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Effect of atmospheric pressure on radial keratotomy: Reply
LETTERS
5. Mader TH, White LJ. Refractive changes at extreme altitude after radial keratotomy. Am J Ophthalmol 1995; 119:733–737 6. Ng JD, White LJ, Parmley VC, et al. Effects of simulated high altitude on patients who have had radial keratotomy. Ophthalmology 1996; 103:452– 454 7. Mader TH, Blanton CL, Gilbert BN, et al. Refractive changes during 72-hour exposure to high altitude after refractive surgery. Ophthalmology 1996; 103:1188 –1195
Reply: We appreciate the opportunity to address the comments of Drs. Yas¸ar and S¸ims¸ek. They are correct in noting that their article was in press in the Japanese Journal of Ophthalmology at the time our article was published. Had we been aware of their article, we would have referenced it. All RK patients in this study had bilateral surgery. The data in Table 2 reflect the 4 eyes of the 2 patients. Eyes 1 and 2 are the right and left eyes of patient 1, and eyes 3 and 4 are the right and left eyes of patient 2. While we felt this was implied, it could have been stated more directly. Our studies were performed 1 year after RK surgery precisely to allow these eyes to heal prior to testing. As stated in the discussion, this article sought to demonstrate that patients who had RK could tolerate the increased atmospheric pressure associated with recreational scuba diving without suffering a temporary change in their visual acuity. This is not the case in skiing or mountaineering at high altitudes in which concomitant hypoxic conditions lead to temporary hyperopic visual disturbances.—N. Timothy Peters, MD
III stage includes surgery under sub-Tenon’s and topical anesthesia using both rigid and foldable intraocular lenses (IOLs). This does not allow one to determine how many of their patients actually received a “state-of-theart” operation, which we would define as surgery under topical anesthesia using a foldable lens in a routine case. Their report follows the mold of earlier papers2– 4 that address the issue of phacoemulsification training for surgeons with some prior exposure to ECCE. With phacoemulsification becoming the preferred method of cataract extraction and a large number of surgeons no longer using ECCE,7 it is increasingly impractical for teaching units to impart experience in ECCE. Patients expect a state-of-the-art operation, and it is not appropriate to perform ECCE merely for training purposes. The time has come for a quantum change in surgical teaching. Experience in ECCE should no longer be seen as a prerequisite to beginning phacoemulsification training. It is already the practice in our units (and others) for trainees to commence phacoemulsification training without previous ECCE experience. We look forward to reports that establish the safety of learning phacoemulsification de novo. SOMDUTT PRASAD, MS, FRCSED Sheffield, United Kingdom
Phacoemulsification Performed by Residents
W
e commend Badoza and coauthors on their paper describing the results of their residency training program for advanced phacoemulsification, including the use of chopping techniques and topical anesthesia.1 It is interesting that the vitreous loss rates in cataract surgery in this and similar earlier reports2– 4 describing a learning-curve scenario are lower than those reported by a national survey.5 This should help relieve anxiety for trainers and trainees and the patients who have surgery within a training program. We would like to comment on some aspects of their report. In their ECCE II stage, they use a capsulorhexis but proceed to cut it in 3 places before nucleus expression. Capsulorhexis is fully compatible with extracapsular cataract extraction (ECCE), and with proper technique, these cuts are unnecessary.6 We think that every effort should be made to preserve the benefits of an intact capsulorhexis in all cataract surgery. Their Phaco 794
GIRISH G. KAMATH, MS, DNB, FRCOPHTH, FRCSED Wirral, United Kingdom
References 1. Badoza DA, Jure T, Zunino LA, Argento CJ. State-of-the-art phacoemulsification performed by residents in Buenos Aires, Argentina. J Cataract Refract Surg 1999; 25:1651–1655 2. Prasad S. Phacoemulsification learning curve: Experience of two junior trainee ophthalmologists. J Cataract Refract Surg 1998; 24:73–77 3. Cruz OA, Wallace GW, Gay CA, et al. Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. Ophthalmology 1992; 99:448 – 452 4. Smith JH, Seiff SR. Outcomes of cataract surgery by residents at a public county hospital. Am J Ophthalmol 1997; 123:448 – 454 5. Desai P, Minassian DC, Reidy A. National Cataract Surgery Survey 1997–1978: a report of the results of the clinical outcome. Br J Ophthalmol 1999; 83:1336 –1340 6. Pande M. Continuous curvilinear (circular) capsulorhexis and planned extracapsular cataract extraction—are they compatible? Br J Ophthalmol 1993; 77:152–157 7. Leaming DV. Practice styles and preferences of ASCRS members—1998 survey. J Cataract Refract Surg 1999; 25:851– 859
Reply: We appreciate the comments of Drs. Prasad and Kamath about our article. The need to teach residents the
J CATARACT REFRACT SURG—VOL 26, JUNE 2000
5. Mader TH, White LJ. Refractive changes at extreme altitude after radial keratotomy. Am J Ophthalmol 1995; 119:733–737 6. Ng JD, White LJ, Parmley VC, et al. Effects of simulated high altitude on patients who have had radial keratotomy. Ophthalmology 1996; 103:452– 454 7. Mader TH, Blanton CL, Gilbert BN, et al. Refractive changes during 72-hour exposure to high altitude after refractive surgery. Ophthalmology 1996; 103:1188 –1195
Reply: We appreciate the opportunity to address the comments of Drs. Yas¸ar and S¸ims¸ek. They are correct in noting that their article was in press in the Japanese Journal of Ophthalmology at the time our article was published. Had we been aware of their article, we would have referenced it. All RK patients in this study had bilateral surgery. The data in Table 2 reflect the 4 eyes of the 2 patients. Eyes 1 and 2 are the right and left eyes of patient 1, and eyes 3 and 4 are the right and left eyes of patient 2. While we felt this was implied, it could have been stated more directly. Our studies were performed 1 year after RK surgery precisely to allow these eyes to heal prior to testing. As stated in the discussion, this article sought to demonstrate that patients who had RK could tolerate the increased atmospheric pressure associated with recreational scuba diving without suffering a temporary change in their visual acuity. This is not the case in skiing or mountaineering at high altitudes in which concomitant hypoxic conditions lead to temporary hyperopic visual disturbances.—N. Timothy Peters, MD
III stage includes surgery under sub-Tenon’s and topical anesthesia using both rigid and foldable intraocular lenses (IOLs). This does not allow one to determine how many of their patients actually received a “state-of-theart” operation, which we would define as surgery under topical anesthesia using a foldable lens in a routine case. Their report follows the mold of earlier papers2– 4 that address the issue of phacoemulsification training for surgeons with some prior exposure to ECCE. With phacoemulsification becoming the preferred method of cataract extraction and a large number of surgeons no longer using ECCE,7 it is increasingly impractical for teaching units to impart experience in ECCE. Patients expect a state-of-the-art operation, and it is not appropriate to perform ECCE merely for training purposes. The time has come for a quantum change in surgical teaching. Experience in ECCE should no longer be seen as a prerequisite to beginning phacoemulsification training. It is already the practice in our units (and others) for trainees to commence phacoemulsification training without previous ECCE experience. We look forward to reports that establish the safety of learning phacoemulsification de novo. SOMDUTT PRASAD, MS, FRCSED Sheffield, United Kingdom
Phacoemulsification Performed by Residents
W
e commend Badoza and coauthors on their paper describing the results of their residency training program for advanced phacoemulsification, including the use of chopping techniques and topical anesthesia.1 It is interesting that the vitreous loss rates in cataract surgery in this and similar earlier reports2– 4 describing a learning-curve scenario are lower than those reported by a national survey.5 This should help relieve anxiety for trainers and trainees and the patients who have surgery within a training program. We would like to comment on some aspects of their report. In their ECCE II stage, they use a capsulorhexis but proceed to cut it in 3 places before nucleus expression. Capsulorhexis is fully compatible with extracapsular cataract extraction (ECCE), and with proper technique, these cuts are unnecessary.6 We think that every effort should be made to preserve the benefits of an intact capsulorhexis in all cataract surgery. Their Phaco 794
GIRISH G. KAMATH, MS, DNB, FRCOPHTH, FRCSED Wirral, United Kingdom
References 1. Badoza DA, Jure T, Zunino LA, Argento CJ. State-of-the-art phacoemulsification performed by residents in Buenos Aires, Argentina. J Cataract Refract Surg 1999; 25:1651–1655 2. Prasad S. Phacoemulsification learning curve: Experience of two junior trainee ophthalmologists. J Cataract Refract Surg 1998; 24:73–77 3. Cruz OA, Wallace GW, Gay CA, et al. Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. Ophthalmology 1992; 99:448 – 452 4. Smith JH, Seiff SR. Outcomes of cataract surgery by residents at a public county hospital. Am J Ophthalmol 1997; 123:448 – 454 5. Desai P, Minassian DC, Reidy A. National Cataract Surgery Survey 1997–1978: a report of the results of the clinical outcome. Br J Ophthalmol 1999; 83:1336 –1340 6. Pande M. Continuous curvilinear (circular) capsulorhexis and planned extracapsular cataract extraction—are they compatible? Br J Ophthalmol 1993; 77:152–157 7. Leaming DV. Practice styles and preferences of ASCRS members—1998 survey. J Cataract Refract Surg 1999; 25:851– 859
Reply: We appreciate the comments of Drs. Prasad and Kamath about our article. The need to teach residents the
J CATARACT REFRACT SURG—VOL 26, JUNE 2000