Surgical training in ophthalmology

The Only Eye Study (OnES): a qualitative study of surgeon experiences of only eye surgery and recommendations for patient safety

OBJECTIVE

Performing surgery on patients with only one seeing-eye, where complications may result in catastrophic vision loss, presents unique challenges for the ophthalmic care team. There is currently no evidence regarding how surgeons augment their care when treating only eye patients and no guidelines for how these patients should be managed in hospital eye services. This study aimed to explore ophthalmic surgeons' experiences of only eye surgery and perceptions of current practice.

DESIGN AND PARTICIPANTS

Ten ophthalmic surgeons were asked to relate their experiences and views on performing only eye surgery in indepth, semistructured interviews. Interviews were audio-recorded and transcribed. Qualitative data were subjected to thematic analysis to identify key themes.

SETTING

Hospital eye service.

RESULTS

Five key themes emerged relating to surgeons' experiences and perceptions of only eye surgery: (1) differences in approach to consent, (2) strategies for risk reduction, (3) unmet training needs, (4) value of surgical mentor and (5) emotional impact of unsuccessful outcomes. Recommendations for improving the surgical journey for both the patient and the surgeon related primarily to better recognition and understanding of the complexities inherent with only eye surgery.

CONCLUSIONS

Outcomes of only eye surgery may be improved through a number of methods, including development of purpose-designed training fellowships, adoption of stress-reducing strategies and enhancement of available support services. The findings identify emerging themes unique to only eye surgery and the need for guidelines on the provision of care for these high-stakes surgical patients.

Trabeculectomy training in England: are we safe at training? Two year surgical outcomes

OBJECTIVES

To define the safety profile of trainee trabeculectomy surgery in the United Kingdom. Surgical exposure for trainees in England is limited due to service requirements, the European working time directive constraints and increasing sub-specialisation of glaucoma surgery. Limited knowledge exists on the outcomes of supervised glaucoma surgery. The aim is to determine the safety of supervised trabeculectomy surgery performed by trainee ophthalmologists.

METHODS

Retrospective case note review of all patients that had trabeculectomy surgery with MMC by consultant and trainee surgeons across multiple UK centres. All eyes have 2-year follow up. Success was determined using WGA guidelines. Two-tailed p values were obtained using Fisher's exact test to ascertain statistical significance between groups.

MAIN OUTCOME MEASURES

intraocular pressure, visual acuity, success and failure rates.

RESULTS

324 eyes were reviewed. 211 (66.4%) cases were performed by glaucoma consultants, 107(33.6%) by trainee ophthalmologists. The majority of eyes in each group were undergoing surgery for POAG. Post-operative IOP control showed no significant difference between consultant and trainee groups at year 1 and year 2. Success rates showed no significant difference between consultant and trainee cases. Failure rates at year 1 showed a significant difference between the two groups. No significant difference was seen at year 2. The trainee group had significantly more complications, when compared with the consultant group. Snellen visual acuity loss was not statistically significant between the two groups at the 2 year time point.

CONCLUSIONS

The outcomes of supervised trainee trabeculectomy compare favourably with consultant cases after 2 year follow up. Trainee cases had higher complication rates than consultant cases. Bleb leaks are a common complication of trainee cases, where closer supervision may be required. There is potential for surgical simulation to help increase the success of such cases. These findings may encourage trainee participation in glaucoma surgery.

'Fast-track' cataract services and diagnostic and treatment centre: impact on surgical training

AIMS

To evaluate the impact of 'Action on Cataracts' and the development of Diagnostic and Treatment Centre (DTC) on cataract surgery training in the Central Manchester and Manchester Children's University Hospital's Trust.

METHODS

We compared all cataract extractions undertaken from April to September 2005 with the same 6-month time period over the preceding 5 years. Surgery was performed on one of four types of lists: Manchester Royal Eye Hospital standard lists (MREH), Cataract Services list, Waiting List Initiative list (WLI), and Diagnostic and Treatment Centre list (DTC). Surgeons were identified by their specific codes and divided into grades.

RESULTS

The total number of cataract operations undertaken on the standard MREH lists has declined significantly over the years (P<0.001 chi(2) test for trend). The number of cataract operations performed by both Specialist Registrars (SpRs) and Senior House Officers (SHOs) demonstrated a statistically significant decline over the years (P<0.001 for both cases, chi(2) test for trend), with the SHOs number dropping dramatically over the last 2 years. When comparing the number of operations performed by junior SpRs and senior SpRs, shift in the balance can be seen towards the senior surgeons. The proportion of operations performed by junior SpRs declined from 50% in 2000 to 28.2% in 2005.

CONCLUSION

Recent changes in cataract care provision have had a significant impact on training. Our results document for the first time that both higher and basic surgical trainees were affected. Future care of our patients could be comprised owing to lack of training.

Cataract surgery for junior ophthalmologists: are there enough cases?

AIM

To evaluate those cases that are suitable for operation by the junior ophthalmic trainee.

METHODS

A prospective survey of 96 consecutive cases from five consultant lists for phacoemulsification over a 1 month period were preoperatively assessed for their suitability for the ophthalmic trainee using set criteria. A checklist was designed for all patients and criteria were marked with reference to suitability by a single examiner. The criteria chosen were arbitrary and had no bearing on a consultant's final decision to allow the junior to operate.

RESULTS

Twenty-two out of 96 cases (22.9%) were deemed to be suitable for operation by a junior ophthalmologist (ie 4.4 cases per consultant list). The three main reasons for exclusion were first eye case, eye for operation with visual acuity 6/12 or better, and mature cataract.

DISCUSSION

Using our results, if 4.4 cases were suitable for a junior ophthalmologist per month, this would allow for adequate exposure during the early stages of training. However, if the number of relatively straightforward cases on training lists were to be reduced owing to unavailability on hospital waiting lists, this could potentially compromise ophthalmic training in the future.

Pig eye trabeculectomy—a wet-lab teaching model

PURPOSE

A teaching model for trabeculectomy is described using pig eyes prepared in formalin.

METHOD

The model enables trainee surgeons to practice various aspects of tissue handling required for successful trabeculectomy including the construction of a fornix-based conjunctival flap, scleral flap with buried releasable sutures, and water-tight conjunctival closure.

RESULTS

Exposure to the necessary skills required to perform trabeculectomy surgery can be improved by the use of wet laboratory practice.

CONCLUSIONS

Trabeculectomy surgery experience is becoming more limited as fewer procedures are being performed due to the efficacy of recent medications. Wet laboratories will become an increasingly important aspect of a comprehensive ophthalmology training programme.

The first cut is the deepest: basic surgical training in ophthalmology

PURPOSE

To examine the basic surgical training received by Senior House Officers (SHOs) in ophthalmology and the influence on training of sociodemographic and organisational factors.

METHODS

Cross-sectional survey of SHOs in recognised UK surgical training posts asking about laboratory training and facilities, surgical experience, demographic details, with the opportunity to add comments.

RESULTS

A total of 314/466 (67%) questionnaires were returned. In all, 67% had attended a basic surgical course, 40% had access to wet labs and 39% had spent time in a wet lab in the previous 6 months. The mean number of part phakoemulsification (phako) procedures performed per week was 0.79; the mean number of full phakos performed per week was 0.74. The number of part phakos performed was negatively correlated, and the number of full phakos completed was positively correlated, with length of time as an SHO. Respondents who had larger operating lists performed more full phakos per week (P<0.001). Compared to men, women were less likely to have access to a wet lab (P=0.013), had completed fewer full phakos per week (P=0.003), and were less likely to have completed 50 full phakos (P=0003). SHOs' comments revealed concerns about their limited 'hands on' experience.

CONCLUSIONS

There are significant shortcomings in the basic surgical training SHOs receive, particularly in relation to wet lab experience and opportunities to perform full intraocular procedures. SHOs themselves perceive their training as inadequate. Women are disadvantaged in both laboratory and patient-based training, but minority ethnic groups and those who qualified overseas are not.