DR. VIVEK ADWE, Dr. Khurshed M Bharucha, Dr. ATUL HEGADE
OBJECTIVES:
To quantify improvement in surgical skills of trainees undergoing phacoemulsification training by ICO-OSCAR and to document independent surgery completion rates.
METHODS:
Prospective evaluation of phacoemulsification trainees undergoing short term(1 month)training programme at a tertiary eye care centre in pune was performed using ICO-OSCAR grading sheets.Trainees were categorized into 3 groups based on previous surgical experience.The main outcome measures were improvement in mean average scores and independent completion rates.
RESULTS:
The study included 41 trainees(22 males and 19 females). Scores in first five and last five cases were considered as pre-training and post-training scores respectively. Each case had 20 steps carrying maximum possible score of 100. The total pre and post-training scores in Group A were 2926 and 6160 respectively, out of 7000. Group B had pre and post-training scores 3910 and 7820 respectively, out of 8500. The total pre and post-training scores in Group C were 2480 and 4741 respectively, out of 5000.
The mean pre-training scores for groups A,B and C were 2.09±0.06; 2.30±0.08 and 2.48±0.04 respectively (p<0.05).The mean post-training scores amongst groups A,B and C were4.40±0.15; 4.60±0.06 and 4.74±0.07 respectively (p<0.05). The independent completion rates amongst groups A,B and C were 64%, 72% and 80% respectively.
CONCLUSION:
Short term training is an effective mean of Phacoemulsification surgical skill transfer and ICO OSCAR is valuable objective rubrics for evaluation of surgical skill transfer.
INTRODUCTION
Cataract is defined as opacification of natural crystalline lens or its capsule or both. Cataract word comes from greek word kataraktes meaning fall of water ,as prior to 1700 AD, people used to believe that cataracts were comprised of an “opaque material flowing,like a waterfall,into the eye.“
An Indian physician MaharshiSushrutarecorded an effective cataract removal process around 800 B.C., using a needle to dislocate the clouded lens into the back of the eye (vitreous cavity) ,which occasionally helped patients obtain limited vision. This was called “couching technique”.1 A method called “needling” was also used by ancient doctors to perform cataract surgery. This procedure sliced the cataract into multiple particles, allowing them to be easily absorbed.8
Samuel Sharp of London developed a strategy to extract the full unbroken lens via an incision by placing pressure with his thumb i.e. Intracapsular cataract Extraction-ICCE surgery. ICCE surgery was created and widely used in the 1980s.1It involves taking out the total natural lens of the eye, along with the capsule.
TheExtracapsular cataract Extraction-ECCE procedure consists of cataract extraction through limbal incision.The lens capsule,isopened through “capsulorrhexis,” or a circular capsular tear and cataract is extracted.The concept of scleral pocket incisionwas a beginning in the direction to reduce size of incision. Thrasher and Buerner showed that 9mm posterior (scleral) incision induces less astigmatism than 6mm limbal incision. Jaffe has stated that 7mm incision 2mm behind the limbus can be left unsutured without fear of induced against the rule astigmatism.
Tools to grasp the lens such as forceps and suction cups were developed by 1900. Cataract extraction techniques continued to markedly improve over next decades. A huge breakthrough occurred in the 1949 in England when Harold Ridley introduced the intraocular lens. It was made up of a material known as polymethyl methacrylate. Reduction in size of incision has played a big role in bringing about faster stability of wound healing and refraction of patients. Smallest possible incision is desirable.
It is being practiced during phacosurgery with advent of foldable IOL. In 1967, Charles Kelman developed phacoemulsification. It is a method of cataract removal that uses ultrasonic vibrations to break up a cataract into small pieces, which are then extracted through a small probe. 2Phacoemulsification is the accepted standard surgery for cataract world over and it is second most common surgery in ophthalmology after Small Incision Cataract Surgery (SICS).
For a cataract surgeon and general ophthalmologist,proficiency in phacoemulsification with technical skill is an essential requirement. In India,there are more than 110 medical colleges that offer ophthalmology postgraduate training programs.3Training in phacoemulsification during postgraduation is often limited to a few cases and more often,there are no specified standard measures to assess how well the surgeries are performed(quality).The learning curve is also steep. Hence many instititutes in india and abroad run a short term phacoemulsification surgery training programme for one or two months. Many young ophthalmologists utilize these short term programs to acquire and improve surgical skills.
Training of novice Phacoemulsification surgeons has changed considerably in the last decade. Demonstration of competency is considered as the preferred method. The formative assessment provides ongoing feedback to improve learning. Summative assessment evaluates learning at the end of an instructional unit. It is like a residency exit examination.3 Effectiveness of trainingprogramme is assessed by uptake of surgical skills by the trainees. Adequate assessment is necessary to demonstrate competence. Method of skill assessment must be objective, reliable, valid and feasible. Phacoemulsification training is being carried out at various centres around India and world, however these courses need to have a regular assessment to assess effectiveness and suggest improvements.
There arefew formal tools for evaluating the surgical competence of ophthalmology trainees. Style and consistency of feedback vary in different training centres. Cremers et al. developed “Objective Assessment of Skills in Intraocular Surgery” to assess residents’ skills in cataract surgery, where an evaluator observes and provides an objective assessment of the surgical steps.4 “Global Rating Assessment of Skills in Intraocular Surgery”(GRASIS) allows the evaluator to assign scores based on a rubric.5 Saleh described OSACSS-“Objective Structured Assessment of Cataract Surgical Skill ” which stratifies phacoemulsification into twenty steps that are scored on a 5‑point Likert scale.6International Council of ophthalmology has designed Ophthalmology Surgical Competency Assessment Rubrics -ICO-OSCAR .
This rubric facilitates assessment and teaching of surgical skill.7 Surgical procedures are broken down into individual steps. Each step is graded on a scale of novice, beginner, advanced beginner and competent. A description of performance necessary to achieve each grade in each step is given. ICO-OSCAR should be completed at the end of the case. To provide timely structured, specific performance feedback it should be immediately discussed with the trainee.These tools were developed by panels of international experts. These are valid assessment of surgical skills.
In this study, we objectively evaluated already ongoing phacoemulsification training programme at our institute,using International Council of ophthalmology’s Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR) as a grading system. We assessed impact of programme by assessing improvement in surgical skills of trainees. Assessment enables evaluation of surgical skill of trainees, record the improvement in skills. This study helped trainees understand how trainers view their professional competence; what they feel are the limiting factors in the pursuit of excellence and how to make training program more effective.It provided insight into further improvement of training programme.
Materials And Methods
This is a longitudinal study that evaluated groups of phacoemulsification trainees over a period of time; the trainees were observed for improvements in skills and outcomes were measured.The study was conducted at a Tertiary eye care centre, Pune (Maharashtra). The study was a duration based study enrolling all short term (1 month) phacoemulsification trainees undertaking training at this institute from November 2017 to June 2018 (8 months). Total number of trainees enrolled were 41.
Inclusion criteria:Qualified ophthalmologists (MD/MS/DO/DOMS) having previous experience in SICS (small incision cataract surgery) were included. Exclusion criteria : Trainees unwilling for assessment of surgical skill transfer were planned to be eliminated from study. However all 41 Trainees participated voluntarily in the study.Trainees were divided in three groups A,B and C based on previous surgical experience. Group A included trainees who performed 50 to 500 independent SICS before training. Group B included trainees who performed more than 500 independent SICS but less than 20 Phacoemulsifications before training. Group C included trainees who performed more than 20 independent phacoemulsifications before training. Number of trainees in groups A,B and C were 14, 17 and 10 respectively.
The phaco procedures were supervised by attending trainer surgeons according to the standard phaco processes: Superior or temporal 3.2 mm clear cornea incision constructed, flap performed using a bent 25‑gauge needle and continuous circular capsulorhexis completed with the capsule forceps, hydrodissection in multiple directions, stop‑chop or divide and conquer technique used to deal with a central nucleus, injection of a foldable intraocular lens after complete cortex removal, and securing the incision with a 10‑0 nylon suture, if necessary. Supervisors had the priority to stop a trainee’s phaco attempt in situations such as anterior capsular runaway, inability to complete continuous curvilinear capsulorhexis (CCC), failure to separate the nucleus after three trials, any dangerous movement in the eye, difficulty keeping a stable anterior chamber depth during any step, and the occurrence of intraoperative complications.
Step wise scores of surgery were dictated by the trainer immediately after carefully observing trainee’s surgery. Steps performed by trainer were allotted zero score.Independent completion was mentioned seperately in the ICO-OSCAR Sheets. If any complication was noted during surgery, the case was handed over to the trainer and managed.The details of the complications and management done were noted in details.Postoperative best uncorrected distant visual acuity (UCVA) wasnoted. Didactic lectures were conducted over phacodynamics, phacoemulsification surgery steps and management of complications. Wet lab training for initial 3 days was conducted for hands on use of phacoemulsification machine.
Feedback of the trainees was noted at the end of training. The data entered on ICO-OSCAR was evaluated for improvement in surgical skill, assessment of rate of complications and rate of independent completion of case.
Data evaluation :Data were listed and counted with Excel (version 2013, Microsoft). The Anova test, Chi‑square and Student t‑tests were used to assess statistical significance between groups.
Results: At the end of study period, 41 trainees had performed total of 1025 phacoemulsification surgeries. Traineesmale to female ratio was 1.15. Each trainee performed a mean of 25 surgeries.The independent completion rates amongst groups A,B and C were 64%, 72% and 80% respectively. Scores in first five and last five cases were considered as pre-training and post-training scores respectively for evaluation . Each case had 20 steps carrying highest score 5, thus maximum possible score of 100 per case. The total pre and post-training scores in Group A were 2926 and 6160 respectively, out of 7000. Group B had pre and post-training scores 3910 and 7820 respectively, out of 8500. The total pre and post-training scores in Group C were 2480 and 4741 respectively, out of 5000.
The mean pre-training scores for groups A,B and C were 2.09±0.06; 2.30±0.08 and 2.48±0.04 respectively (p<0.05).The mean post-training scores amongst groups A,B and C were 4.40±0.15; 4.60±0.06 and 4.74±0.07 respectively (p<0.05).
Complication rates: Rates of anterior capsule tear or runaway in groups A, B and C were 2.94 %, 2% and 0.92 % respectively (p < 0.05) .Rates of difficulty faced in nucleus cracking in groups A, B and C were 1.05 %, 1% and 0.61% respectively (p< 0.05). Posterior capsule rupture while Phacoemulsification of nucleus (Phaco 2) rates among groups A,B and C were 2.94%, 2% and 0.92% respectively (p < 0.05) . Posterior capsule rupture while cortex aspiration (Phaco 3) rates among groups A,B and C were 3.1%, 2.2% and 0.98% respectively (p < 0.05) . Iris tissue damage was noted to be 2.94%, 2% and 0.92% respectively among groups A,B and C (p < 0.05).
Regional zonulodialysis was noted in 1.05%, 1% and 0% in groups A,B and C respectively. Intraoperative nucleus drop was noted in 1 case in each of group A and B constituting 0.2% rate.
Discussion
India has rapidly aging population and the largeunoperated cataract subject pool.India has raised its cataract surgical rate from just over 700 in 1981, to 6,000 in 20129,10.However the estimated cataract surgical rate of 8,000–8,700 needed to eliminate blindness due to cataract in India11. Key solution to accommodate this situation is to enhance the efficiency and safety in current phaco-training programs to cultivate better qualified cataract surgeons
In this study, all training procedures were carried out in patient eyes by trainees under supervision in order to ensure that patient safety remains the primary objective for both trainees and trainers. Most trainers are happy to transfer their skills, if no unexpected outcomes occur during the procedure.
Experience in SICS does offer some benefits for improving basic surgical behavior in phaco procedures performed by trainees. Wound construction, capsulorhexis, and wound closure of SICS were modified to accommodate current phaco procedures. Trainees having performed less SICS have less experience performing capsulorhexis, which was one of the most difficult steps. Study showed that intraoperative complication rates were comparably low for surgeons experienced with both SICS and phacoemulsification.
Our training programmeis an effective, efficient, and safe approach to progressively master phaco skills for trainees with SICS experience. In addition, the program offers a smooth and friendly teaching process due to increased control of the teaching procedure for the trainer. Thus, the step‑by‑step training program may enhance successful teaching phacoemulsification procedures and patient safety. ICO-OSCAR being a concise and minimally burdensome evaluation rubrics, provides constructive feedback immediately after surgery as well as at the end of training. Information obtained is purely objective, without interratorvariability. Trainees appreciate having all the information on one easy-to-read sheet.
Thus, short term training is an effective mean of Phacoemulsification surgical skill transfer. ICO OSCAR rubrics is valuable objective rubrics for evaluation of surgical skill transfer.
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