The Art of Refractive Cataract Surgery (eBook)

2 Am I Ready to Become a Refractive Cataract Surgeon?–A Check-up List Before You Start

Fuxiang Zhang, Alan Sugar, and Lisa Brothers Arbisser

Abstract

This chapter briefly discusses some clinical prerequisites before a resident or a beginner starts serious engagement in refractive cataract surgery (RCS). It does not mean that each and every item in the list must be fulfilled to prepare for RCS, but the surgeon should make a full self-evaluation and careful planning to maximize the chance of success. On the other end, it also means that not everyone should be a refractive cataract surgeon.

Keywords: refractive cataract surgery, readiness for refractive cataract surgery, prerequisite

2.1 Introduction

Loaded with all the ophthalmic knowledge and surgical skills you learned from your mentors during your 3 years of ophthalmology residency, you enter a new chapter of your career. If cataract surgery is the main surgical service you choose for your practice, you will have to decide whether to engage in refractive cataract surgery (RCS). Without the ability to meet patient's increasing expectations for relative spectacle independence, one's practice may be compromised in today's competitive environment.

We expect that more and more young ophthalmologists, as well as those who have not yet had a chance to integrate RCS into their current practice, will decide to initiate RCS. The next question will be “Am I ready?” This chapter will discuss 10 checklist-like topics. You do not have to be perfectly prepared for everything before your actual engagement, but these 10 items may help you to make your decision.

1.Reasonable surgical skills with low complication rate: Making all patients happy is a challenge, and often stressful. This may be amplified for RCS patients as the extra money they pay comes with added expectations. It does not make sense to initiate this premium service if you have not even achieved an acceptable outcome with your standard surgery. No one expects a young ophthalmic surgeon to have a surgical complication rate only 10% of the national average, but young cataract surgeons should sharpen their surgical skills first, approaching the national average complication rate as a goal before starting premium services.

It is also very important to know how to fix problems intraoperatively. Complications happen to every surgeon. What makes a good surgeon stand out is not only a lower complication rate, but also the knowledge and the skill to appropriately fix problems intraoperatively and postoperatively. Until you feel comfortable on your operating room (OR) days, our advice is that you wait to start RCS. You need to be familiar with the use of different ophthalmic viscoelastic devices (OVD) for different situations, anterior vitrectomy, intraocular lens (IOL) repositioning, and IOL exchange, etc., independently without the luxury of having a supervisor.

For a cataract surgeon, it is absolutely necessary to know your phacoemulsification machine very well. Do not be shy about having the manufacturer's representative come to your OR for personal in-service tutorials. Pick a day when you do not have a fully packed schedule and have the expert technician observe all or most of your cases. After completion of all the cases, spend time to have a detailed discussion about the machine settings. It is even more important that you know how to make adjustments to the phaco machine for different settings in different situations because no phaco machine company's representative will be with you every single OR day.

No doubt there are many naturally gifted surgeons, but usually we all need continuous self-education to improve our skills. During my residency and first year of practice, I did not have access to a training simulator as do today's residents. I probably did hundreds of, if not thousands, simulated continuous curvilinear capsulorhexis (CCC) with my personal loupes and foil paper at home since that was the most challenging step for my cataract surgery at the time. I also religiously reviewed hundreds of my own routine surgical videos in my first postgraduate year. Watching my own videos helped me greatly in identifying subtle issues and improving my surgical skill.

2.Proficiency with LRI and toric IOLs: It is premature to start to insert extended depth of focus (EDOF), multifocal IOLs (MFIOLs), and trifocal IOLs before you feel comfortable with manual limbal relaxing incisions (LRI) and toric IOLs. We have watched some of our colleagues give up RCS permanently after a few attempts due to their inability to fix astigmatism. EDOF IOLs such as the Tecnis Symfony (Johnson & Johnson) are believed to be more forgiving in terms of residual astigmatism, but we would recommend that you approach it in the same way as you would an MFIOL and trifocal IOL. Do not rely on forgiveness to result in a happy patient. Our recommendation is to start by performing IOL monovision with manual LRI and/or a toric IOL. Pseudophakic monovision, especially mini-monovision and moderate monovision, provides great vision quality, and patients do not have to pay as much as for premium IOLs, so the expectation is tempered due to the lower cost. You will not have great clinical outcomes from IOL monovision if you do not know how to fix astigmatism with all modalities: realistic and informative preoperative consultation, reliable biometry, and solid surgical skills.

3.Familiarity with modern IOL formulas and online calculators: Accuracy and precision are the core of modern RCS. The IOL power and the axis of a toric IOL are calculated with IOL formulas. With this said, we know how critical it is to use the most accurate advanced IOL formulas. We did not understand the posterior corneal astigmatism until the much-appreciated study done by Douglas Koch and his colleagues in 2011. If you ignore these important factors, or if you are not familiar with the limitations of the most commonly used IOL formulas, you cannot expect to get satisfactory outcomes from RCS. Such peer-reviewed studies typically provide good guidelines.

4.Familiarity with different IOL options: There should be an ongoing accumulation of knowledge and experience, though not necessarily an absolute requisite. It will be very helpful if you already have a good grasp of the big picture at the very beginning. As we will discuss in Chapter 8, IOL monovision can be a starting point for RCS. However, IOL monovision is not and should not be the only option. In the spectrum of RCS, beginners should be knowledgeable about the existence of other options. What can we expect from Crystalens, EDOF, MFIOL, trifocals, and light adjustable lens? What are the pros and cons for each of them? What are the relative contraindications we should avoid?

5.Reasonable basic consultation skill: As suggested by the name of this book, The Art of Refractive Cataract Surgery, RCS is a combination of science and art. The purpose of RCS is to improve uncorrected near, intermediate distance, and far distance vision to make the patient happy. Unfortunately, happiness is a rather subjective psychological and mental state. You should never underestimate the importance of preoperative consultation and postoperative comprehensive management. These skills are enhanced by cumulative experience in practice.

A key component is to complete a thorough preoperative history and examination, on which to base a professional and honest consultation. The rationale for a thorough history and eye examination prior to decision-making is to reveal any hidden, but important, ocular comorbidities in order to educate patients about the possible limitations. This kind of observation and discussion does not help as much if it is done postoperatively without preoperative discussion. Focus on each individual preference, rather than the pure spectacle independence rate. Because we truly have no perfect option to restore vision to youthful perfection, the one thing we should never forget is the principle of “under promise and over deliver.” Pursuing only a high rate of conversion to premium IOLs rather than patient satisfaction is not advisable or ethical.

6.Passing your board examination: The details of RCS are specific but general ophthalmic knowledge is critical to the safe diagnosis and treatment of every patient. We are not necessarily saying you should ignore RCS before you pass your ophthalmology board exam, but it probably does not make much sense to spend lots of time and energy on this premium service at the time when you are still dealing with all the challenges of your board certification tests. Basically, you should at least feel pretty comfortable for the board test before you concentrate on RCS.

7.A smoothly run office: It is reasonable to say that there are three fundamental bases for a surgeon: home, office and OR. Each base should be appropriately sound and well run. Otherwise, it is hard to offer premium RCS as this will undoubtedly add more challenges and stress.

You must have a smoothly run office with a high patient satisfaction rate and relatively busy volume. Knowledge is the core of practice for a good physician. Continuous education and self-motivated learning will help us stay knowledgeable and competent.

Do not underestimate the importance of office appearance. The overall setting should be clean and neat. Patients should feel comfortable in your waiting room as well as in your examination lane. The appearance of your office is as vital as the appearance of your face, your hair, and your choice of clothing each morning...