Transcript Document 7344612

Vanderbilt Eye Institute
Joshua Ki Hu
Vanderbilt Eye Institute
Ophthalmology, PGY-4
DATE 05.30.08
Introduction

Cataract surgery is one of the most
commonly performed surgeries in the
world, with over 1 million performed per
year in the United States alone.

Resident education designed
accordingly.

In 2002 a resident survey revealed that:
- the number of phacoemulsification procedures
performed by a single resident ranged from 50 to 300
- the majority perform between 80 and 140 (avg. 120)
- 25% performed less than 80

In 2007, the Residency Review
Committee of the ACGME increased the
minimum number of resident performed
phacoemulsification procedures from 45
to 86.

Few studies to date attempt to identify
time point/case number for significant
improvement in resident performed
surgery.

The aim of this study is to identify a time
point/case number for which a
significant decline in complication rates
occurs.

Also as a measure of internal “quality” of
Vanderbilt’s residency program.

Are patients being subjected to an
acceptable level of complications in the
early parts of training?
Materials and Methods

Retrospective chart review

VA Hospitals, Nashville, TN, charts from
patients who had undergone resident
performed phacoemulsification during a
6 year period from July 8, 1999, through
June 28, 2005 were reviewed.

The surgical cases were categorized
based on the resident surgeon
performing the cataract surgery, and
then sorted chronologically and given a
sequential case number.

The total number of intraoperative
complications including posterior
capsular tear, vitreous loss, and retained
lens fragments were recorded, as well
as the case numbers for which they
occurred.

The study was powered at 80% with
statistical significance set at p = 0.05 to
detect a 50% change in complication
frequency (estimated to be 15%)

Sample size = 304

The cases were divided into groups
spanning every 20 procedures

Statistical analysis was performed
- using chi square analysis
- calculating 95% confidence intervals
Results

19 resident surgeons

Under guidance 23 different attending
surgeons

99.4% cases performed on males

51.6% Right eyes, 48.4% Left eyes
Number of Cases Sorted by Resident Surgeon
120
115
N = 1442
Mean: 76
Range: 58 - 115
100
91
87
80
Case Number
74
69
65
60
60
58
88
80
78
80
86
72
73
75
66
63
63
40
20
0
A
B
C
D
E
F
G
H
I
J
K
Surgeon
L
M
N
O
P
Q
R
S
Overall Complication Rate
12.00%
11.17%
10.00%
Complication Rate
8.00%
8.25%
6.00%
4.00%
2.00%
0.69%
0.00%
Posterior Capsular Tear
Vitreous Loss
Type of Complication
Retained Lens Fragment
Rate of Posterior Capsular Tear vs. Surgical Case Number
16.00%
14.00%
13.70%
13.42%
Complication Rate
12.00%
10.00%
9.26%
7.84%
8.00%
7.56%
6.67%
6.00%
4.00%
2.00%
0.00%
1-20
21-40
41-60
61-80
Case Numbers
81-100
101-120
Rate of Posterior Capsular Tear vs. Surgical Case Number
25.00%
20.00%
Complication Rate
p = 0.0244
15.00%
10.00%
13.70%
13.42%
5.00%
9.26%
7.84%
p = 0.0710
7.56%
6.67%
0.00%
1-20
21-40
41-60
61-80
Case Numbers
81-100
101-120
Rate of Vitreous Loss vs. Surgical Case Number
12.00%
9.74%
10.53%
10.00%
Rate of Complication
8.00%
6.35%
6.67%
5.88%
6.00%
5.88%
4.00%
2.00%
0.00%
1-20
21-40
41-60
61-80
Case Numbers
81-100
101-120
Rate of Vitreous Loss vs. Surgical Case Number
25.00%
20.00%
Rate of Complication
p = 0.0386
15.00%
10.00%
5.00%
9.74%
10.53%
5.88%
6.35%
6.67%
5.88%
0.00%
1-20
21-40
41-60
61-80
Case Numbers
81-100
101-120
Conclusions

There is a statistically significant decrease in
intraoperative complications in resident
performed phacoemulsification cataract
surgery once the surgeon has performed 80
procedures.
 61-80 for Posterior Capsular Tears
 41-60 for Vitreous Loss

The results of this study are in line with
the ACGME recommendation to
increase minimum amount of
phacoemulsification procedures from 45
to 86.

There was also a trend of continued
reduction in intraoperative complication
rates with increasing surgical
experience.
Resident Teaching
Institution
Number of
Posterior
Cases
Capsular Tear
Vitreous
Loss
Retained Lens
Fragment
Vanderbilt University
1442
11.2%
8.2%
0.7%
Emory University
680
4.9%
3.4%
0.4%
New Jersey Medical School
719
6.7%
5.4%
1.0%
University of California – San
Francisco
218
-
8.7%
-
Penn State College of
Medicine
332
-
4.8%
-
Baylor College of Medicine
181
9.9%
5.5%
-
University of Chicago
343
-
4.7%
-
University of Arizona
136
-
14.7%
-
University of Utah
396
-
1.8%
-
Royal Eye Infirmary, England
102
5.8%
2.9%
-
Istanbul/Akdeniz University,
Turkey
296
10.5%
6.4%
2.4%

Overall, phacoemulsification complication
rate 3-4%

Resident performed cataract surgery
complication rate has been deemed
“acceptably low”

What about the early cases?

Roll of adjunctive surgical learning tools
Limitations

Case series subject to limitations of
retrospective study.

Accuracy of medical record?

The data included only those procedures
performed at the VA Hospital.
Acknowledgements
Dr. Amy Chomsky
 VA Staff
 Vanderbilt Eye Institute Residents and
Teaching Faculty

References
Randleman JB, et al. The Resident Surgeon Phacoemulsification Learning Curve. Arch
Ophthalmol. 2007; 125(9): 1215-1219.
Bhagat N, et al. Complications in resident-performed phacoemulsification cataract surgery
at New Jersey Medical School. Br J Ophthalmol. 2007; 91: 1315-1317.
Smith JH, et al. Outcomes of cataract surgery by residents at a public county hospital. Am
J Ophthalmol. 1997; 123(4): 448-454.
Quillen DA, et al. Visual Outcomes and Incidence of Vitreous Loss for Residents
Performing Phacoemulsification Without Prior Planned Extracapsular Cataract Extraction
Experience. Am J Ophthalmol. 2003; 135: 732-733.
Ang GS, et al. Effect and outcomes of posterior capsular rupture in a district hospital
setting. J Cataract Refract Surg. 2006; 32(4): 623-627.
Chan FM, et al. Short-term outcomes in eyes with posterior capsule rupture during catarat
surgery. J Cataract Refract Surg. 2003; 29(3): 537-541.
Pingree MF, et al. Cataract surgery complications in 1 year at an academic institution. J
Cataract Refract Surg. 1999; 25: 705-708.
Rowden A, et al. Resident cataract surgical training in United States residency programs.
J Cataract Refract Surg . 2002; 28(12): 2202-2205.
Cruz OA, et al. Visual results and complications of phacoemulsification with intraocular lens
implantation performed by ophthalmology residents. Ophthalmology. 1992; 99(3): 448-452.
Corey RP, et al. Surgical outcomes of cataract extractions performed by residents using
phacoemulsification. J Cataract Refract Surg. 1998; 24(1): 66-72.
Tarbet KJ, et al. Complications and results of phacoemulsification performed by residents.
J Cataract Refract Surg . 1995; 21(6): 661-665.
Prasad S. Phacoemulsification learning curve: experience of two junior trainee
ophthalmologists. J Cataract Refract Surg. 1998; 24(1): 73-77.
Unal Mustafa, et al. Phacoemulsification with topical anesthesia: Resident experience. J
Cataract Refract Surg. 2006; 32: 1361-1365.
Allinson RW, et al. Incidence of vitreous loss among third-year residents performing
phacoemulsification. Ophthalmology . 1992; 99: 448-452.
Albanis CV, et al. Outcomes of extracapsular cataract extraction and phacoemulsification
performed in university training program. Ophthalmic Surg Lasers. 1998; 29: 643-648.