Cataract surgery: Lessons from the first 100

May 1, 2006

I recently passed a residency milestone: my 100th cataract surgery.It turned out to be a tough case with a very dense cataract and theneed for iris hooks. But it went well, and it felt good.

I recently passed a residency milestone: my 100th cataract surgery. It turned out to be a tough case with a very dense cataract and the need for iris hooks. But it went well, and it felt good.

I've had my ups and downs during these 100 cases. It is interesting that the first 14 seemed to go perfectly. OK, what I really mean is that they went well.

Reality quickly set in and the next 35 cases had me wondering if I was really cut out for ocular surgery. On number 15, the capsule broke and the nucleus dropped (this would happen again). On the next 10 or so cases, my corneal incisions seemed to be either too long or too short (or they leaked). The next problem was hydrodissection, and somehow, on case 31, less-than-perfect technique resulted in 180° of zonular dehiscence.

Then suddenly, magically, I completed number 32 flawlessly in 19 minutes! A fellowship program to which I applied asked for a videotape of one of my surgeries; I sent them number 32.

What that fellowship program never learned was that this was immediately followed by number 33, which required anterior vitrectomy.

Somehow, during number 47, a good portion of Descemet's membrane ended up detached and floating between the cornea and iris, which prompted the attending to say, "Now that's something I've never seen before." That's never a good thing to hear.

Then things started coming together. My cases started going more smoothly. The last 50 cases have had minimal intraoperative complications, and I'm starting to feel like maybe I can do this.

Peaks and troughs

I've realized from these first 100 cases that the acquisition of surgical skill is a sine curve of peaks and troughs. What you're working toward is a curve that trends upward with less frequent troughs as time goes on. The peaks come with the emotional highs of self-confidence and developing skill. The troughs come with the emotional lows of self-doubt. Training programs should have a mechanism in place to address these difficult experiences when they occur for their residents.

At my residency program, we have a monthly gathering of all the third-year residents with the program director to discuss how our surgeries are going. We discuss anything and everything related to cataract surgery: the rationale behind different techniques, what different instruments are used for, and anterior vitrectomy settings, to name a few topics. We show each other videotapes of our surgeries, good or bad. And we analyze each other's difficulties without judgment.

The gathering is known as the "No Vitreous Society," and its motto is "Whatever is discussed here, stays here." It is part social (we usually meet at the program director's house for dinner), part didactic, and largely therapeutic. The most important benefit of the No Vitreous Society, in my opinion, is that each resident learns that his or her colleagues are going through very similar peaks and troughs.

Dealing with complications

Complications are inevitable-they happen to us all. During my complicated cases, my attendings remained calm and confident, guiding me through each one. I feel fortunate that my patients all eventually ended up with good visual outcomes.

Looking back over these first 100 cases, I have also realized that learning to handle the complications is just as important as learning to do the surgery itself. I will soon be leaving the safe haven of residency, and will be facing complications on my own.

In those tense moments, I hope that I will be as calm and confident as my attendings taught me to be. Although I do not wish complications on anyone, I am, in a way, grateful for the ones I have encountered.