Training a cataract surgeon
The major goal of Vision 2020: The Right to Sight is to make high quality eye care services available, accessible and affordable to all through a sustainable delivery system. One of the key pre-requisites to achieve the above goals is the development of adequate and appropriate human resources. An analysis of current practices reveals problems related to number, distribution, quality of training and utilization of various categories of eye care personnel. Fundamentally, most eye care delivery services in developing countries lack appropriate human resource development, including planning and training and, therefore, implementation of services is adversely affected. 1
Identification of tasks
Cataract surgery is now, in effect, refractive surgery – which is more than just removing the opaque lens. It includes thorough pre-operative assessment, skilled surgical techniques and proper post-operative follow up with a focus on the best possible visual recovery.
An important step in cataract surgery training is the identification of tasks that a cataract surgeon is expected to learn and practice.
A cataract surgeon should take care of the following important steps (S’s) of cataract surgery training:
1. Case selection (Selection). The cataract surgeon should have thorough knowledge of the patients before surgery. Diseases such as corneal scars, age-related macular degeneration, diabetic retinopathy, advanced glaucoma, etc. may be present and cataract surgery will not give the desired and required results.1
2. Sterility and the Surgical field (Sterility). Procedures such as effective ‘scrubbing’, ‘gowning’ and ‘gloving’ should be strictly observed. Cleaning the periorbital skin prior to surgery with povidone iodine will reduce the bacterial load and can prevent post-operative endophthalmitis.2
3. Anaesthesia and intraocular pressure (Soft eye). A soft, well-anaesthetised eye is vital to the success of cataract surgery. Peribulbar injections and intermittent digital pressure are best suited for trainee surgeons or technicans.2
4. Intra-operative surgical complications (Safe surgery). The cataract surgeon should have good control over:
- Wound construction
- Nuclear delivery
- Cortex irrigation and aspiration
- Lens implantation
- Wound reconstruction.
A safe cataract surgeon should know how to respect corneal endothelium, uveal tissues and posterior capsule and should avoid any damage to such tissues. In the case of posterior capsular rupture, he/she should know how to manage vitreous loss.
5. Uncorrected refractive errors (Spectacles). Significant astigmatism and uncorrected refractive errors from lost or broken aphakic glasses is an important cause of low vision and blindness following cataract surgery. It can be overcome by:
- Biometry and the implantation of a customized intraocular lens that will ensure significant improvement in visual outcome
- The appropriate removal of sutures to reduce significant astigmatism, followed by spectacle correction of the residual refractive error 6-8 weeks after surgery.3
6. Post-operative complications (Sequelae). There may be early or late complications. Persistent inflammation in the early post-operative period and posterior capsule opacification in the late period can adversely affect visual results. To avoid or minimise these, a cataract surgeon should take care of careful post-operative follow-up with early detection and treatment of post-operative complications. Routine follow-up on the first post-operative day, after 1 week and 6 weeks is recommended.3
1. Length and content. The cataract surgeon should have the opportunity of adequate supervised training. There will be considerable individual variations but as a minimum standard, 2-4 weeks of training in ECCE with IOL of an already qualified person and a minimum of 50 surgeries is recommended to reach a desired level of competency.
Training should include:
- Didactic teaching
- ‘Hands on’ training.
Training should be an ongoing process and not a one-time activity. Trainees should get an opportunity to refresh their skills and learn new techniques. Refresher training opportunities should be available according to the needs of the trainees. During the basic training period the trainee surgeon should not operate on ‘only’ eyes (the other eye being blind); eyes where the first eye has had a serious operative complication (e.g., vitreous loss), or children’s eyes.
2. Monitoring and evaluation. The trainee surgeons should monitor their own surgical skills. Monitoring for surgeons in the initial phase should be to compare ‘themselves with themselves’ over time.
Evaluation of training needs to be done by the trainer through regular close observation and assessment of skills.
3. Certification and competency. Certification of training is the responsibility of the trainer, certifying trainees as safe cataract surgeons or recommending further training under supervision.
Requirements of a trainee
- A trainee cataract surgeon should have, at least, basic knowledge of the eye and some experience in ocular surgery
- A commitment to improvement which should provide the necessary motivation, enthusiasm and determination that is required
- A trainee cataract surgeon should have binocular single vision
- Should be comfortable with the use of the microscope
- A trainee in cataract surgery should be able to master and practise the safest and simplest techniques.
Equipment and training materials
A trainee should be given a kit containing the following:
- curriculum of the cataract surgery training attended with information on sterilization, pre-operative assessment, operating room management and post-operative evaluation
- Videos of the surgery they have performed themselves
- A video on standard cataract surgical techniques
- A microscope
- Two cataract surgical sets
- 100 IOLs.
A Cataract Training Centre
A Centre should have:
- Adequate physical space
- Adequate equipment, good quality instruments and consumables, as requested and required
- `Wet’ laboratory for the trainees to familiarize themselves with the instruments and microscope
- Audio-visual system for the recording of surgeries, for learning, monitoring and further reference
- Careful ophthalmic instrument maintenance and care by a trained ophthalmic technician / assistant / nurse who is also trained in the use of the microscope and other equipment maintenance and operating room management.
Requirements of a surgical instructor/trainer
A trainer should be or have:
- A highly skilled surgeon
- An aptitude for teaching and training
- The necessary time and patience needed for surgical skills transfer
- Ready to take over the moment a patient’s safety is at risk.