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Cataract surgery evaluation tool
LETTERS
fact, Little et al. provided a sequence of figures demonstrating the application and efficacy of their technique with the capsulorrhexis torn in the area of zonule attachments. Our common experience is that the technique works perfectly in a safe, controlled, and predictable way every time it has been adopted. It is therefore routinely taught to our trainees, who almost immediately feel comfortable with it. It is of note that Coelho et al. described their technique as “an aggressive movement . . . to be performed by experienced surgeons,” and we wonder whether they would feel comfortable adopting their aggressive technique in cases of shallow anterior chamber and weak zonular fibers, which are among the ocular conditions that they identified as predisposing to capsulorrhexis tear-out. We also challenge the authors to agree that this complication is always the result of the surgeon's mistake, such as letting the anterior chamber collapse during the flap creation, choosing the wrong ophthalmic viscosurgical device (OVD), or making a purely manual error. It is even more obviously the surgeon's mistake to proceed with maneuvering the capsule flap until the tear reaches the area of anterior zonule attachments. Finally, when rescuing a capsulorrhexis, it is essential not only to deepen the anterior chamber but also to ensure that the chamber remains deep during further flap manipulation, preferring the adoption of a cohesive OVD. Gianluca Carifi, MD London, United Kingdom Bruno Zuberbuhler, PhD Manchester, United Kingdom
REFERENCES 1. Coelho RP, Paula JS, Neto JMR, Messias AMV. Capsulorhexis rescue after peripheral radial tear-out: quick-pull technique. J Cataract Refract Surg 2012; 38:737–738 2. Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg 2006; 32:1420–1422
Reply : We disagree with the comments of Drs. Carifi and Zuberbuhler that tear-out is always the result of a surgeon's mistake, but we believe it is a common complication during the learning curve of phacoemulsification. According to Dooley et al.,1 capsulorrhexis is subjectively one of the most difficult stages of cataract surgery and has the lowest completion rate in the hands of trainee surgeons. The main difference between Little et al.’s2 technique and our quick-pull technique is that the initial pull is circumferentially backward in the former and forward in our technique. According to Little
1875
et al., the other point to consider in the event the capsule will not tear easily is that a rescue maneuver should be abandoned to avoid a wrap-around capsule tear. We suggest that after the technique of Little et al. fails, the quick-pull technique should be considered. Finally, we believe that the technique described by Little et al. is most commonly used in practice because the tear-out is fortunately identified before the capsulorrhexis root reaches the extreme periphery. However, if the root stops at the zonular fibrils, this technique may not allow the surgeon to return to the curvilinear path and at this point, rescue can be attempted through redirection to the desired circumferential path using quick traction.dRoberto Pinto Coelho, MD, PhD, Jayter S. Paula, MD, PhD, Jose M. Neto, MD, Andre M. Messias, MD, PhD REFERENCES 1. Dooley IJ, O’Brien PD. Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg 2006; 32:604–608 2. Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg 2006; 32:1420–1422
Cataract surgery evaluation tool In their recent article, Smith et al.1 described a method to quantitatively assess the capsulorrhexis portion of cataract surgery performed by residents. The study inspired us to look for further investigations and to plan new studies for validating other steps of cataract surgery. We would like to delve further into some features of this study. In our opinion, in the first evaluation tool, questions 2 (instrument handling), 7 (number of times a forceps was removed from the eye), and 8 (number of times an ophthalmic viscosurgical device [OVD] was injected) are valuable questions. Their validities should be evaluated with further investigations in which the number of cases and reviewers are increased. Instrument handling could be used as a question in the overall evaluation of surgery rather than in the capsulorrhexis step. The number of times a forceps was removed from the eye is an important factor that indicates the experience and confidence of the surgeon. Although there was no removal of inserted forceps in Smith et al.’s cases, most beginner surgeons frequently remove the forceps one or more times during capsulorrhexis. This situation can also be rarely observed even in the surgeries of veteran surgeons. Because the frequency of forceps’ removal is correlated with the surgeon’s experience, it can be used as an important indicator in evaluating the performance of cataract surgery.
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
1876
LETTERS
The number of times an OVD was injected is also a valuable question that reflects the experience and mastery of the surgeon. As Smith et al. mentioned in the article, if the cystotome tip was on the OVD syringe, the OVD could easily be instilled or reinstilled without removing the tip. Considering that many surgeons in the world would use a cystotome separately, this step of the study could be reevaluated using a cystotome without an OVD syringe. Another possibility is to include or exclude this question in the evaluation tool in accordance with the type of syringe that is attached to the cystotome. Although it is not possible to evaluate verbal intervention of the attending surgeon by raters on video records, after validating a standard tool, it may be possible to add whether there was verbal intervention and the level of verbal intervention by the attending surgeon as another question in the scale. As Smith et al. mentioned, to establish a basis for evaluating videos independently, exemplifying specific grades for each question would be efficacious and it would also be possible for surgeons to share their records with the authors or other surgeons investigating this method. Ertu grul Can, MD Samsun, Turkey € Pelin Ozyol, MD Ordu, Turkey REFERENCE 1. Smith RJ, McCannel CA, Gordon LK, Hollander DA, Giaconi JA, Stelzner SK, Devgan U, Bartlett J, Mondino BJ. Evaluating teaching methods of cataract surgery: validation of an evaluation tool for assessing surgical technique of capsulorhexis. J Cataract Refract Surg 2012; 38:799–806
€ Reply : We agree with Drs. Can and Ozyol and are delighted that our paper has spurred interest to more precisely and accurately measure surgical technique and help advance evidence-based surgical training. We invite all those who are involved in teaching surgical technique to use any questions from our evaluation tool that would be most suited to their training environment along with the best questions from our study. We found that the reliability and accuracy of the measurements appear to depend on the form and content of the question. The 4 most accurate and reliable questions in our study were visual Likert scale questions. In our article, in addition to describing the best questions based on association with surgical training level and lowest interobserver variability, we also discussed the problems with each question and insights toward improving questions
to obtain more accurate and reliable measurements of surgical technique. Evaluation question 2, which asks the grader to evaluate instrument handling on a visual Likert scale from 1 to 5, was associated with surgical training level (PZ.049); however, the question had slightly more interobserver variability than the best questions, and with an intraclass correlation coefficient of 0.71, it missed the criteria of 0.75 for the best questions in our study. Questions 7 and 8, as was pointed out, were designed to measure multiple unnecessary reinsertions of instruments into the eye. We have also observed multiple reinsertions in some cases of novice surgeons, but multiple reinsertions were not present in any of the 4 resident cases in our study. Perhaps with a larger study size or in a different setting, these questions may prove valuable. We appreciate Drs. € Can and Ozyol's suggestion to study audio as well as video recording of surgery in the future. Voices could be electronically masked to allow the audio and video to be masked for grading. Analysis of audio recording may identify useful verbal cues for attending surgery. Use of the questions from our study in different centers and with larger numbers of residents and larger numbers of cases will further establish the validity of the evaluation measurements. We believe that validated evaluation tools could provide prompt specific feedback to trainees and could be applied before and after teaching interventions to identify the most effective interventions. Ophthalmology is at the cusp of bringing science to the art of surgical training, and advancing the field of evidence-based training will improve our residents’ surgical skill and patient outcomes.dRonald J. Smith, MD, Colin A. McCannel, MD, Lynn K. Gordon, MD, PhD, David A. Hollander, MD, JoAnn A. Giaconi, MD, Sadiqa K. Stelzner, MD, Uday Devgan, MD, John Bartlett, MD, Bartly J. Mondino, MD
Complications related to the explantation of cosmetic iris implants The article by Hoguet et al.1 questions the safety of NewColorIris cosmetic iris implants (Kahn Medical Devices), as they have been found to cause uveitisglaucoma-hyphema (UGH) syndrome and corneal decompensation owing to their lack of sizing and flawed design. While Hoguet et al.’s series is the largest from a single institution, we would like to note 2 other articles reporting NewColorIris implantrelated complications that were not available before publication of their article.2,3 These articles describe a similar clinical course and treatment outcome, validating Hoguet et al.’s observations.
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
fact, Little et al. provided a sequence of figures demonstrating the application and efficacy of their technique with the capsulorrhexis torn in the area of zonule attachments. Our common experience is that the technique works perfectly in a safe, controlled, and predictable way every time it has been adopted. It is therefore routinely taught to our trainees, who almost immediately feel comfortable with it. It is of note that Coelho et al. described their technique as “an aggressive movement . . . to be performed by experienced surgeons,” and we wonder whether they would feel comfortable adopting their aggressive technique in cases of shallow anterior chamber and weak zonular fibers, which are among the ocular conditions that they identified as predisposing to capsulorrhexis tear-out. We also challenge the authors to agree that this complication is always the result of the surgeon's mistake, such as letting the anterior chamber collapse during the flap creation, choosing the wrong ophthalmic viscosurgical device (OVD), or making a purely manual error. It is even more obviously the surgeon's mistake to proceed with maneuvering the capsule flap until the tear reaches the area of anterior zonule attachments. Finally, when rescuing a capsulorrhexis, it is essential not only to deepen the anterior chamber but also to ensure that the chamber remains deep during further flap manipulation, preferring the adoption of a cohesive OVD. Gianluca Carifi, MD London, United Kingdom Bruno Zuberbuhler, PhD Manchester, United Kingdom
REFERENCES 1. Coelho RP, Paula JS, Neto JMR, Messias AMV. Capsulorhexis rescue after peripheral radial tear-out: quick-pull technique. J Cataract Refract Surg 2012; 38:737–738 2. Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg 2006; 32:1420–1422
Reply : We disagree with the comments of Drs. Carifi and Zuberbuhler that tear-out is always the result of a surgeon's mistake, but we believe it is a common complication during the learning curve of phacoemulsification. According to Dooley et al.,1 capsulorrhexis is subjectively one of the most difficult stages of cataract surgery and has the lowest completion rate in the hands of trainee surgeons. The main difference between Little et al.’s2 technique and our quick-pull technique is that the initial pull is circumferentially backward in the former and forward in our technique. According to Little
1875
et al., the other point to consider in the event the capsule will not tear easily is that a rescue maneuver should be abandoned to avoid a wrap-around capsule tear. We suggest that after the technique of Little et al. fails, the quick-pull technique should be considered. Finally, we believe that the technique described by Little et al. is most commonly used in practice because the tear-out is fortunately identified before the capsulorrhexis root reaches the extreme periphery. However, if the root stops at the zonular fibrils, this technique may not allow the surgeon to return to the curvilinear path and at this point, rescue can be attempted through redirection to the desired circumferential path using quick traction.dRoberto Pinto Coelho, MD, PhD, Jayter S. Paula, MD, PhD, Jose M. Neto, MD, Andre M. Messias, MD, PhD REFERENCES 1. Dooley IJ, O’Brien PD. Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg 2006; 32:604–608 2. Little BC, Smith JH, Packer M. Little capsulorhexis tear-out rescue. J Cataract Refract Surg 2006; 32:1420–1422
Cataract surgery evaluation tool In their recent article, Smith et al.1 described a method to quantitatively assess the capsulorrhexis portion of cataract surgery performed by residents. The study inspired us to look for further investigations and to plan new studies for validating other steps of cataract surgery. We would like to delve further into some features of this study. In our opinion, in the first evaluation tool, questions 2 (instrument handling), 7 (number of times a forceps was removed from the eye), and 8 (number of times an ophthalmic viscosurgical device [OVD] was injected) are valuable questions. Their validities should be evaluated with further investigations in which the number of cases and reviewers are increased. Instrument handling could be used as a question in the overall evaluation of surgery rather than in the capsulorrhexis step. The number of times a forceps was removed from the eye is an important factor that indicates the experience and confidence of the surgeon. Although there was no removal of inserted forceps in Smith et al.’s cases, most beginner surgeons frequently remove the forceps one or more times during capsulorrhexis. This situation can also be rarely observed even in the surgeries of veteran surgeons. Because the frequency of forceps’ removal is correlated with the surgeon’s experience, it can be used as an important indicator in evaluating the performance of cataract surgery.
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012
1876
LETTERS
The number of times an OVD was injected is also a valuable question that reflects the experience and mastery of the surgeon. As Smith et al. mentioned in the article, if the cystotome tip was on the OVD syringe, the OVD could easily be instilled or reinstilled without removing the tip. Considering that many surgeons in the world would use a cystotome separately, this step of the study could be reevaluated using a cystotome without an OVD syringe. Another possibility is to include or exclude this question in the evaluation tool in accordance with the type of syringe that is attached to the cystotome. Although it is not possible to evaluate verbal intervention of the attending surgeon by raters on video records, after validating a standard tool, it may be possible to add whether there was verbal intervention and the level of verbal intervention by the attending surgeon as another question in the scale. As Smith et al. mentioned, to establish a basis for evaluating videos independently, exemplifying specific grades for each question would be efficacious and it would also be possible for surgeons to share their records with the authors or other surgeons investigating this method. Ertu grul Can, MD Samsun, Turkey € Pelin Ozyol, MD Ordu, Turkey REFERENCE 1. Smith RJ, McCannel CA, Gordon LK, Hollander DA, Giaconi JA, Stelzner SK, Devgan U, Bartlett J, Mondino BJ. Evaluating teaching methods of cataract surgery: validation of an evaluation tool for assessing surgical technique of capsulorhexis. J Cataract Refract Surg 2012; 38:799–806
€ Reply : We agree with Drs. Can and Ozyol and are delighted that our paper has spurred interest to more precisely and accurately measure surgical technique and help advance evidence-based surgical training. We invite all those who are involved in teaching surgical technique to use any questions from our evaluation tool that would be most suited to their training environment along with the best questions from our study. We found that the reliability and accuracy of the measurements appear to depend on the form and content of the question. The 4 most accurate and reliable questions in our study were visual Likert scale questions. In our article, in addition to describing the best questions based on association with surgical training level and lowest interobserver variability, we also discussed the problems with each question and insights toward improving questions
to obtain more accurate and reliable measurements of surgical technique. Evaluation question 2, which asks the grader to evaluate instrument handling on a visual Likert scale from 1 to 5, was associated with surgical training level (PZ.049); however, the question had slightly more interobserver variability than the best questions, and with an intraclass correlation coefficient of 0.71, it missed the criteria of 0.75 for the best questions in our study. Questions 7 and 8, as was pointed out, were designed to measure multiple unnecessary reinsertions of instruments into the eye. We have also observed multiple reinsertions in some cases of novice surgeons, but multiple reinsertions were not present in any of the 4 resident cases in our study. Perhaps with a larger study size or in a different setting, these questions may prove valuable. We appreciate Drs. € Can and Ozyol's suggestion to study audio as well as video recording of surgery in the future. Voices could be electronically masked to allow the audio and video to be masked for grading. Analysis of audio recording may identify useful verbal cues for attending surgery. Use of the questions from our study in different centers and with larger numbers of residents and larger numbers of cases will further establish the validity of the evaluation measurements. We believe that validated evaluation tools could provide prompt specific feedback to trainees and could be applied before and after teaching interventions to identify the most effective interventions. Ophthalmology is at the cusp of bringing science to the art of surgical training, and advancing the field of evidence-based training will improve our residents’ surgical skill and patient outcomes.dRonald J. Smith, MD, Colin A. McCannel, MD, Lynn K. Gordon, MD, PhD, David A. Hollander, MD, JoAnn A. Giaconi, MD, Sadiqa K. Stelzner, MD, Uday Devgan, MD, John Bartlett, MD, Bartly J. Mondino, MD
Complications related to the explantation of cosmetic iris implants The article by Hoguet et al.1 questions the safety of NewColorIris cosmetic iris implants (Kahn Medical Devices), as they have been found to cause uveitisglaucoma-hyphema (UGH) syndrome and corneal decompensation owing to their lack of sizing and flawed design. While Hoguet et al.’s series is the largest from a single institution, we would like to note 2 other articles reporting NewColorIris implantrelated complications that were not available before publication of their article.2,3 These articles describe a similar clinical course and treatment outcome, validating Hoguet et al.’s observations.
J CATARACT REFRACT SURG - VOL 38, OCTOBER 2012