surgical numbers

[ms2009]

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hoping to start a threat with general surgical numbers (cataracts mainly, but also glaucoma, retina, strabs, plastics) for ophtho residenty programs...

i seem to not have written these down during the interview process and cannot remember...i'm sure others are in a similar position.

 

[rubensan]

hoping to start a threat with general surgical numbers (cataracts mainly, but also glaucoma, retina, strabs, plastics) for ophtho residenty programs...

i seem to not have written these down during the interview process and cannot remember...i'm sure others are in a similar position.

seems like a good idea. i remember asking this question a lot when i interviewed. doheny = 130-140 cataracts. but also ask what that number means? you want to feel comfortable with all aspects of cataract surgery, not just 20/50 clear cornea phacos. i think that strong programs teach you how to do an extracap well (afterall, that is what you need to convert to if/when the clear cornea phaco goes south). also, knowing how to do a scleral tunnel is the basis for many other microsurigical techniques (trab, PPL, etc). the best training programs also have their residents (not the fellows) do the really tough cases (iris hooks, capsular tension rings, monocular patients, vitrectimized eyes, etc).

Good luck!

 

[Andrew_Doan]

Please post these numbers in the program compendium:

http://forums.studentdoctor.net/showthread.php?t=470595

 

[Olddog1]

seems like a good idea. i remember asking this question a lot when i interviewed. doheny = 130-140 cataracts. but also ask what that number means? you want to feel comfortable with all aspects of cataract surgery, not just 20/50 clear cornea phacos. i think that strong programs teach you how to do an extracap well (afterall, that is what you need to convert to if/when the clear cornea phaco goes south). also, knowing how to do a scleral tunnel is the basis for many other microsurigical techniques (trab, PPL, etc). the best training programs also have their residents (not the fellows) do the really tough cases (iris hooks, capsular tension rings, monocular patients, vitrectimized eyes, etc).

Good luck!

I agree in most part with what you say, however, there are a few points I would like to make. Note this is from someone who was a resident, fellow and attending. First, extracaps have gone the way of the Dodo. It is not the standard of care, and unfortunately the residents (and those that staff them) are suffering. The lack of suturing really hurts the current crop of reisidents. At my prior job I staffed one of two extracaps done in two years. At my current job we have done 2 in almost two years. I just find it hard to bring myself to OK an eye to be fillet open when today's technology will go through all but a black or very brunescent lens. I find myself asking is it the right thing for the patient? In my heart I know I could vertical chop all but the hardest lens and likely save an elderly person from a prolonged recovery. I don't think I have taught a sceral tunnel in 4 years but with the endophtalmitis incidence increasing with CCCE I am thinking it may not be a bad idea.

Applicants should remember there are many very good programs without anterior segment fellows. I know, I taught at one. I think they received excellent training, and numbers, without competing with fellows.

Lastly, as far as "the best training programs also have their residents (not the fellows) do the really tough cases (iris hooks, capsular tension rings, monocular patients, vitrectimized eyes, etc)." Be careful what you wish for. Many of my patients are monocular (mostly glaucoma practice) so I have alot of high sphincter tone OR days. I have no problem with iris hooks, or CTRs, and I made a living out of vitrectomized eyes, but what is right about having someone with a whopping 100 cataract cases (or significantly less) under their belt operating on a monocular person? This is where I am rethinking residency training in general. Yes, residents need numbers, and need to be trained coming out of residency. However, I think (and I probably did the same thing) the drive to do the most cataracts or the most difficult cataracts blinds residents to the real goal; which is the best interest of the patient. Long after you have forgotten how much of a FUBAR it was operating on the monocular patient who _________ (fill in the blank: capsular tear, dropped lens, pseudophakic bullous keratopathy, RD, etc....), that patient is left to a life of blindness or at best low vision. For what? To satisfy a machiso? Be happy operating successfully on a two eyed individual. Trust me, if you are a good cataract surgeon, you are a good cataract surgeon. The small pupils, and post PPV eyes will behave themselves if you know what you are doing. For the record I no longer will staff monocular cases, I don't want that on my hands. I am now removing the soapbox.

 

[7ontheline]

I completely agree with olddog re: monocular patients. I don't care how good a resident is, it's not fair to the patient. They deserve every chance they can get with their one shot at vision, which is definitely NOT a resident surgeon.

 

[rubensan]

I agree in most part with what you say, however, there are a few points I would like to make. Note this is from someone who was a resident, fellow and attending. First, extracaps have gone the way of the Dodo. It is not the standard of care, and unfortunately the residents (and those that staff them) are suffering. The lack of suturing really hurts the current crop of reisidents. At my prior job I staffed one of two extracaps done in two years. At my current job we have done 2 in almost two years. I just find it hard to bring myself to OK an eye to be fillet open when today's technology will go through all but a black or very brunescent lens. I find myself asking is it the right thing for the patient? In my heart I know I could vertical chop all but the hardest lens and likely save an elderly person from a prolonged recovery. I don't think I have taught a sceral tunnel in 4 years but with the endophtalmitis incidence increasing with CCCE I am thinking it may not be a bad idea.

Applicants should remember there are many very good programs without anterior segment fellows. I know, I taught at one. I think they received excellent training, and numbers, without competing with fellows.

Lastly, as far as "the best training programs also have their residents (not the fellows) do the really tough cases (iris hooks, capsular tension rings, monocular patients, vitrectimized eyes, etc)." Be careful what you wish for. Many of my patients are monocular (mostly glaucoma practice) so I have alot of high sphincter tone OR days. I have no problem with iris hooks, or CTRs, and I made a living out of vitrectomized eyes, but what is right about having someone with a whopping 100 cataract cases (or significantly less) under their belt operating on a monocular person? This is where I am rethinking residency training in general. Yes, residents need numbers, and need to be trained coming out of residency. However, I think (and I probably did the same thing) the drive to do the most cataracts or the most difficult cataracts blinds residents to the real goal; which is the best interest of the patient. Long after you have forgotten how much of a FUBAR it was operating on the monocular patient who _________ (fill in the blank: capsular tear, dropped lens, pseudophakic bullous keratopathy, RD, etc....), that patient is left to a life of blindness or at best low vision. For what? To satisfy a machiso? Be happy operating successfully on a two eyed individual. Trust me, if you are a good cataract surgeon, you are a good cataract surgeon. The small pupils, and post PPV eyes will behave themselves if you know what you are doing. For the record I no longer will staff monocular cases, I don't want that on my hands. I am now removing the soapbox.

many excellent points made here. we should always do what is in the best interest of the patient. and i agree that the stakes are very high in cataract surgery, even higher in monocular patients. i'm a bit confused, is learning how to do an extracap a good thing or a bad thing? i would like to get to your level of chopping even the densest NSCs, but i've had a few cases where the infinity wouldn't slice through even with 100% phaco and torsional amplitude and ECCE saved my butt and more importantly gave the pt a good outcome. but i agree, those cases are the exception.

 

[Olddog1]

I am confused as well about extracaps. I think it is a great skill to know, esp when things go south. When I was a resident, this century, (we walked uphill both ways...) the threshold for doing an extracap was lower. Not that I did a ton, I think 15-20. Really, I think doing 5 would be great, but I don't see the nuclear density I would deem a good ECCE patient. I know someone who did/saw their first extracap, three months out of residency. Luckily, one of their partners was in the next room and talked him through it. So, in summary I don't know the right answer, or how to improve ECCE numbers, short of a field trip to the developing world where access to phaco is limited.

You must be growing some super dense cataracts in Cali. With Infinti/Ozil or to a lesser extent the Stellaris I don't even chop that much anymore. The machine efficiency is unbelievable.

 

[toulouselautrec]

I find myself asking is it the right thing for the patient? In my heart I know I could vertical chop all but the hardest lens and likely save an elderly person from a prolonged recovery.

At Academy last month, I attended two courses, one with David Chang and the other with Robert Osher, two well-known cataract surgeons. They showed multiple videos of their own cases in which they either converted to extracap and/or had to put in ACIOLs (which you could also argue is going the way of the dodo?). Of course, they must do so many cases that these couple of difficult ones must be just a small percentage of their total volume, as with your practice. But even these high-status surgeons had to do it from time to time...so you have to learn it and you have to know how to do it, right?

And about chopping...so if nobody is supposed to do extracap anymore, is it safe for a resident to learn how to chop after only doing 60 or 70 cases? Plenty can go wrong with inexperienced chopping. Should residents just refuse to do brown cataracts until they know how to vertical chop?

And how does one know what to do--whether as a resident or an attending--when things go wrong during a surgery if it's never happened to him/her?

 

[mustang7848]

Very interesting the discussion. At the beginning of this year my second year, I have the great oportunity to do a misionary trip where I performed 23 extracaps. At the begining I was slow and worry about the patient outcomes since my experience at the OR is limitted, but with good supervision, as every case was done I was feeling more comfident and my technique was much better. Since that experience my level of confidence and ability at the OR is much better, even when doing other type of surgery (simple as sutturing better).
So I will recommend for every resident, if have the chance to do an extracap (with a good supervision), you never know when you will have to convert.
I think that residency is to learn as much as you can, not just the most common thing, not every case will be straight forward.

 

[Pastrami King]

Come hang out down in San Jose at the county hospital. White lenses and LP brown cataracts as far as the eye can see (or can't as the case may be).

One of our chief residents did a study last year surveying the extracap experiences of graduating residents across the country. Most desired greater exposure to this technique than they had already.

 

[baya]

Come hang out down in San Jose at the county hospital. White lenses and LP brown cataracts as far as the eye can see (or can't as the case may be).

One of our chief residents did a study last year surveying the extracap experiences of graduating residents across the country. Most desired greater exposure to this technique than they had already.

Can you post Stanford's surgical numbers for us?

 

[Stark]

All training programs are different.

At New York Eye & Ear. Several of the last class did zero extracaps. Others did up to nine extracaps. It depends on the resident, the case, and the attending physician.

My recommendation: do a few extracaps in residency. A patient WILL walk in your door within the first six months of private practice who requires an extracap. 20/400 vision, and brown cataract that looks more like tree-bark than a lens. Just immigrated from Mexico, PR or Africa. Whether your in the midwest or coast, pts who need extracap will come in.

Stark
www.ApolloAudiobooks.com

 

[Wolverine98]

All training programs are different.

At New York Eye & Ear. Several of the last class did zero extracaps. Others did up to nine extracaps. It depends on the resident, the case, and the attending physician.

My recommendation: do a few extracaps in residency. A patient WILL walk in your door within the first six months of private practice who requires an extracap. 20/400 vision, and brown cataract that looks more like tree-bark than a lens. Just immigrated from Mexico, PR or Africa. Whether your in the midwest or coast, pts who need extracap will come in.

I agree with your point that it's good to know how to do an extracap, but I disagree that these patients will require them. Especially with the newer machines and tips, you can cut through anything I've come across (I'm currently using the Infiniti microcoaxial with the 45 degree tip, just for reference; and no, I have no financial relationship with Alcon). I've been able to do LP lenses with this without difficulty (we see it a fair amount in Detroit). I have some family members and friends who go to Africa every year, and take equipment with them. There they run into cataracts that have gone beyond the US version of dense and have turned black. They've been able to cut through those without difficulty with torsional phaco. Granted they (and I for my cases) have the knowledge and the equipment available to convert to an extracap if necessary, but it hasn't been.

IMO, it's the trauma patients when you really need to be ready to do an extracap (but even then, you can often do a phaco if you're willing to do some gymnastics to make a good video 😉 ).

 

[Wolverine98]

Note this is from someone who was a resident, fellow and attending. First, extracaps have gone the way of the Dodo. It is not the standard of care, and unfortunately the residents (and those that staff them) are suffering. The lack of suturing really hurts the current crop of reisidents. At my prior job I staffed one of two extracaps done in two years. At my current job we have done 2 in almost two years. I just find it hard to bring myself to OK an eye to be fillet open when today's technology will go through all but a black or very brunescent lens. I find myself asking is it the right thing for the patient? In my heart I know I could vertical chop all but the hardest lens and likely save an elderly person from a prolonged recovery.

I completely agree with all of this. The main reason I don't do planned extracaps is that I can never convince myself that it's in the best interest of that given patient. IME, the latest technology can go through those black lenses (as I was mentioning in my last post). I do think that these are the cases that are worth doing as planned extracaps for the residents. I have a hard time when people do 20/50 or 20/70 cataracts as ECCE just because they have to get those numbers before being allowed to do phaco; I don't think that's fair to the patient, and I think that it would be tough to defend in a lawsuit in this day and age.

I also agree that the lack of suturing ability is a problem.

I guess I'm in an agreeable mood, because I also agree with you on the monocular patient issue. At our program, residents do operate on monocular patients at times. If a second year comes to me with a monocular patient, I usually encourage them to "refer" that patient to one of the more experienced third years (who can, in turn, refer patients with burgeoning cataracts to that second year when they leave in exchange, or some other such deal). The primary difference is in how I staff the case when they operate with me. I will have a much lower threshold for taking over (I have a relatively high threshold for this anyway). Also, once I take over, I'm likely to do more before I switch back, and, depending on how big the problem is, I'm less likely to switch back at all. Obviously I don't do this to be a jerk, or to be harsh to the resident, but to make sure the patient has a good outcome.

 

[Free Radicle]

phaco's only
1st year - two, supposed to be extracaps, but our attendings agree with the above posts, they you can pretty much get through anything with torsion/phaco

2nd year - 70-90, mostly routine stuff, iris hooks, some floppy iris

3rd year - ~200, mosty hard stuff, mono, iris hooks, s/p ppv, s/p trauma, pxf, etc

overall ~300 phacos by the end of the residency

as for the monocular patient debate above, our seniors are really good and would fell comfortable letting them do surgery on family members.

good luck to all applicants this year

 

[Mirror Form]

i think that strong programs teach you how to do an extracap well (afterall, that is what you need to convert to if/when the clear cornea phaco goes south).

This definitely is a very intersting discussion. I'm still a resident, and have only done one planned extracap so far, and one unplanned one (although the staff member I was with had done tons of extracaps over many medical missions). Without doing a medical mission, I don't see how I could ever get good extracap numbers.

Which brings up the point I wanted to discuss: If you're not well trained in extracaps, should you even consider converting? I've seen one really bad outcome where a surgeon that was not experienced in extracaps tried to convert in order to prevent the nucleus from going south. Whereas, with today's retina PPV techonology (which has also been advancing rapidly) most patients do okay after a dropped nucleus. Granted my experience is very limited. But based on what I've seen so far, unless I have an experienced extacap surgeon on hand to help me out, I'll probably just do the best job I can to get all the pieces out w/ the phaco. If the lens drops, it drops.

 

[Stark]

There is a difference between converting to an extracap because the nucleus is going south, and because the lens is so dense the phaco tip just can't seem to cut it.

If the lens is going south, opening the eye with a huge extracap wound is a bad idea. You have a busted bag, and opening the eye further will allow vitreous to further prolapse into the AC and out the wound, and you may be pulling on vitreous strands, and the retina when removing the lens.

If the lens is still mainly in the AC, better to float it up with viscoat, do a kenalog assisted anterior vitrectomy, and remove the lens fragments with the phaco tip, if you as sure you are not sucking up vitreous in the tip. If the lens falls back........let her go. Vitrectomy is what this eye needs.

Now, on the other hand, converting to an extracap because the lens is "too hard" to phaco (which is debatable as mentioned above), is an entirely different animal. The bag is presumably intact. You are still in control of the anterior chamber, the vitreous face is intact, and you can, in a controlled manner, remove the lens on the lens loop.


Converting to extracap for a falling lens is a bad idea. I'd let it fall.

Stark
www.ApolloAudiobooks.com

 

[SAcornea]

I read this forum often but rarely post; however, i felt it was imperative to relay to residents the importance of learning ecce skills, namely small incision extracaps that can be closed with 1-2 sutures (some left sutureless).


if done well (see article below), SICS is better than phaco, especially in situations in which there are dense lenses and no retina docs to fish out nuclear fragments.

But to do SICS properly, you have to know how to make a scleral tunnel (truly a lost skill), use an A/C maintainer, a lens loop...

As you are in your residency, you should learn the basics and learn them well (divide + conquer, ECCE, suturing), so that you have a basis with which to experiment with chopping, topical cases, CTRs, hooks, rings, etc.

Nothing is more annoying than listening to residents trying to one-up each other with their war stories of white cataracts with zonular dehiscence that they phaco chopped with a modified horizontal/vertical technique using capsular support hooks, healon 5, and the latest phaco handpiece when all along one could have done an ECCE/SICS more safely and quickly.

Please review the abstract that i've attached that supports the above statments...




A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal.

Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, Shrestha M, Paudyal G.
Tilganga Eye Center, Bagmati Pul, Gaushala, Kathmandu, Nepal.
PURPOSE: To compare the efficacy and visual results of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery (SICS) for the treatment of cataracts in Nepal. DESIGN: Prospective, randomized comparison of 108 consecutive patients with visually significant cataracts. METHODS: settings: Outreach microsurgical eye clinic. patients: One hundred eight consecutive patients with cataracts were assigned randomly to receive either phacoemulsification or SICS. intervention Cataract surgery with implantation of intraocular lens. main outcome measures: Operative time, surgical complications, uncorrected and best-corrected visual acuity (BCVA), astigmatism, and central corneal thickness (CCT). RESULTS: Both surgical techniques achieved excellent surgical outcomes with low complication rates. On postoperative day 1, the groups had comparable uncorrected visual acuity (UCVA) (P = 0.185) and the SICS group had less corneal edema (P = 0.0039). At six months, 89% of the SICS patients had UCVA of 20/60 or better and 98% had a best-corrected visual acuity (BCVA) of 20/60 or better vs 85% of patients with UCVA of 20/60 or better and 98% of patients with BCVA of 20/60 or better at six months in the phaco group (P = 0.30). Surgical time for SICS was much shorter than that for phacoemulsification (P < .0001). CONCLUSION: Both phacoemulsification and SICS achieved excellent visual outcomes with low complication rates. SICS is significantly faster, less expensive, and less technology dependent than phacoemulsification. SICS may be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world.

 

[Mirror Form]

Please review the abstract that i've attached that supports the above statments...




A prospective randomized clinical trial of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery in Nepal.

Ruit S, Tabin G, Chang D, Bajracharya L, Kline DC, Richheimer W, Shrestha M, Paudyal G.
Tilganga Eye Center, Bagmati Pul, Gaushala, Kathmandu, Nepal.
PURPOSE: To compare the efficacy and visual results of phacoemulsification vs manual sutureless small-incision extracapsular cataract surgery (SICS) for the treatment of cataracts in Nepal. DESIGN: Prospective, randomized comparison of 108 consecutive patients with visually significant cataracts. METHODS: settings: Outreach microsurgical eye clinic. patients: One hundred eight consecutive patients with cataracts were assigned randomly to receive either phacoemulsification or SICS. intervention Cataract surgery with implantation of intraocular lens. main outcome measures: Operative time, surgical complications, uncorrected and best-corrected visual acuity (BCVA), astigmatism, and central corneal thickness (CCT). RESULTS: Both surgical techniques achieved excellent surgical outcomes with low complication rates. On postoperative day 1, the groups had comparable uncorrected visual acuity (UCVA) (P = 0.185) and the SICS group had less corneal edema (P = 0.0039). At six months, 89% of the SICS patients had UCVA of 20/60 or better and 98% had a best-corrected visual acuity (BCVA) of 20/60 or better vs 85% of patients with UCVA of 20/60 or better and 98% of patients with BCVA of 20/60 or better at six months in the phaco group (P = 0.30). Surgical time for SICS was much shorter than that for phacoemulsification (P < .0001). CONCLUSION: Both phacoemulsification and SICS achieved excellent visual outcomes with low complication rates. SICS is significantly faster, less expensive, and less technology dependent than phacoemulsification. SICS may be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world.

Interesting study. Although I'm a bit skeptical of applying it to anything beyond it's stated conclusion. That's because a lot of those surgeons in the developing world do thousands upon thousands of extracaps. If you had that sort of experience it would be very safe. Keep in mind that those guys can do sutureless extracaps (a mazarati technique) in almost the same time that we do routine phaco's.

Unfortunately, there is no way any surgeon in the US could ever get that experience w/o doing medical missions (many medical missions). And even then, if you were out of practice on ECCE's your skill would likely erode. Given how close things were in the study, would it not be better to stick with your bread and butter?

 

[Wolverine98]

Interesting study. Although I'm a bit skeptical of applying it to anything beyond it's stated conclusion. That's because a lot of those surgeons in the developing world do thousands upon thousands of extracaps. If you had that sort of experience it would be very safe. Keep in mind that those guys can do sutureless extracaps (a mazarati technique) in almost the same time that we do routine phaco's.

Unfortunately, there is no way any surgeon in the US could ever get that experience w/o doing medical missions (many medical missions). And even then, if you were out of practice on ECCE's your skill would likely erode. Given how close things were in the study, would it not be better to stick with your bread and butter?

I completely agree. Geoff Tabin (one of the authors) spends about 6 months of the year overseas doing surgery.

Also, some of the as yet unpublished longer term data is skewing towards phaco.

Even their own conclusion gives you the most important point: "SICS may be the more appropriate surgical procedure for the treatment of advanced cataracts in the developing world. "