Joshua Ki Hu

Vanderbilt Eye Institute

Ophthalmology, PGY-4

DATE 05.30.08

Vanderbilt Eye Institute

Introduction

Cataract surgery is one of the most commonly performed surgeries in the world, with over 1 million performed per year in the United States alone.

Resident education designed accordingly.

In 2002 a resident survey revealed that:

- the number of phacoemulsification procedures performed by a single resident ranged from 50 to 300

- the majority perform between 80 and 140 (avg. 120)

- 25% performed less than 80

In 2007, the Residency Review Committee of the ACGME increased the minimum number of resident performed phacoemulsification procedures from 45 to 86.

Few studies to date attempt to identify time point/case number for significant improvement in resident performed surgery.

The aim of this study is to identify a time point/case number for which a significant decline in complication rates occurs.

Also as a measure of internal “quality” of Vanderbilt’s residency program.

Are patients being subjected to an acceptable level of complications in the early parts of training?

Materials and Methods

Retrospective chart review

VA Hospitals, Nashville, TN, charts from patients who had undergone resident performed phacoemulsification during a 6 year period from July 8, 1999, through June 28, 2005 were reviewed.

The surgical cases were categorized based on the resident surgeon performing the cataract surgery, and then sorted chronologically and given a sequential case number.

The total number of intraoperative complications including posterior capsular tear, vitreous loss, and retained lens fragments were recorded, as well as the case numbers for which they occurred.

The study was powered at 80% with statistical significance set at p = 0.05 to detect a 50% change in complication frequency (estimated to be 15%)

Sample size = 304

The cases were divided into groups spanning every 20 procedures

Statistical analysis was performed

- using chi square analysis

- calculating 95% confidence intervals

Results

19 resident surgeons

Under guidance 23 different attending surgeons

99.4% cases performed on males

51.6% Right eyes, 48.4% Left eyes

Number of Cases Sorted by Resident Surgeon

N = 1442Mean: 76Range: 58 - 115

Overall Complication Rate

Rate of Posterior Capsular Tear vs. Surgical Case Number

Rate of Posterior Capsular Tear vs. Surgical Case Number

p = 0.0710

p = 0.0244

Rate of Vitreous Loss vs. Surgical Case Number

Rate of Vitreous Loss vs. Surgical Case Number

p = 0.0386

Conclusions

There is a statistically significant decrease in intraoperative complications in resident performed phacoemulsification cataract surgery once the surgeon has performed 80 procedures.61-80 for Posterior Capsular Tears41-60 for Vitreous Loss

The results of this study are in line with the ACGME recommendation to increase minimum amount of phacoemulsification procedures from 45 to 86.

There was also a trend of continued reduction in intraoperative complication rates with increasing surgical experience.

Resident Teaching Institution

Number of

Cases

Posterior Capsular

Tear

Vitreous Loss

Retained Lens Fragment

Vanderbilt University 1442 11.2% 8.2% 0.7%

Emory University 680 4.9% 3.4% 0.4%

New Jersey Medical School 719 6.7% 5.4% 1.0%

University of California – San Francisco

218 - 8.7% -

Penn State College of Medicine

332 - 4.8% -

Baylor College of Medicine 181 9.9% 5.5% -

University of Chicago 343 - 4.7% -

University of Arizona 136 - 14.7% -

University of Utah 396 - 1.8% -

Royal Eye Infirmary, England 102 5.8% 2.9% -

Istanbul/Akdeniz University, Turkey

296 10.5% 6.4% 2.4%

Overall, phacoemulsification complication rate 3-4%

Resident performed cataract surgery complication rate has been deemed “acceptably low”

What about the early cases?

Roll of adjunctive surgical learning tools

Limitations

Case series subject to limitations of retrospective study.

Accuracy of medical record?

The data included only those procedures performed at the VA Hospital.

Acknowledgements

Dr. Amy Chomsky VA Staff Vanderbilt Eye Institute Residents and

Teaching Faculty

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