Journey of a 1^st-year ophthalmology resident through first 50 manual small incision cataract surgeries

INTRODUCTION

The technique of cataract surgery has evolved remarkably over the past few decades.^[1] However, despite continuous advancements in this field, the latest data by the WHO still identifies cataract to be the leading cause of blindness across the world.^[2] This could be partly due to resource constraints and partly due to a lack of training opportunities in many countries around the world. Studies show that out of all the techniques of cataract surgery, manual small incision cataract surgery (MSICS) is the most cost-effective technique in developing countries, with outcomes comparable to the latest techniques like phacoemulsification.^[3,4]

In the backdrop of the huge socio-economic burden that results from cataract, multiple surveys conducted across various medical institutes in India have revealed the surprising inadequacy of cataract surgical training imparted in post-graduation (PG) ophthalmology programs in this country.^[5] There are but a few centres across the country that provide a holistic surgical exposure to their residents.^[5,6]

At the centre where this study was conducted, PG residents are trained in MSICS as well as phacoemulsification. In this article, we assess the surgical journey of a 1^st-year ophthalmology resident by objectively analysing the outcomes of their first 50 MSICS surgeries. Our aim is to assess the effectiveness of such a training programme for creating independent cataract surgeons.

MATERIALS AND METHODS

RESULTS

The mean age of presentation of patients in this study was 66.18 years. Out of 50, 20 were male (40%) and 30 were female (60%). The mean age of presentation was 65.3 years among males and 66.76 years among females. Twenty-five out of 50 patients (50%) had mature cataract (total white cataract), 2 (4%) had brown cataract and the rest (46%) had immature senile cataract of grades nuclear sclerosis (NS) 2–3.^[5]

Table 1 shows the baseline characteristics of all patients included in this study.

Visual acuity (VA) at all visits was measured using the Snellen V chart. Forty-four of 50 (88%) patients had pre-operative VA of 6/60 or less. Other 6 patients (12%) had VA between 6/24 and 6/36. No patient in this study had a pre-operative VA of 6/18 or better. Figure 1 shows the distribution of BCVA preoperatively.

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Figure 1:

Distribution of pre-operative visual acuity of patients.

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The time taken for performing the surgery ranged from 30 to 89 min [Figure 2]. Out of 50, in 22 cases (44%), intervention of the trainer was required and 28 cases (56%) were done independently. The need for the trainer to intervene reduced significantly after the first 25 cases. Out of 50, 32 patients (64%) gained final BCVA of 6/12 or better, 6 (12%) gained 6/18, 5 (10%) gained 6/24, 2 (4%) gained 6/36 and 1 patient (2%) was recorded to have BCVA of 2/60 at POD 6 weeks – the last patient was found to have outer retinal layer loss on optical coherence tomography. Another patient (2%) was found to have total glaucomatous optic atrophy postoperatively; this patient ended up with no perception of light. For the remaining three patients, last recorded BCVA was 6/60 or less, after which they were lost to follow-up. One patient with VA 6/18 was later found to have scarred parafoveal telangiectasia [Figure 3].

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Figure 2:

Time taken for surgery.

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Figure 3:

Distribution of patients according to final post-operative best-corrected visual acuity (BCVA).

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There were two intraoperative complications (complication rate = 4%), both were posterior capsular rent (PCR) – one with vitreous loss and one without. In the first case, anterior vitrectomy was done, and AC intraocular lens implanted, whereas in the second case, posterior chamber intraocular lens could be placed in the bag. Both patients eventually gained a VA of 6/9.

DISCUSSION

Preoperatively, cataract grading was done using the lens opacities classification system (LOCS) grading system.^[7] More than half of the cases had mature white cataract. This varies from the data in other similar studies, where most training cases had an immature cataract of grade NS 2–3.^[8,9] This follows from the fact that at our institute, trainees are initially given to operate on mature white (non-intumescent) cataracts, as nucleus manipulation is relatively easier in these cases. They also require minimal irrigation and aspiration which is generally considered the toughest step of MSICS surgery. Gradually, softer grades of cataract, brown cataract and lastly the intumescent and hypermature variety are permitted.

For the initial 20 cases, the time taken to complete the surgery was around 60 mins, which fell to about 35–40 mins in the later cases. The decline in time was, however, not gradual, with intermittent cases requiring significantly more time than others. As per the author’s literature search, no other study talks about the time taken by trainee surgeons per surgery.

The need for the trainer to intervene also decreased over time; trainer intervention was needed in 19 of the first 25 cases (76%), whereas in the next 25 cases, the trainer needed to take over in only 3 (12%). Similar results have been found in other studies documenting the surgical journey of trainees.^[8]

The WHO has recommended the desired number of patients achieving different grades of VA (UCVA and BCVA) after getting cataract surgery. It is as depicted in Table 2.

The visual outcome of patients in this study was slightly less than the WHO-recommended criteria [Table 3].

There are only a few studies that document the visual outcomes of the cataract surgeries performed by resident surgeons; most such studies focus on the complication rates. The author found one study like this one conducted at an eye hospital in South India; this study showed a slightly better visual outcome, with 90.3% patients achieving a ‘good’ VA.^[8] This can be attributed to the fact that there was an obvious difference in the skill sets of the trainees in these two studies – the trainee in the south Indian study had previous surgical experience where the one in this study was a complete novice.^[8]

The complication rate in this study (4%) was slightly higher than that documented in a study conducted at Aravind eye hospital, evaluating the MSICS learning curve of their residents, which was 2.60%.^[10] In another study conducted at Aravind eye hospital, the overall complication rate for MSICS was 1.01%; this study evaluated the overall complication rate of cataract surgery for all their cataract surgeons with different levels of experience.^[11] The slightly higher complication rate in this study can be attributed to the zero surgical experience of the trainee and the sample size of this study being significantly smaller as compared to all the other studies quoted here.

Considering the fact that the trainee in this study was just starting their surgical career, minor complications were naturally expected and only those complications falling in Grades 2 or 3 as per the oxford cataract treatment and evaluation team (OCTET) system of complication grading were considered for the purpose of this study.^[12]

Grading of complications according to the OCTET definitions:

• Grade 1: Trivial complications that may have needed medical therapy but were not likely to contribute to a drop in VA

• Grade 2: Intermediate complications that needed medical therapy and were likely to result in a marked drop in VA if left untreated

• Grade 3: Serious complications that would have needed immediate medical and surgical intervention to prevent gross visual loss.

The intra-operative complications falling in the different grades according to the OCTET system are enumerated in Table 4.

Most studies considering complications in cataract surgery have stated PCR to be the most common intraoperative complication, followed by zonular dialysis.^[9,10,11] PCR was also the most common complication encountered in our study (100%). In one of the studies mentioned above, 89% patients ultimately achieved a ‘good’ visual outcome after an MSICS complication.^[11] In our study, both patients (100%) with complicated surgery achieved BCVA of 6/9.

CONCLUSION

Ophthalmologists well-trained in cataract surgery are the need of the hour, especially in a developing country like ours, which has the highest population in the world. However, as is evident from the literature, surgical training in ophthalmology residency programs is inadequate all over India. As a result, many ophthalmology postgraduates need to undergo further training to become proficient in cataract surgery. In this backdrop, our study suggests that having a methodical training program like that discussed in this study is a simple yet effective way to make residents capable of performing independent cataract surgery in the duration of residency itself.