining phaco surgeons the rhexis is the hardest step. make your life easy and try discovisc or use a soft shell technique (viscoat the provisc under it in the a/c , or dispersive on top and cohesive below) it will make doing your rhexis much easier. and if it runs out stop right away and put a cohesive viscoelastic like provisc not viscoat.

 

[ckyuen]

Being aggressive doesn't mean being a jerk and stealing cases. I think to get your numbers up you have to see more patients in clinic this will generate more surgical cases in itself. Also, calling them like your wife does helps a lot. And being very personable will get you more cases because people have two eyes and often two cataracts if they liked you on the first one they'll be more likely to come back to you for the second eye. I had a lot of patients request that I do their second eye or they would not have the procedure done. Don't treat your patients any differently based on their backgrounds and you will see the results. I always say treat everyone like they are your mother or father. A lot of my coresidents dumped cases on me they did not want to do, mature cataracts, non-english speaking, cases they had a complication on the previous eye, small pupils you name it. As a result I graduated with almost 40 complex cataract cases much more than anyone else in my class and I put in more iris hooks, CTR, used more ICG than anyone else. It also made me more proficient at these techniques. You can stain the capsule very carefully and get a 20/25 result post op day one. Most of my early ones were count fingers at 5 ft post op day one, but as you get better by doing more the results improve. You can also get more cases by making the best use of your OR time. Don't ever yell at nurses or anesthesia it is 100% guaranteed to make them move slower. If you are efficient and nice to them they will let you book more cases. For some residents at my program they would only let them book 4 cases and would complain, delay, try anything to get any additional cases cancelled. I treated them great, always made conversation. Thanked them each day for helping me, and listened to any advice they had to offer. The result they told me book more cases I wasn't doing enough they didn't want some other resident to butcher the eye. They would tell me book 7 cases instead of 5. This will obviously get your numbers up. Also if there was available OR time I would run my clinic and do a few cases at the same time on my non OR days. In retrospect I would have only done one case extra on those days before clinic. Most importantly don't try to steal cataract cases. We had some residents always complaining they did not get enough catarct surgery, saying that's when they were slower. In the end they had a lot more cataracts but nothing else and they were definitely not any quicker or better. However when they go to practice they will not be able to do dcrs, ptosis, pterygium with conj autografts, trabs, filters etc. Believe me the only way I fill out my OR schedule now, is by doing a variety of cases.

Also one point I want to emphasize is that yes the rhexis is the hardest part of cataract surgery but please do yourself a favor and use either discovisc or do a soft shell technique you need the cohesive (healon or provisc) component to make it easier so the rhexis doesn't run out. With these I think my rhexis takes all of 10 to 15 seconds. When I have just used viscoat in residency and in the past it takes me 3 or 4 times as long with a lot more stress. And the second instrument choice matters a lot. In residency I used a wayan, this is not a good instrument. I don't like the conventional chopper everyone uses that huge chopping surface and small protective ball at the end and 90 degree angle on the tip is just too dangerous and usually does more inadvertent damage to the iris than it benefits the case. Remember if optoms are refering you patients and you ding the iris say good bye to future referals even if they are 20/20. optoms have slit lamps and can scurtinize your work more closely than a pcp. Almost forgot. The second instrument I LOVE is the seibel nucleus chopper by reichert, think that's the right spelling, no financial interest. It has a nice protective big ball at the end to hold back the capsule when you eat the last piece, the angle b/t the chopping blade and the shaft is oblique, making it much easier to get in an out of the eye with less trauma and it doesn't kill the iris with and inadvertent pass. And the chopping blade is just large enough to chop the core of the nucleus. THIS second insturment is great and well worth the 400.00 it cost especially if you don't have to pay for it. Residents call your surgical reps and tell them you need one to fully benefit from their infinity machine or their whitestar machine. It's educational they have budgets for that.

 

[ckyuen]

previous post was getting too long.
Everyone will laugh at me for saying this, but every ophthalmology resident needs an xbox 360 or playstation 2 soon to be 3. The manual dexterity skills I developed playing xbox made me a much more efficient surgeon in every technique rather than trying to find a faster way to do cataracts. My rule is NEVER look at the clock, it will only mess you up because you will try to hurry and when you do that you make mistakes. Earlier I gave and estimate for my times and that was incorrect because I dont look at the clock. This week my anesthesiologist was timing me and calling out the times from the time a placed the drape until I was finished checking the wound and called for my patch. And my average time for the procedure was 10.5 minutes. In the end if I took 20 or 30 minutes would it have mattered? NO, I spent 15 minutes typing this post. What matters is all my patients except one who has a conservator and can't effectively communicated, so I'm not sure of best VA were 20/30 or better post op day one. I waste a lot of time doing other things so my time is not so valuable that saving a few extra minutes matters, and it's not like I have enough surgery to make that savings matter. I don't think I will ever be able to get that many patients where it will b/c I can't get enough patients like a hundred people a day in clinic and give each one the time they need to feel they are not cattle being herded through, and that's not the way I want to practice.

 

[Andrew_Doan]

I always say treat everyone like they are your mother or father...

Don't ever yell at nurses or anesthesia it is 100% guaranteed to make them move slower. If you are efficient and nice to them they will let you book more cases.

Welcome back ckyuen! Are you loving Hawaii?! 👍

Being a successful physician requires high EQ and social skills. I don't respect physicians who yell, pout, throw things, and act like babies. It's counterproductive.

I highly recommend this book for those who want to increase their success AND income as physicians or anything they do in life:

http://www.studentdoctor.net/bookstore/index.php?mode=Books&item=0671723650

How to Win Friends & Influence People

 

[Surgess]

Welcome back ckyuen! Are you loving Hawaii?! 👍

Being a successful physician requires high EQ and social skills. I don't respect physicians who yell, pout, throw things, and act like babies. It's counterproductive.

I highly recommend this book for those who want to increase their success AND income as physicians or anything they do in life:

http://www.studentdoctor.net/bookstore/index.php?mode=Books&item=0671723650

How to Win Friends & Influence People

One of my favorites, I read it all of the time, over and over.

 

[Frumps]

previous post was getting too long.
Everyone will laugh at me for saying this, but every ophthalmology resident needs an xbox 360 or playstation 2 soon to be 3. The manual dexterity skills I developed playing xbox made me a much more efficient surgeon in every technique rather than trying to find a faster way to do cataracts.

Yeah! My time with Halo 2 will pay off then!!

 

[Andrew_Doan]

Yeah! My time with Halo 2 will pay off then!!

Becareful, however. I played a lot of video games too, developed carpel tunnel, and then had to quit the game playing. I also saw people suffer academically because of video games addiction. Everything in moderation... 😉

 

[ckyuen]

Andrew,
Hawaii is wonderful, we have a low of the high 60's or 70's at night and it's in around 80 or so in the day and this is winter. Much warmer than Texas. I'm sure you're loving Westwood compared to Iowa. Try the cuban restaurant Versaille while you're there. Wonderful roast chicken and beef tongue. I'll look for that book you recommended. Also I agree moderation in video games no more than 20 hours a week or so... he he.

 

[rubensan]

dear ckyuen and andrew,
i really appreciate the advice. you guys also have a very positive perspective on things that is very refreshing for me, especially after this past week when i felt like i hit my internship-lul. keep posting1

I had a lot of patients request that I do their second eye or they would not have the procedure done. Don't treat your patients any differently based on their backgrounds and you will see the results. I always say treat everyone like they are your mother or father.