A major skill to be acquired prior to independent cataract surgical practice is the management of posterior capsular rupture, with or without vitreous loss. The posterior capsule is the thin layer at the back of the natural lens capsule that separates the eye into two compartments. The posterior compartment is filled with vitreous, and any vitreous that presents to the anterior chamber requires careful, planned removal via anterior vitrectomy. With planning, this skill can be taught, and trainees can acquire the knowledge and enough practical experience to proceed to supervised anterior vitrectomy, with the end goal being independent practice by the completion of RANZCO ophthalmology training.
Complication training is not just for trainees. This area has often been under-emphasised during training, leading to a lack of the required skills to achieve good results. In addition, technology and machines change frequently. Add these conditions to the fact that these complications are rare, and it is obvious that we should be up-skilling frequently.
The complications associated with poorly managed vitreous presentation include poor post-operative visual outcome due to uveitis, raised intraocular pressure, cystoid macular oedema, retinal detachment, and endophthalmitis.1 Recent research from the UK, where trainees gain considerable experience in cataract surgery with high surgical volume similar to Australian trainees, suggests that the average rate of posterior capsular rupture amongst junior and senior trainees is 2.48% and 1.41%, respectively.2 However, less than 10% of trainees surveyed recently within a single postgraduate UK training centre felt confident to complete cataract surgery complicated by posterior capsular tear without senior support.3 Corresponding figures amongst Australian ophthalmic trainees are lacking, and we have consequently commenced collection of this data.
As with any surgical skill, especially complication management, management of vitreous loss requires both the knowledge of what to do and why as well as the equipment and skills to carry out the procedure. Training in this task has become a significant focus at Ear + Eye throughout 2018. Introduction was made with one of the first year lessons covering the basic information and skills, and some of our trainees attended a specific course on this topic run as the Advanced Training Day at the Australasian Society of Cataract and Refractive Surgeons Annual Meeting in Noosa during October. The next step is Geneye 2019, where we look forward to sharing this training with a wider community of ophthalmologists.
We have developed an “anterior vitrectomy challenge” for use during these training courses. During this challenge, the surgeon has 7 minutes during which to respond appropriately to development of a complication. They need to adjust machine fluidics and complete the required steps to manage a posterior capsular tear. Results are then presented as a score out of 100 (figure). Who will get the highest score?
Figure Example of data generated during “anterior vitrectomy challenge training”. As more repetitions are completed, graphical representation becomes useful in showing improvement or otherwise.
References
1. Ti Se, Yang YN, Lang SS, and Chee SP. A 5-Year Audit of Cataract Surgery Outcomes After Posterior Capsule Rupture and Risk Factors Affecting Visual Acuity. AJO 2014;157:180-5.
2. Johnston RL, Taylor H, Smith R, Sparrow JM. The Cataract National Dataset electronic multi-centre audit of 55,567 operations: variation in posterior capsule rates between surgeons. Eye 2010; 24(5): 888–893.
3. Turnbull AMJ and Lash SC. Confidence of ophthalmology specialist trainees in the management of posterior capsule rupture and vitreous loss. Eye. 2016;30:943-48