- Email: [email protected]
Using endoscopy to teach cataract surgery
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
Using endoscopy to teach cataract surgery Bonnie An Henderson, MD, Rasha Ali, Jae Yong Kim, MD, PhD, Christine Shortsleeve Ament, MD
Current methods of teaching cataract surgery include lectures, wet-lab sessions, and participation in real surgery. We describe a new method using a microendoscopic cyclophotocoagulation device during phacoemulsification cataract extraction and posterior chamber intraocular lens (IOL) implantation in 4 eyes of 4 patients. Endoscopic visualization during surgery aided in construction of the corneal incision, location of the capsulorhexis edge, and estimation of the lens groove depth. It also demonstrated clinical findings not observable with the surgical microscope such as misplaced IOL haptics and residual lens cortex. Use of the endoscope enhanced the educational value of the surgery and the final surgical outcome. J Cataract Refract Surg 2006; 32:1606–1610 Q 2006 ASCRS and ESCRS
Learning how to perform cataract surgery is one of the most challenging parts of residency training. As the proportion of aging adults in the population grows, the annual rate of cataract surgery in the United States is expected to rise exponentially. It is estimated that by the year 2020, 30.1 million Americans will have cataracts.1 Acquiring competency in cataract surgery is an integral part of becoming a proficient ophthalmologist, regardless of one’s subspecialty. Current methods of teaching cataract surgery include a progression from didactic lectures to practical wet-lab sessions and, finally, to participation in real surgery.2–4 While the current educational methods are effective, it is incumbent upon educators to optimize surgical training using relevant new technologies. Academicians involved in training residents have created checklists4 and objective and subjective assessment tools to evaluate competency.5,6 Alternative methods being developed involve computer simulations with ‘‘virtual’’ surgery.7 The use of intraocular endoscopy was first described by Thorpe in 1934.8 Since then, endoscopy has been used mainly for posterior segment surgery and removal of
Accepted for publication April 17, 2006. From Massachusetts Eye and Ear Infirmary (Henderson, Kim, Ament), Harvard Medical School, Boston, Massachusetts, and the University of Illinois College of Medicine (Ali), Chicago, Illinois, USA. Supported in part by grants from Research to Prevent Blindness and the Norman Knight Ophthalmology Legacy Fund. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Bonnie An Henderson, MD, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, Massachusetts 02114, USA. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
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foreign bodies.9–11 It has also been used in intraocular lens (IOL) implantation to assist with capsulorhexis,12 posterior chamber implantation,13,14 and sulcus implantation15–18 and in surgery in eyes with opaque corneas.19 It has also been used in vitro12 and for cycloablative procedures.20 We propose the use of endoscopy as a tool in teaching cataract surgery to residents. TECHNIQUE
The endoscope used in this study was Medtronic’s Solan microendoscopic cyclophotocoagulation device, originally developed by Martin Uram, MD. It consists of a 20-gauge endoprobe and an equipment console. The endoprobe combines light; video imager; and high-density, multifiber fiber-optic laser fibers to provide a 110-degree field of intraocular visibility with a depth of focus ranging from 1 to 30 mm. A 10 KB pixel resolution allows imaging of ocular tissues from the anterior or posterior segment. The equipment console consists of a video camera, a light source, and a semiconductor diode laser tuned to 810 nm wavelength and is used in conjunction with a television monitor (Medtronic product information available at: http:// www.medtronic.com. Accessed October 28, 2005).21–23 The endoscope was connected to the digital versatile disk/ computer monitor. Phacoemulsification cataract extraction and posterior chamber IOL implantation were successfully performed in 4 eyes of 4 patients using the endoscope to aid in visualizing the internal ocular structures. An initial paracentesis incision was created and widened to approximately 2.0 mm. Chondroitin sulfate, an ophthalmic viscosurgical device (OVD), was injected into the anterior chamber. The endoscope/light pipe was placed in the anterior chamber through the paracentesis site. The endoscope was 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.04.034
TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
controlled by the surgical assistant. The endoscopic view was displayed on a monitor in the operating room. The endoscope was directed toward the cornea as the clear corneal incision was made. The keratome blade was visualized from inside the anterior chamber as the blade penetrated the posterior cornea (Figure 1). The endoscope remained in the anterior chamber while the capsulorhexis was created with the cystotome and capsule forceps (Figure 2). During grooving of the lens nucleus with the phacoemulsification handpiece, the endoscope was placed in the groove to evaluate its depth (Figure 3). After phacoemulsification and cortex removal by irrigation/aspiration (I/A), the endoscope was used to scan the angle and sulcus for nuclear remnants; after IOL implantation, it was used to survey the position of the haptics. In 1 of the 4 patients, the view from the surgical microscope was obstructed by a corneal stromal scar. In a second patient, endoscopic evaluation revealed a small hidden nuclear fragment under the iris, which was successfully removed (Figure 4). In a third patient, endoscopic evaluation revealed that 1 haptic was in the sulcus instead of the capsular bag. The misplaced haptic was repositioned in the capsular bag (Figure 5). No intraoperative complications occurred during any procedure. DISCUSSION
The term endoscopy is derived from the Greek roots endon and skopein, meaning ‘‘not otherwise visible.’’ Endoscopy provides excellent visualization and surgical access
Figure 2. Creation of the capsulorhexis with the cystotome (A) and completion of the curvilinear capsulorhexis with a capsule forceps (B).
Figure 1. Visualization of the keratome from inside the anterior chamber as the clear corneal incision is constructed.
through very small incisions and is used in many areas of medicine including gastroenterology, pulmonology, gynecology, urology, otolaryngology, and orthopedics.24 The use of endoscopy dates at least to Hippocrates (460–375 BC), who described a rectal speculum that used ambient light for illumination.25 In 1806, Bozzini26,27 developed the first known endoscope (‘‘Lichtleiter’’ [light conductor]) by reflecting light from a candle and a tube to view the female urethra.
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
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TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
Figure 3. Internal view of the lens groove depth.
Figure 4. Endoscopic evaluation revealed a small hidden nuclear fragment.
Since Bozzini, clinicians have reported the use of ophthalmic endoscopes in vitreoretinal surgery, cataract extraction, and laser endophotocoagulation.10,13,26 Further improvements in ophthalmic endoscopy include the development of a disposable endosocopic system27 and a stereoscopic ophthalmic microendoscope system that allows the surgeon to monitor 3-dimensional endoscopic and microscopic images simply by looking into the eyepiece of the surgical microscope.28 Today, ophthalmic endoscopes are used in many aspects of ophthalmologic practice from intraoperative endoscopic-guided fluorescein angiography29 to endoscopic cyclophotocoagulation and endoscopic selective trabecular surgery.30 Endoscopy has also been used in cataract surgery with transscleral IOL fixation,18 in which endoscopic observation of the retroiridal space during transscleral suture placement facilitates accurate haptic placement. We propose the use of endoscopy as an adjunct to teaching cataract surgery. When novice surgeons begin performing cataract surgery, they may not fully understand the dimensions and spatial relationships between intraocular structures. Endoscopy provides a unique view of these structures and can be useful in nearly every step of the procedure. Endoscopic visualization of the posterior cornea may help the beginner judge corneal thickness and therefore construct clear corneal incisions of appropriate length. Endoscopic visualization of the anterior capsule capsulorhexis that has proceeded peripherally allows the beginner to locate and redirect the edge before it continues past the lens zonules.
Surgeons who are learning phacoemulsification often misjudge the depth of the lens nucleus grooves. Novices usually do not groove deeply enough for fear of going past the lens into the posterior capsule. Without proper groove depth, it is nearly impossible to crack the lens and difficult to remove the nuclear quadrants. The endoscope can assist in this step by providing an internal perspective of lens depth. The IOL must be placed properly to prevent tilt and decentration. The endoscope can be used to determine whether the haptics are correctly placed in the capsular bag. It can also be used to find hidden lens or cortical fragments lodged in the angle or underneath the iris. These fragments are often missed during routine I/A and OVD removal and can cause prolonged postoperative inflammation. There are several disadvantages associated with the endoscope. It increases the cost of surgery, additional surgical time is used to manipulate the scope, and the incision that admits the endoscope is larger than a standard paracentesis wound. There is a learning curve associated with endoscopy. Image clarity, focus, and brightness depend on proper scope orientation, cleanliness, and proximity to the target tissue. The routine use of the endoscope for resident-performed cataract surgery is not practical due to these limitations. However, understanding the educational value of this instrument may be helpful in certain clinical situations. Recently, much attention has been given to resident education competencies. The Accreditation Council for Graduate Medical Education has mandated that
1608
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
education is challenging, and instructors need to be creative in finding ways to teach and think ‘‘outside’’ the wet-lab box. With limited choices and often limited resources, surgical instructors must be able to use the currently available tools to enhance the students’ knowledge of the eye. Surgical competence is impossible without a thorough understanding of the eye’s anatomy. We propose the use of the endoscope to augment understanding of the 3-dimensional relationships of the ocular structures that aid in learning how to manipulate these structures during surgery. We advocate including the endoscope in the armamentarium for resident education.
REFERENCES
Figure 5. A: The intraocular haptic is visualized in the ciliary sulcus. B: The misplaced haptic is repositioned in the capsular bag.
ophthalmology residency programs use objective assessment tools to evaluate residents’ competence in 6 areas of proficiency: medical knowledge, patient care, professionalism, interpersonal and communications skills, and practice- and systems-based learning. The American Board of Ophthalmology includes surgery as an additional area of competence for ophthalmology residents.31–33 Surgical
1. The Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004; 122:487–494 2. Laurell C-G, So¨derberg P, Nordh L, et al. Computer-simulated phacoemulsification. Ophthalmology 2004; 111:693–698 3. Hikichi T, Yoshida A, Igarashi S, et al. Vitreous surgery simulator. Arch Ophthalmol 2000; 118:1679–1681 4. Ross DG, Harris CA, Jones DJ. A comparison of operative experience for basic surgical trainees in 1992 and 2000. Br J Surg 2002; 89(suppl 1):60 5. Cremers SL, Ciolino JB, Ferrufino-Ponce ZK, Henderson BA. Objective assessment of skills in intraocular surgery (OASIS). Ophthalmology 2005; 112:1236–1241 6. Cremers SL, Lora AN, Ferrufino-Ponce ZK. Global rating assessment of skills in intraocular surgery (GRASIS). Ophthalmology 2005; 112:1655– 1660 7. Sinclair MJ, Peifer JW, Haleblian R, et al. Computer-simulated eye surgery: a novel teaching method for residents and practitioners. Ophthalmology 1995; 102:517–521 8. Thorpe HE. Ocular endoscopy: an instrument for the removal of intravitreous non-magnetic foreign bodies. Trans Am Acad Ophthalmol Otolaryngol 1934; 39:422–424 9. Ciardella AP, Fisher YL, Carvalho C, et al. Endoscopic vitreoretinal surgery for complicated proliferative diabetic retinopathy. Retina 2001; 21:20–27 10. Uram M. Ophthalmic laser microendoscope endophotocoagulation. Ophthalmology 1992; 99:1829–1832 11. Boscher C, Lebuisson DA, Lean JS, Nguyen-Khoa JL. Vitrectomy with endoscopy for management of retained lens fragments and/or posteriorly dislocated intraocular lens. Graefes Arch Clin Exp Ophthalmol 1998; 236:115–121 12. Moore JE, Herath GD, Sharma A. Continuous curvilinear capsulorhexis with use of an endoscope. J Cataract Refract Surg 2004; 30:960–963 13. Leon CS, Leon JA. Microendoscopic ocular surgery: a new intraoperative, diagnostic and therapeutic strategy. Part I: endoscopic equipment/methodology applied to cataract surgery with intraocular lens implantation. J Cataract Refract Surg 1991; 17:568–572 14. Leon CS, Leon JA, Rich WJ. From ‘‘blind’’ implantation to endoscopic posterior implantation: a new surgical concept. Eur J Implant Refract Surg 1992; 4:271–272 15. Leon JA, Leon CS, Aron-Rosa D, et al. Endoscopic technique for suturing posterior chamber intraocular lenses. J Cataract Refract Surg 2000; 26:644–649 16. Ju¨rgens I, Lillo J, Buil JA, Castilla M. Endoscope-assisted transscleral suture fixation of intraocular lenses. J Cataract Refract Surg 1996; 22:879–881
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
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TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
17. Althaus C, Sundmacher R. Intraoperative intraocular endoscopy in transscleral suture fixation of posterior chamber lenses: consequences for suture technique, implantation procedure, and choice of PCL design. Refract Corneal Surg 1993; 9:333–339 18. Althaus C, Sundmacher R. Transscleral suture fixation of posterior chamber intraocular lenses through the ciliary sulcus: endoscopic comparison of different suture techniques. Ger J Ophthalmol 1992; 1:117–121 19. Jacobi PC, Dietlein TS, Krieglstein GK. Microendoscopic trabecular surgery in glaucoma management. Ophthalmology 1999; 106:538– 544 20. Uram M. Combined phacoemulsification, endoscopic ciliary process photocoagulation, and intraocular lens implantation in glaucoma management. Ophthalmic Surg 1995; 26:346–352 21. Uram M. Endoscopic cyclophotocoagulation in glaucoma management. Curr Opin Ophthalmol 1995; 6(2):19–29 22. Sheindlin JA, Hirose T, Hartnett ME. Ophthalmic endoscopy: applications in intraocular surgery. Int Ophthalmol Clin 1999; 39(1):237– 247 23. Eguchi S, Araie M. A new ophthalmic electronic videoendoscope system for intraocular surgery. Arch Ophthalmol 1990; 108:1778– 1781 24. Hirschowitz B. Development and application of endoscopy. Gastroenterology 1993; 104:337–342
1610
25. Gordon A. The history and development of endoscopic surgery. In: Sutton C, Diamond MP, eds, Endoscopic Surgery for Gynaecologists. London, Philadelphia, WB Saunders, 1993; 3–11 26. Leon CS, Leon JA. Microendoscopic ocular surgery: a new intraoperative, diagnostic and therapeutic strategy. II: preliminary results from the study of glaucomatous eyes. J Cataract Refract Surg 1991; 17:573–576 27. Fisher YL, Slakter JS. A disposable ophthalmic endoscopic system. Arch Ophthalmol 1994; 112:984–986 28. Eguchi S, Kohzuka T, Araie M. Stereoscopic ophthalmic microendoscope system. Arch Ophthalmol 1997; 115:1336–1338 29. Uram M. Endoscopic fluorescein angiography. Ophthalmic Surg Lasers 1996; 27:849–855 30. Jacobi P, Dietlein TS. Endoscopic surgery in glaucoma management. Curr Opin Ophthalmol 2000; 11:127–132 31. Lee AG, Carter KD. Managing the new mandate in resident education, a blueprint for translating a national mandate into local compliance. Ophthalmology 2004; 111:1807–1812 32. Lee AG, Volpe N. Impact of the new competencies on resident education in ophthalmology [editorial]. Ophthalmology 2004; 111:1269–1270 33. Mills RP, Mannis MJ. Report of the American Board of Ophthalmology Task Force on the Competencies; the American Board of Ophthalmology Program Directors’ Task Force on Competencies [editorial]. Ophthalmology 2004; 111:1267–1268
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
Using endoscopy to teach cataract surgery Bonnie An Henderson, MD, Rasha Ali, Jae Yong Kim, MD, PhD, Christine Shortsleeve Ament, MD
Current methods of teaching cataract surgery include lectures, wet-lab sessions, and participation in real surgery. We describe a new method using a microendoscopic cyclophotocoagulation device during phacoemulsification cataract extraction and posterior chamber intraocular lens (IOL) implantation in 4 eyes of 4 patients. Endoscopic visualization during surgery aided in construction of the corneal incision, location of the capsulorhexis edge, and estimation of the lens groove depth. It also demonstrated clinical findings not observable with the surgical microscope such as misplaced IOL haptics and residual lens cortex. Use of the endoscope enhanced the educational value of the surgery and the final surgical outcome. J Cataract Refract Surg 2006; 32:1606–1610 Q 2006 ASCRS and ESCRS
Learning how to perform cataract surgery is one of the most challenging parts of residency training. As the proportion of aging adults in the population grows, the annual rate of cataract surgery in the United States is expected to rise exponentially. It is estimated that by the year 2020, 30.1 million Americans will have cataracts.1 Acquiring competency in cataract surgery is an integral part of becoming a proficient ophthalmologist, regardless of one’s subspecialty. Current methods of teaching cataract surgery include a progression from didactic lectures to practical wet-lab sessions and, finally, to participation in real surgery.2–4 While the current educational methods are effective, it is incumbent upon educators to optimize surgical training using relevant new technologies. Academicians involved in training residents have created checklists4 and objective and subjective assessment tools to evaluate competency.5,6 Alternative methods being developed involve computer simulations with ‘‘virtual’’ surgery.7 The use of intraocular endoscopy was first described by Thorpe in 1934.8 Since then, endoscopy has been used mainly for posterior segment surgery and removal of
Accepted for publication April 17, 2006. From Massachusetts Eye and Ear Infirmary (Henderson, Kim, Ament), Harvard Medical School, Boston, Massachusetts, and the University of Illinois College of Medicine (Ali), Chicago, Illinois, USA. Supported in part by grants from Research to Prevent Blindness and the Norman Knight Ophthalmology Legacy Fund. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Bonnie An Henderson, MD, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, Massachusetts 02114, USA. E-mail: [email protected]. Q 2006 ASCRS and ESCRS Published by Elsevier Inc.
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foreign bodies.9–11 It has also been used in intraocular lens (IOL) implantation to assist with capsulorhexis,12 posterior chamber implantation,13,14 and sulcus implantation15–18 and in surgery in eyes with opaque corneas.19 It has also been used in vitro12 and for cycloablative procedures.20 We propose the use of endoscopy as a tool in teaching cataract surgery to residents. TECHNIQUE
The endoscope used in this study was Medtronic’s Solan microendoscopic cyclophotocoagulation device, originally developed by Martin Uram, MD. It consists of a 20-gauge endoprobe and an equipment console. The endoprobe combines light; video imager; and high-density, multifiber fiber-optic laser fibers to provide a 110-degree field of intraocular visibility with a depth of focus ranging from 1 to 30 mm. A 10 KB pixel resolution allows imaging of ocular tissues from the anterior or posterior segment. The equipment console consists of a video camera, a light source, and a semiconductor diode laser tuned to 810 nm wavelength and is used in conjunction with a television monitor (Medtronic product information available at: http:// www.medtronic.com. Accessed October 28, 2005).21–23 The endoscope was connected to the digital versatile disk/ computer monitor. Phacoemulsification cataract extraction and posterior chamber IOL implantation were successfully performed in 4 eyes of 4 patients using the endoscope to aid in visualizing the internal ocular structures. An initial paracentesis incision was created and widened to approximately 2.0 mm. Chondroitin sulfate, an ophthalmic viscosurgical device (OVD), was injected into the anterior chamber. The endoscope/light pipe was placed in the anterior chamber through the paracentesis site. The endoscope was 0886-3350/06/$-see front matter doi:10.1016/j.jcrs.2006.04.034
TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
controlled by the surgical assistant. The endoscopic view was displayed on a monitor in the operating room. The endoscope was directed toward the cornea as the clear corneal incision was made. The keratome blade was visualized from inside the anterior chamber as the blade penetrated the posterior cornea (Figure 1). The endoscope remained in the anterior chamber while the capsulorhexis was created with the cystotome and capsule forceps (Figure 2). During grooving of the lens nucleus with the phacoemulsification handpiece, the endoscope was placed in the groove to evaluate its depth (Figure 3). After phacoemulsification and cortex removal by irrigation/aspiration (I/A), the endoscope was used to scan the angle and sulcus for nuclear remnants; after IOL implantation, it was used to survey the position of the haptics. In 1 of the 4 patients, the view from the surgical microscope was obstructed by a corneal stromal scar. In a second patient, endoscopic evaluation revealed a small hidden nuclear fragment under the iris, which was successfully removed (Figure 4). In a third patient, endoscopic evaluation revealed that 1 haptic was in the sulcus instead of the capsular bag. The misplaced haptic was repositioned in the capsular bag (Figure 5). No intraoperative complications occurred during any procedure. DISCUSSION
The term endoscopy is derived from the Greek roots endon and skopein, meaning ‘‘not otherwise visible.’’ Endoscopy provides excellent visualization and surgical access
Figure 2. Creation of the capsulorhexis with the cystotome (A) and completion of the curvilinear capsulorhexis with a capsule forceps (B).
Figure 1. Visualization of the keratome from inside the anterior chamber as the clear corneal incision is constructed.
through very small incisions and is used in many areas of medicine including gastroenterology, pulmonology, gynecology, urology, otolaryngology, and orthopedics.24 The use of endoscopy dates at least to Hippocrates (460–375 BC), who described a rectal speculum that used ambient light for illumination.25 In 1806, Bozzini26,27 developed the first known endoscope (‘‘Lichtleiter’’ [light conductor]) by reflecting light from a candle and a tube to view the female urethra.
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
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TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
Figure 3. Internal view of the lens groove depth.
Figure 4. Endoscopic evaluation revealed a small hidden nuclear fragment.
Since Bozzini, clinicians have reported the use of ophthalmic endoscopes in vitreoretinal surgery, cataract extraction, and laser endophotocoagulation.10,13,26 Further improvements in ophthalmic endoscopy include the development of a disposable endosocopic system27 and a stereoscopic ophthalmic microendoscope system that allows the surgeon to monitor 3-dimensional endoscopic and microscopic images simply by looking into the eyepiece of the surgical microscope.28 Today, ophthalmic endoscopes are used in many aspects of ophthalmologic practice from intraoperative endoscopic-guided fluorescein angiography29 to endoscopic cyclophotocoagulation and endoscopic selective trabecular surgery.30 Endoscopy has also been used in cataract surgery with transscleral IOL fixation,18 in which endoscopic observation of the retroiridal space during transscleral suture placement facilitates accurate haptic placement. We propose the use of endoscopy as an adjunct to teaching cataract surgery. When novice surgeons begin performing cataract surgery, they may not fully understand the dimensions and spatial relationships between intraocular structures. Endoscopy provides a unique view of these structures and can be useful in nearly every step of the procedure. Endoscopic visualization of the posterior cornea may help the beginner judge corneal thickness and therefore construct clear corneal incisions of appropriate length. Endoscopic visualization of the anterior capsule capsulorhexis that has proceeded peripherally allows the beginner to locate and redirect the edge before it continues past the lens zonules.
Surgeons who are learning phacoemulsification often misjudge the depth of the lens nucleus grooves. Novices usually do not groove deeply enough for fear of going past the lens into the posterior capsule. Without proper groove depth, it is nearly impossible to crack the lens and difficult to remove the nuclear quadrants. The endoscope can assist in this step by providing an internal perspective of lens depth. The IOL must be placed properly to prevent tilt and decentration. The endoscope can be used to determine whether the haptics are correctly placed in the capsular bag. It can also be used to find hidden lens or cortical fragments lodged in the angle or underneath the iris. These fragments are often missed during routine I/A and OVD removal and can cause prolonged postoperative inflammation. There are several disadvantages associated with the endoscope. It increases the cost of surgery, additional surgical time is used to manipulate the scope, and the incision that admits the endoscope is larger than a standard paracentesis wound. There is a learning curve associated with endoscopy. Image clarity, focus, and brightness depend on proper scope orientation, cleanliness, and proximity to the target tissue. The routine use of the endoscope for resident-performed cataract surgery is not practical due to these limitations. However, understanding the educational value of this instrument may be helpful in certain clinical situations. Recently, much attention has been given to resident education competencies. The Accreditation Council for Graduate Medical Education has mandated that
1608
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
education is challenging, and instructors need to be creative in finding ways to teach and think ‘‘outside’’ the wet-lab box. With limited choices and often limited resources, surgical instructors must be able to use the currently available tools to enhance the students’ knowledge of the eye. Surgical competence is impossible without a thorough understanding of the eye’s anatomy. We propose the use of the endoscope to augment understanding of the 3-dimensional relationships of the ocular structures that aid in learning how to manipulate these structures during surgery. We advocate including the endoscope in the armamentarium for resident education.
REFERENCES
Figure 5. A: The intraocular haptic is visualized in the ciliary sulcus. B: The misplaced haptic is repositioned in the capsular bag.
ophthalmology residency programs use objective assessment tools to evaluate residents’ competence in 6 areas of proficiency: medical knowledge, patient care, professionalism, interpersonal and communications skills, and practice- and systems-based learning. The American Board of Ophthalmology includes surgery as an additional area of competence for ophthalmology residents.31–33 Surgical
1. The Eye Diseases Prevalence Research Group. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004; 122:487–494 2. Laurell C-G, So¨derberg P, Nordh L, et al. Computer-simulated phacoemulsification. Ophthalmology 2004; 111:693–698 3. Hikichi T, Yoshida A, Igarashi S, et al. Vitreous surgery simulator. Arch Ophthalmol 2000; 118:1679–1681 4. Ross DG, Harris CA, Jones DJ. A comparison of operative experience for basic surgical trainees in 1992 and 2000. Br J Surg 2002; 89(suppl 1):60 5. Cremers SL, Ciolino JB, Ferrufino-Ponce ZK, Henderson BA. Objective assessment of skills in intraocular surgery (OASIS). Ophthalmology 2005; 112:1236–1241 6. Cremers SL, Lora AN, Ferrufino-Ponce ZK. Global rating assessment of skills in intraocular surgery (GRASIS). Ophthalmology 2005; 112:1655– 1660 7. Sinclair MJ, Peifer JW, Haleblian R, et al. Computer-simulated eye surgery: a novel teaching method for residents and practitioners. Ophthalmology 1995; 102:517–521 8. Thorpe HE. Ocular endoscopy: an instrument for the removal of intravitreous non-magnetic foreign bodies. Trans Am Acad Ophthalmol Otolaryngol 1934; 39:422–424 9. Ciardella AP, Fisher YL, Carvalho C, et al. Endoscopic vitreoretinal surgery for complicated proliferative diabetic retinopathy. Retina 2001; 21:20–27 10. Uram M. Ophthalmic laser microendoscope endophotocoagulation. Ophthalmology 1992; 99:1829–1832 11. Boscher C, Lebuisson DA, Lean JS, Nguyen-Khoa JL. Vitrectomy with endoscopy for management of retained lens fragments and/or posteriorly dislocated intraocular lens. Graefes Arch Clin Exp Ophthalmol 1998; 236:115–121 12. Moore JE, Herath GD, Sharma A. Continuous curvilinear capsulorhexis with use of an endoscope. J Cataract Refract Surg 2004; 30:960–963 13. Leon CS, Leon JA. Microendoscopic ocular surgery: a new intraoperative, diagnostic and therapeutic strategy. Part I: endoscopic equipment/methodology applied to cataract surgery with intraocular lens implantation. J Cataract Refract Surg 1991; 17:568–572 14. Leon CS, Leon JA, Rich WJ. From ‘‘blind’’ implantation to endoscopic posterior implantation: a new surgical concept. Eur J Implant Refract Surg 1992; 4:271–272 15. Leon JA, Leon CS, Aron-Rosa D, et al. Endoscopic technique for suturing posterior chamber intraocular lenses. J Cataract Refract Surg 2000; 26:644–649 16. Ju¨rgens I, Lillo J, Buil JA, Castilla M. Endoscope-assisted transscleral suture fixation of intraocular lenses. J Cataract Refract Surg 1996; 22:879–881
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006
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TECHNIQUES: USING ENDOSCOPY TO TEACH CATARACT SURGERY
17. Althaus C, Sundmacher R. Intraoperative intraocular endoscopy in transscleral suture fixation of posterior chamber lenses: consequences for suture technique, implantation procedure, and choice of PCL design. Refract Corneal Surg 1993; 9:333–339 18. Althaus C, Sundmacher R. Transscleral suture fixation of posterior chamber intraocular lenses through the ciliary sulcus: endoscopic comparison of different suture techniques. Ger J Ophthalmol 1992; 1:117–121 19. Jacobi PC, Dietlein TS, Krieglstein GK. Microendoscopic trabecular surgery in glaucoma management. Ophthalmology 1999; 106:538– 544 20. Uram M. Combined phacoemulsification, endoscopic ciliary process photocoagulation, and intraocular lens implantation in glaucoma management. Ophthalmic Surg 1995; 26:346–352 21. Uram M. Endoscopic cyclophotocoagulation in glaucoma management. Curr Opin Ophthalmol 1995; 6(2):19–29 22. Sheindlin JA, Hirose T, Hartnett ME. Ophthalmic endoscopy: applications in intraocular surgery. Int Ophthalmol Clin 1999; 39(1):237– 247 23. Eguchi S, Araie M. A new ophthalmic electronic videoendoscope system for intraocular surgery. Arch Ophthalmol 1990; 108:1778– 1781 24. Hirschowitz B. Development and application of endoscopy. Gastroenterology 1993; 104:337–342
1610
25. Gordon A. The history and development of endoscopic surgery. In: Sutton C, Diamond MP, eds, Endoscopic Surgery for Gynaecologists. London, Philadelphia, WB Saunders, 1993; 3–11 26. Leon CS, Leon JA. Microendoscopic ocular surgery: a new intraoperative, diagnostic and therapeutic strategy. II: preliminary results from the study of glaucomatous eyes. J Cataract Refract Surg 1991; 17:573–576 27. Fisher YL, Slakter JS. A disposable ophthalmic endoscopic system. Arch Ophthalmol 1994; 112:984–986 28. Eguchi S, Kohzuka T, Araie M. Stereoscopic ophthalmic microendoscope system. Arch Ophthalmol 1997; 115:1336–1338 29. Uram M. Endoscopic fluorescein angiography. Ophthalmic Surg Lasers 1996; 27:849–855 30. Jacobi P, Dietlein TS. Endoscopic surgery in glaucoma management. Curr Opin Ophthalmol 2000; 11:127–132 31. Lee AG, Carter KD. Managing the new mandate in resident education, a blueprint for translating a national mandate into local compliance. Ophthalmology 2004; 111:1807–1812 32. Lee AG, Volpe N. Impact of the new competencies on resident education in ophthalmology [editorial]. Ophthalmology 2004; 111:1269–1270 33. Mills RP, Mannis MJ. Report of the American Board of Ophthalmology Task Force on the Competencies; the American Board of Ophthalmology Program Directors’ Task Force on Competencies [editorial]. Ophthalmology 2004; 111:1267–1268
J CATARACT REFRACT SURG - VOL 32, OCTOBER 2006