• Learning Surgery During a Pandemic: How to Make the Most of Training

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    Glaucoma surgery (Photo Credit: Roger Barone/Wills Eye Hospital)

    How can you develop the level of surgical skill you want—and your patients deserve—when an ongoing pandemic has reduced the hours of hands-on practice your institution provides? One key is to get the most you can out of each procedure you witness or try. In this article, I’ll show you how pre- and post-surgery group rounds can help you maximize your surgical training.

    During my time as a residency program director and attending physician in the Veterans Health Administration, I found these group rounds invaluable—particularly in the case of cataract surgery, the linchpin of ophthalmic resident surgical training. Whether or not residents operated, these rounds ensured all residents had a chance to learn from every case performed.

    I recommend you consolidate surgical planning onto one sheet for each case, making it available in the OR for each surgery. This helps organize the trainees’ surgical preparation and minimizes the potential for error once in the operating room.

    1. Demographic and general medical information

    The first third of the group round should review general details relevant to the type of surgery. The following example lists some common areas of attention to ensure a safe cataract surgery. Such conditions commonly affect a range of aspects relevant to surgical flow. These include:

    • Comfort with eye drapes;
    • Difficult surgical positioning;
    • Intra-operative floppy iris; and
    • Use of certain antibiotics.

    In addition, the patient’s age can sometimes help you anticipate density of lens changes. For example:

    • Younger patients may be more apprehensive peri-operatively, lowering the threshold for use of mild anxiolytics during surgery.
    • Mature lenses may beget higher levels of anesthesia, such as a local block and use of extracapsular cataract extraction

    Demographic

    Identifier Confirmation

    Relevant Medical Conditions

    Medications

    Allergies

        

     

    Name

    Anxiety

    Tamsulosin

    NSAIDs

     

     

    Age

    COPD

    Coumadin

    Penicillin

     

     

    Date of Birth

    BPH

     

     

     

     

    Surgical Site

    Kyphosis

     

     

     

     

     

    Atrial fibrillation

     

     

     

     

    2. Ophthalmologic exam

    The second third of the round focuses on the surgical site itself and relevant details of the fellow eye’s status.

    • In the fictitious scenario below, treating the left eye with a target of emmetropia will induce severe anisometropia. The surgeon will have to discuss this with the patient well before surgery.
    • The presence of glaucoma could dictate use of peri-operative medications to ward off acute post-operative elevation of intraocular eye pressure.
    • The presence of retinopathy could dictate the use of topical NSAIDs.
    • Other co-morbidities like corneal endothelial disease or trauma warrant their own extra attention and drive different surgical planning (e.g., dispersive viscoelastic or soft-shell technique, scleral tunnel, capsular tension rings, etc.).
    • A history of pars plana vitrectomy clearly affects chamber mechanics during surgery.

     

    Acuity

    MRx

    Cataract Type

    Glaucoma

    Retinopathy/ Corneal Disease

    OD

    20/20

    -7.0 sphere

    Minimal NSC

    Y

    N

    OS

    20/400

    -9.0 sphere

    4+ PSC

    Y

    Post PPV for RD

     

    3. Biometric device output

    The final third of the round confirms patient identifiers and the operative site and reviews biometric markers and refractive goals. This should include the choice of intraocular lens.

    Make sure to confirm the chosen biometric formula. You should review it from top to bottom, with attention to the following:

     

    Biometric Marker

     

     

    AL

    >26mm

    ●        Consider formula choices.

    ●        Anticipate working in deep eye and needing more viscoelastic and an intra-operative pupillary block.

    <22mm

    ●        Consider formula choice.

    ●        Anticipate a very shallow eye.

    Ks

    Plan incision location and IOL choice if you deem the astigmatism clinically significant.

    Consider role of toric IOLs or astigmatic keratotomy for significant regular astigmatism.

    WTW

    Infer eye and sulcus anatomy if you anticipate any sulcus position for the IOL used.

     

    LT

    >6mm

    Consider extra depth needed if disassembling any portion of lens with sculpting.

     

    ACD

    <3.0 mm

    Consider implications of working in a very shallow space to avoid corneal damage: e.g., dispersive viscoelastic and short keratome wound.

     

     

    Postop

    Recorded cases are reviewed in a group to discuss phaco settings, choice of instrumentation surgical technique and complication avoidance. This allows for the maximizing of each case for the entire group of residents. Seeing cases and decisions being made in real time allows new surgeons to place themselves in real situations with real consequences without having to enter the OR.

    Initial lectures with residents cover standard cases but increase in complexity to gradually integrate scenarios like post-corneal refractive surgery cases and discussion of toric and premium IOL discussion. Other areas of complexity also elevate the group dialogue.

    Generally, I have found that over about four sessions, residents solidify their grasp of the nuances of how each case should be approached. By preparing methodically, each resident shows improved performance and usually has a shorter learning curve.

    Although I implemented this method before the pandemic, the current stresses on resident education have made it a more powerful educational tool than ever before.

    About the author: Hoon Jung, MD, is an assistant ophthalmology professor at Eastern Virginia Medical School.