Safety & Flexibility: Alcon Intrepid Polymer I/A Tips

Released by Alcon in late 2009, the Alcon Intrepid Polymer I/A tip has brought a sense of increased safety and flexibility into cataract procedures.  Although, not as soft as the Alcon silicone I/A tip, this polycarbonate material still provides the same safety in allowing to polish the capsule and maintaining the integrity of the capsular bag.

In addition to not only providing safety through its design, it is also a “true” single use device that is disposed of after each case thusly reducing potential factors (such as residual, cortical material)  that could attribute to TASS.  The tips come in three configurations, a straight, 20 degree soft curve, and the 35 degree bent tip.  Each of the tip configurations has a .3mm aspiration port and the flange design to allow for proper placement of the sleeve. All of the tips are fully compatible with the threaded Ultraflow handpieces and with all MicroSmooth sleeves.  The Intrepid Polymer I/A tips are unique and quality products to add to any cataract surgeons procedures.

Mock Surgery day

The 19^TH Annual Mock Surgery day at Brackenridge Hospital was a huge success. Approximately 1500 people attended the event. A wide variety of groups and organizations were represented as they shared information on various topics pertaining to good health and general safety. Those who attended learned about subjects like; kidney disease, diabetes, cancer, fire safety and more. The hospital also had staff on hand to show people how to bandage wounds and even the trauma department was represented.

Vantage Outsourcing was invited to participate in the event and for the first time ever cataracts were covered. Information was shared, which answered a variety of questions, such as:

• What is a cataract?
• How does it form?
• Who can get cataracts?
• How long does the procedure take?

Along with this information, the cataract surgery was described, the surgical instruments were on hand for viewing and some of the different types of lens implants were discussed. Overall, a lot of information was provided.

Vantage Outsourcing had a great time at this public event and is looking forward to further the publics knowledge when it comes to Cataract Procedures.

Red reflex test to all newborns recommended

Physicians at The Vision Center of Children’s Hospital, Los Angeles, are strongly advocating a basic eye exam, including a red reflex test, be given to all children shortly after birth, the center said. Angela Buffenn, M.D., M.P.H., Director of the Orbit and Eye Movement Institute and Diana Dennis, M.A. of the Therapeutic Living Center for the Blind, reported on the problem of inadequate childhood vision screenings in Pediatric News. The red reflex test involves looking at the infant\’s eyes through an ophthalmoscope in a dimly lit room to see if there are any abnormalities in the back of the eye or white spots in the eyeball. The test is used to screen for abnormalities in the eye itself as well as ocular misalignment. If the red reflex is found to be abnormal, the child should be examined by a pediatric ophthalmologist in order to test for strabismus (crossed eyes), cataracts, glaucoma, retinoblastoma, retinal abnormalities, and high refractive errors. Oftentimes, the test is first administered by a pediatrician or family physician. The red reflex test has been endorsed as an important part of a well child visit by the American Academy of Pediatrics and the American Academy for Pediatric Ophthalmology and Strabismus.

“Too often we see children with developmental delay whose visual system has not been properly evaluated. Sometimes, parents also think that vision loss is less important than treating the seizure disorder or developmental disability, when the truth is we can address both at the same time,” said Dr. Buffenn.

Staying Motivated & Proactive in Today’s Ophthalmic World

Elective case volumes are down in this poor economy; government healthcare plan is reducing Medicare reimbursements even further; and your house hasn’t recovered in value since the 2008-09 real estate down turn. What’s a healthcare person to do?!?  

Like our forefathers, we need to adapt and modify the way in which we do business and expend monies during poor economic times. Perhaps to counter the decrease in cases, you might look to provide added value services to your patients. An example would be to provide hearing tests and hearing aids to your patients. To elaborate on hearing services, here are some little known facts; (1)  50%+ of all senior citizens have significant hearing loss, (2) 80% of them have never been tested for such loss, and (3) hearing aids are the only effective treatment for 90% of such patients.  So think about it — for every 100 patients who come through your waiting room, 50 of these patients have a hearing problem and 40 have done nothing to address it. Baby-boomers’ hearing loss is far greater than earlier generations. Plus, this group is more apt to seek treatment. Hearing services could prove to be a natural fit in ophthalmology.

Another step forward would be to engage the creative side of you & your staff by having brainstorming sessions with your key people. The objective for these meetings would be to come up with ideas for added services, ways to improve efficiencies, and areas for cost cutting.

Most importantly, remember to focus on your blessings, not your misfortunes. It’s a known fact that positive people are more successful (and with less health problems) than negative thinkers. If you have difficulty staying positive, I would encourage you to give yourself daily pep talks and keep telling yourself “I can’t change this bad situation, but I can certainly change my attitude toward it.”

Vision through updates.

Cataracts occur when the eye’s natural lens becomes cloudy with age.

Cataracts don’t harm the eye but can progressively impair vision.

Cloudy lenses can be removed and replaced with artificial lenses designed to correct a range of vision problems.

With a variety of new replacement lenses on the market, it’s wise to talk to your eye doctor about your options.

Like bum knees and crow’s feet, cataracts are the price we pay for getting older. Cataracts form when the normally transparent lens of the eye turns cloudy. At least three out of five people over age 60 will eventually develop them. Today, thanks to a steady march of advances, cataract replacement surgery often gives people better vision than they’ve had in years.

Progress in the field has been nothing short of astonishing, experts say, starting with the development of artificial lenses about 30 years ago.

Patients can now choose from a wide range of artificial lenses. The most common are monofocal lenses, which focus vision at a single distance, the way a pair of standard glasses does. Before surgery, ophthalmologists test the eyes to choose the best prescription for the artificial lens, based on whether patients are nearsighted or farsighted or have normal vision.

Multifocal lenses designed to focus both up close and at a distance, are a newer option. They are particularly appealing because by the time people develop cataracts, usually starting in their 60s, most suffer from presbyopia and require reading glasses. Presbyopia occurs when the body’s natural lens stiffens with age and eye muscles can no longer focus it for close vision.

Techniques to insert the new lenses have also been refined. In the past, doctors had to make a relatively large incision in the clear capsule that contains the natural lens. Now a technique called phacoemulsification breaks up the damaged lens so it can be removed in fragments through a much smaller opening. Replacement lenses are made of a material pliable enough to be rolled up and inserted through the opening. Once inside, they unfold to fill the capsule. The entire procedure usually takes less than 30 minutes and is typically performed using an anesthetic eye drop.

Monofocal lenses, which have long been in use and are covered by insurance, remain the most common choice of replacement lens. But multifocal lenses are growing in popularity.

A variety of multifocal brands are available, but they all work in one of two basic ways. One design presents two images to the retina, one focused close and the other at a distance. The brain then chooses which one to “see.” The second design, called an accommodating lens, incorporates a kind of hinge that allows eye muscles to focus the lens either near or far.

These so-called premium lenses are not considered medically necessary, they aren’t covered by Medicare or private insurance. The additional cost can run up to $3,000 per eye.

Another new artificial lens design, called a Toric lens, corrects astigmatism, which is caused by an abnormal curvature of the cornea. Like multifocal lenses, they are considered premium lenses and aren’t covered by most insurance plans.

But there are drawbacks. Patients sometimes complain about seeing haloes around lights at night. In addition, multifocal lenses designed to present two images to the retina can decrease contrast, making it more difficult to see in dim light.

Some doctors believe the drawbacks outweigh the benefits, especially because the majority of patients end up having to wear reading glasses for very fine print.

Most eye specialists expect multifocal lens designs to improve. One approach under development is a plastic gel that would be injected into the capsule that held the original lens and would form a highly pliable new lens.

Monofocal lenses, meanwhile, are already so refined that the results for many patients are dramatic.

Multifocal IOLs-Adverse Visual Effects and Their Treatment

Multifocal IOLs-Adverse Visual Effects and Their Treatment

Monofocal intraocular lenses (IOLs) have long been the standard in lens replacement after cataract removal.  However, in the last few years multifocal IOLs have established a firm presence in the marketplace.  Monofocal IOLs can only be used to give a single defined focusing point.  This allows a patient the choice to either see distance or close up. Therefore glasses must be used to correct either the presbyopia or myopia.  Multifocal IOLs, of course, allow for multiple areas of focus and allows for spectacle independence.  Although multifocal intraocular lenses appear to be an easy choice for a patient, there have been problems associated with these types of IOLs such as halos, reduced contrast sensitivity, and blurred vision.  These symptoms, though troubling to the patient and the surgeon, have been shown to be resolved the majority of the time.

OSN Super Site recently cited a study in which it was shown, that of 43 eyes included in the study approximately 81% achieved improved vision after a conservative treatment regimen, 7% improved after IOL exchange, and only 12% showed no improvement.  The treatments included excimer, drug therapy, laser iridioplasty, and YAG laser capsulotomy.  The authors of the study, as well as Dr. Jay Pepose in the review of the OSN article stated that YAG capsulotomy should be one of the last treatment choices.  This is due to the possibility the YAG not being effective and if an IOL exchange needs to be done the capsular bag is now compromised and it makes for a much more difficult procedure.  Further studies have shown that patients that have had multifocal IOL implantation may need a 6 month neuroadaption period.  This simply means that the brain needs adequate time to develop or alter neural pathways to improve visual function after the IOL has been implanted.

Although Multifocal IOLs have been shown to have certain post op adversity, one can’t deny the success they have had in freeing a patient from being tied to their glasses.  Nearly all patients either receive treatment or neuroadaptation takes place to accommodate for the multifocal IOL and the adverse visual effect are resolved.  Patient satisfaction and positive outcomes are always the wishes of the surgeons implanting these IOLs.  Proper patient education in the rewards, possible adverse effects, and the treatments of these adverse effects are essential when planning to implant a multifocal IOL.

Making Cataracts More Profitable

Improving profitability in an already efficient operation has its challenges. However as the saying goes, when one stops improving, one stops growing.  The key to improving is to continually evaluating your efficiencies when it comes to patient & staff scheduling, doctors block time, labor mix and related costs, disposable costs and anesthesia expenditures.

Scheduling patients at the right time to make certain you have the right amount of patients in the queue for your staff and surgeon is crucial. Avoiding lateness (whether it’s the patient, surgeon or staff) is the key, along with making sure your surgeon and/or staff do not take breaks between cases.

Efficient staffing of your pre-op, operating room(s) and post op often times involves hiring part-time staff who can pick up the extra load whether it be prepping the patient, scrubbing or circulating in the OR, cleaning instruments, etc…  Staffing your center with more part time staff can reduce your benefit costs and staff overhead. Each function in the center should be done by someone with the proper skills and appropriate pay scale.  It has proven to be very economical to utilize outsourcing services, such as Vantage Outsourcing. They not only provide staff, but also all the equipment, micro instruments and disposables used in a cataract procedures.

Disposable costs are a major cost of doing cataract procedures. Every six months to a year, asking your surgeon/owner to evaluate his/her surgical preferences and consider alternative disposables and/or suppliers can prove to be very profitable. When surgeon asks for a more expensive supply, provide the surgeon with a cost/benefit analysis of adding this supply and the impact of profitability on each of their cases. WIth the expertise of companies such as Vantage Outsourcing, they too can help you reduce our case costs by sharing with you what other facilities and/or doctors are doing and by recommending quality disposable items to use as an alternative to your current costly disposables.

2 OR set up may be good for some, but not for all.  Many surgeons like working in an environment where they go back and forth between two ORs. Vantage Outsourcing generally recommends to their clients that unless the surgeon is doing five or more cases an hour and at least 20 cases a day, we have found that the 2 OR set up to be inefficient. Keep in mind with 2 ORs, the center needs to equip each room with a phacoemulsification equipment and microscope, as well as staff. Unless a surgeon is fast and doing significant volumes, your paid staff and anesthesia person may be waiting on the surgeon to complete cases, which becomes very inefficient and costly to a center.

The easiest way to improving profitability is to increase case volume. This may mean taking time out of your busy day to visit with the area optometric businesses to find out to which surgeon they are referring their patients. Let them know what your center and surgeon have to offer their patients. As part of the outsourcing service, Vantage Outsourcing is able to share with you the referral patterns of ODs in a particular market, in relations to the various MDs. This information is extremely valuable and helpful in determining where a facility and/or doctor needs to put forth their efforts in terms of OD relationships.

In summary, you need to know, evaluate & improve your efficiencies and identify the sources of your surgeon’s referral base, in order to improve your cataract service profitability.

Looking Ahead

While adding ophthalmology services may not produce impressively high profit margins, ambulatory surgery centers (ASCs) may find that case volume, driven by cataract surgeries in particular, could boost revenue streams. Many ophthalmology-related procedures, including cataracts, can be performed quickly and can fill up an empty OR for an entire morning or afternoon. A 2008 survey from VMG Health Intellimarker stated that ophthalmology is the third highest specialty in total case volume, representing 15 percent of all case volumes in the United States. The Centers for Disease Control and Prevention (CDC)’s recent report on outpatient surgery confirms that there were 3.1 million cataract surgeries completed in 2006.1

“I’ve seen surgeons do four (procedures) in an hour,” says Dick Minors, director of access services and sales administration at SightPath Medical. “But I’d say on average, a surgeon can do three in an hour. So the (surgeons and staff) can turn around a room quickly and have another procedure up and running in a short amount of time.”

Minors acknowledges the small profit margins associated with cataract surgeries but compares them to orthopedic cases: “Although you make a large gross margin on an orthopedic case, you might be able to do three, four or five cataract procedures in the same time that you’re doing that one orthopedic case. I think in fairness, you’d have to say that the margins per case are not big, but they can do a lot of cases in a morning.”

Baby boomers and their eye-care needs are partially driving the spike in cataract procedures. By 2010, the older population is projected to be at 40 million, due to the fact that the baby boomer generation will turn 65 in 2011. This will result in a doubling of the older population by 2030, growing from 35 million to 72 million. And many of those seniors will be in need of cataract surgery, states Ann Deters, a member of the cataract division staff at Vantage Outsourcing.

“The older population will continue to grow at a faster pace than the total population and this trend will continue well into the 21st century.” She continues, “With this scenario present, expanding residency training programs to their maximum capacity will maintain the current national ophthalmologist-to-population ratio. But, it will not be enough to address the shift in demographics as baby boomers age. Bottom line is that we need to start putting things in place over the next 12 years in order to meet the growing demand of cataract patients.”

Another issue for adding ophthalmology is the equipment and the costs involved. Melissa Waldroup, a product manager in the ophthalmology division of Leica Microsystems, states that new, state-of-the-art equipment for ophthalmic procedures is readily available, and can have a dramatic effect on saving case times.

“In considering something like a new surgical microscope, which is a high-dollar capital budget expense, physicians and facilitators should look at how this piece of equipment will do more than give a good view. New microscopes offer features like auto reset, rotatable beam splitters, small footprint and programmable preference lists, which can together save eight minutes per case.”

One way that surgery centers can improve profit margins is through outsourcing, says Minors. “I think the other part is if I owned a surgery center, and it was a multispecialty surgery center, I would look to bring a service in. Because if you’re just going to bring in one ophthalmologist or two — ophthalmologists are like other doctors — they’ll either stay or they may not stay. Is it really smart to buy the $300,000 worth of equipment, instrumentation and capital, then six months later, the physician leaves? Even after you lose one surgeon and gain another, it doesn’t mean they’re going to like the same equipment. And there isn’t just one company’s product that’s popular out there.”

For multispecialty surgery centers who want to utilize their space without making any capital expenditures, outsourcing is the best way to go, Minors believes. “I think the combination of the aforementioned programs works quite nicely in that they’ve got an OR; they want to fill it with procedures one day a week or two days a week all morning.”

Another factor could be reimbursement from the Centers for Medicare and Medicaid Services (CMS). Unlike other specialties that have taken a considerable hit in payments, ophthalmology has stayed relatively free of reductions in recent years. There is, however, a planned cut of 2 percent coming in Medicare’s payment schedule for 2010. But not to worry, states Waldroup.

“It is still a worthy specialty to get into, even with the state of Medicare and the future outlook,” says Waldroup. “Ophthalmology still seems of the highest volume of cases of any other specialty. The volume seen still makes this specialty profitable, but with the outlook of Medicare, hospitals will need to tighten their belt, and ASCs will either continue to fight for higher reimbursement rates or be absorbed into hospitals.

“Truth be told,” says Minors, “it depends on what you look at with Medicare reimbursement. There’s an ambulatory surgery center reimbursement and there’s a hospital reimbursement. And of course, there’s the provider side or the surgeon side. And the provider side has been going down. I want to say, every year it goes down a few dollars. A lot of people would say it hasn’t gone down a lot, but if you’re a surgeon, you might say if it goes down $5 to $8 per year, that’s a lot. It’s a mixed bag because ASC (reimbursement) has been going down the last few years. Actually for about two or three years, it stayed the same — $979 per procedure and then it’s come down $10 or $15. But hospitals for the last seven or eight years have actually gone up every year; four to six percent every year.” He also feels that because surgery centers don’t have all the expenses hospitals do is a big reason why Medicare chooses to pay hospitals more. He also warns that ASCs also need to and are exceptionally on top of their costs, and what they’ll accept, to avoid the sting of reimbursement reductions.

Deters also believes CMS, other than the upcoming reduction in 2010, will not significantly reduce reimbursement for cataract procedures. She points out that the ophthalmology industry did take significant hits received over the past 10 to 20 years from Medicare, and doesn’t feel that they would delve any deeper in ophthalmology. “I feel CMS is looking to other fields, such as orthopedics, for reimbursement reductions.”

Reference

1. Cullen KA, et al. Ambulatory Surgery in the United States, 2006. Centers for Disease Control and Prevention, National Health Statistics Reports No. 11. Jan. 28, 2009.

Economic Survey Results are Gloomy, but a Silver Lining for ASCs is Their Flexibility

With the U.S. recession lingering for more than 20 months now, a little good news would be most welcome. While the results of a recent survey conducted by the Accreditation Association for Ambulatory Health Care (AAAHC)’s Institute for Quality Improvement add to the doom and gloom, there is a silver lining in the dark clouds — ambulatory surgery centers (ASCs) will weather this storm if owners/operators are smart about adapting their operations to the current economic climate.

That’s the message Naomi Kuznets, PhD, managing director of the AAAHC Institute, is hoping to promulgate along with the delivery of the sour news that the economic downturn is having a measurable negative effect on ambulatory healthcare. Although the survey was conducted in March — at a time when there was some talk of recovery — Kuznets says that essentially, many people are waiting for the other shoe to drop.

The study, which was completed by 985 ambulatory healthcare organizations, reported that 60 percent of respondents were experiencing a decrease in demand for services over the past 12 months, with 11 percent of these reporting a decrease of 20 percent or greater.

Of the organizations, which represented all geographic areas of the U.S., 64 percent were owned by physicians, 12 percent by hospitals and physicians, 10 percent by public/governmental bodies, 5 percent by physicians and corporations and 4 percent by corporations. The greatest decrease in volume of services was reported by physician-owned organizations (69 percent).

While the ASC industry is certainly robust — recent data say that ambulatory care in the U.S. accounts for 35 million surgeries and procedures — there are certain surgical specialties that remain among the hardest hit by the recession.

“The medical specialties seeing the greatest decreases included not only those providing elective services, such as cosmetic surgery, but also those that offer basic services such as pediatrics, obstetrics/gynecology, urology, general or oral surgery, ENT, pain medicine, gastroenterology and orthopedics,” says Kuznets. The greatest decreases in demand were reported for high-cost procedures (reported by 35 percent), services that were self-paid by the patient (51 percent), and elective procedures (57 percent). A higher proportion of organizations reporting decreases were located in the Midwest, Southeast and Southwest.

The survey revealed that 76 percent of respondents reported a negative impact on patients’ ability to pay co-pays or deductibles. Many other healthcare consumers who are able to afford to pay for elective surgical services are sensing that bargains are to be had in the medical marketplace. “Providers of aesthetic procedures are among the hardest hit,” Kuznets says, “and they are seeing consumers who are shopping around. The message we see in the marketplace is that if you either wait for prices to drop or if you shop around, you should get a great price on a procedure from a great surgeon. I think some consumers will continue to spend out of their own pockets if they can get a decent price. It’s not going to be for cataracts and colonoscopies, of course.”

Kuznets explains, “The survey results are particularly interesting to a lot of people because they show that some sectors are really feeling the pinch, while other sectors are perhaps concerned and many are in a ‘watchful waiting’ mode, where they are trying to be as conservative as possible with their finances and their business practices,”

No matter where ASC owners/operators are on the “panic scale” these days, the common denominator is concern about the trickle-down effect. “Healthcare consumers are not coming in, therefore ASCs are not making capital equipment purchases or making new hires, and so there are going to be significant ramifications in other sectors in the economy because of this, just as there have been generally when consumers don’t make purchases,” Kuznets says. “Surgery centers are now such an integral part of the U.S. economy that people need to be aware of how much they impact other sectors and are in return impacted by the rest of the economy.”

According to the survey, two-thirds (67 percent) of respondents reported that the economy has had a negative impact on making capital purchases (44 percent), purchasing supplies (31 percent), hiring or retaining staff (29 percent), purchasing services (12 percent), floating payroll expenses (9 percent), giving raises or bonuses (2 percent), staffing hours (2 percent) and wages (1 percent).

Kuznets says that a number of ASCs are endeavoring to avoid layoffs. “They want to keep their good workers, even though there may not be an increase in their hours or pay – because cutting their wages is demoralizing. They are probably making less, but at least ASCs are trying to keep them employed.”

That heroic effort is coming at a time when ASCs must not only decrease their prices, but include these prices in their marking materials to appease healthcare consumers wanting improved transparency. The recession is affecting other business practices, including increasing collections from patients and payors. Through written comments, survey respondents expressed concern about notable increases in patients’ delaying, cancelling or not showing up for appointments due to unmanageable co-pays/deductibles or the fear of losing a job for taking time away from work. Comments also pointed to ASC owners/operators’ concerns about a general need for “belt-tightening” and that the recession will linger excessively, creating a problematic future filled with bad debt, uncompensated care and escalating costs.

That said, Kuznets reminds the industry of its incredible flexibility and its ability to weather storms in the past. “Surgery centers are adaptive and they have made a number of important adaptations to better withstand a faltering economy,” she says. “Surgery centers also are very nimble; they are able to shift hours, change their procedure mix, they can even close for a day if necessary. They are able to seek out lower supply costs, they don’t get themselves stuck in huge long-term contracts for the most part, and they are very flexible organizations able to respond to tougher times. With a change of procedure mix comes a change in payors, and a little bit of suffering goes along with it because, for example, instead of dealing with private payors, you are dealing with more public payors (with whom organizations may be less well acquainted). But surgery centers are very adept and will figure out how to work the system.”

That includes scrutinizing how the money flows in and out of an ASC, according to Kuznets. “One of the reasons we did the survey was to show surgery centers how others are coping with the economic downturn,” she says. “We do see varied reports on the economy, but we think, for the most part, that our AAAHC-accredited organizations will make it through this,” she adds. “It will be tough, but it’s time for centers to think creatively. They have done all of the logical things, such as decreasing the facility’s hours or moving procedures to different days. But it’s also a reminder to re-examine things like supply costs; because of what happened with gas prices last year they may be paying more now and may have not renegotiated these contracts. Be sure to look closely at all suppliers, at scheduling options, at everything that will impact a facility’s bottom line. A number of folks are looking at their benefits costs; they should be shopping around, just like consumers. Yes, it takes time, but you may have more time right now.”

Kuznets continues, “When you look at some of the business practices that surgery centers have already put into place, yes, they have streamlined things a great deal and they may feel they have done as much as they can — a lot of them probably have cut to the bone, so to speak. But every time we do our benchmarking studies, someone has found a new way to be more efficient. If any sector can get it together enough to weather this economy, this is probably it. The people in this sector are entrepreneurial, they are very aware of the issues they have with their businesses and they are ready to do what’s necessary to remain viable.”

Is backwards better?

The principle surgical experience that residents obtain during their training in the developing world is phacoemulsification of cataracts. This is not surprising, since cataract surgery will be the most common surgical procedure they will perform as they enter practice and for the foreseeable future. However, the past has a major impact on this learning experience because, traditionally, we learn how to perform cataract surgery from the initial steps of the procedure forward to the final steps on the operation.
I finished my own residency at the Santa Casa Hospital in Sao Paulo, Brazil, in January 2008. At that time, I began my cornea fellowship and also continued training residents in cataract surgery. My own training was in a traditional method, performing surgery commencing with the incision and ending with viscoelastic removal and incision closure. My experience, like so many other surgeons in training, was made difficult because mistakes made at the onset of the operation, making all of the sequential steps more difficult. For instance, an improperly constructed incision, perhaps too large, too small or architecturally improper, can plague the surgeon throughout the entire rest of the operation. An improperly constructed capsulorrhexis may create obstacles that are very difficult to overcome and may, in fact, prejudice the outcome.
As I was beginning my own activities as a teacher of cataract surgery, Dr. Jonathan Lake, who was chief of the Cataract Surgery Section at our hospital at that time, in conjunction to others in Brazil, instituted a new system for training residents in phacoemulsification of cataracts. The new system involved residents performing the final steps of the operation as the first intraocular maneuvers they were trained in, and, with increasing experience, going backwards sequentially to learn and master each of the preceding steps.
So, the initial cataract surgical maneuver performed by the residents was removal of residual viscoelastic. Once they were experts at that, they were taught how to implant the intraocular lens. After they master that, they start to perform cortical clean-up. The initial nuclear removal technique they learned was the mobilization of the second and third quadrants; then, removal of the first quadrant and finally removal of the last quadrant, perhaps the most dangerous part of quadrant removal, because of the exposed posterior capsule.
After they were experts at quadrant removal, they would learn how to groove and crack nuclei and only then would be taught how to chop nuclei. By this time, the residents were quite capable of performing nuclear disassembly and phacoemulsification of segments. Now, they were ready to learn hydrodissection and hydrodelineation, capsulorrhexis and incision construction.
With this system, mistakes made by the inexperienced residents, in his or her initial intraocular maneuvers, were unlikely to undo the case or create a disasterous complication. With increasing experience, going backwards in the steps, their intraocular maneuvers became more skilled and more precise, so that by the time they were doing the initial steps of the surgery, they had adequate dexterity to avoid problems that could plague them from the rest of the case.
It has frequently been stated that in teaching the teacher learns more than the student. I found that in teaching each of these steps, I was highly focused on the subtle maneuvers that allow precision and accuracy, and I became a better surgeon myself in the process.
I found it easier to both learn and teach using this method. It became obvious to me that the learning curve was shorter and less traumatic. Complications were fewer, more easily compensated for, resulting in greater patient’s safety. We all know that the phacoemulsification is step-dependent and that an early error is more likely to result in a less than perfect outcome. It seems to me that all training programs should give this system a trial, to enhance resident training and patient outcomes.

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