Building Confidence in a New Generation of Eye Surgeons

Ophthalmology residents and fellows gain experience with cutting-edge cataract surgery technology.

By Virginia Pickles, Contributing Editor

Keeping up with advances in technology is a challenge faced by every educational institution, but nowhere is it more critical than in medical schools preparing the next generation of eye surgeons. Cataract surgeons in particular are poised on the cusp of a new era of technologically advanced procedures that inevitably will raise the expectations for refractive outcomes among patients and surgeons alike.

"The femtosecond laser will change the way we approach cataract surgery," says Jose de la Cruz, MD, assistant professor of ophthalmology at the University of Illinois at Chicago (UIC) College of Medicine and director of Millennium Park Eye Center. "At our institution, we want to be at the cutting edge of technology, not only to provide our patients with the most advanced treatments, but also as educators, to prepare our residents to be at the forefront of ophthalmology."

James P. McCulley, MD, professor and chair of the department of ophthalmology at the University of Texas (UT) Southwestern Medical Center in

Dallas, is also eager to have his residents learn to use the new technology. "If our residents aren't prepared to perform image-guided laser-assisted cataract surgery when they graduate, then we've put them at a disadvantage in the job market," he says.

Both of these educators have integrated LenSx® Lasers (Alcon Laboratories, Inc.) into their residency and fellowship programs. In this article, they share their observations about the laser's utility in the educational setting and in practice.

Precise and Predictable

Since 2009, the LenSx Laser has gained several FDA clearances in quick succession. It's now cleared for anterior capsulotomies, corneal incisions, phacofragmentation and flaps (future capability). "The LenSx Laser today, compared with the LenSx Laser when it was first rolled out in clinical trials for FDA consideration, is substantially improved," Dr. McCulley says. "The laser is much more precise than a blade or a needle in a surgeon's hand. The recent addition of the SoftFit™ Patient Interface is a major advancement (Figure 1). It minimizes corneal distortion, enabling the surgeon to reliably create complete 360-degree capsulorhexes. In addition, the OCT imaging is clearer than the previous LenSx Laser OCT imaging." Dr. de la Cruz also appreciates these improvements. "The contact lens-based patient interface is a great addition to a system that we were already happy with," he says. "It makes surgery even more precise and predictable. What's also exciting is that we can image the anterior chamber, the cornea, the iris and particularly the lens. This gives us an idea of what we're dealing with before we enter the eye, so we can plan for the type of energy we need and know how much effort will be required."

Figure 1. The SoftFit Patient Interface offers a proprietary soft contact lens technology that enables the natural curvature of the cornea to conform to a soft contact lens insert.

Another consideration for Dr. de la Cruz in choosing the LenSx Laser was the university's prior experience with Alcon. "The technology fits well in our operating room, because we already have the Infiniti phaco system," Dr. de la Cruz says. "We were confident the company would provide good support and maintenance."

In addition, Dr. McCulley notes, having the LenSx Laser creates an opportunity to expand the platform when enhancements become available. "We've had the great pleasure and opportunity to evaluate the CENTURION® Vision System," he says. "It's not just a next-generation phacoemulsification machine. It's a revolutionary one. The company has made major improvements to fluidics and precision."

High-tech Surgical Training

Dr. de la Cruz has been using the LenSx Laser in his training program at UIC for about 2 years; the SoftFit™ Patient Interface was introduced in the spring of 2013. This technology is integral to his approach to teaching cataract surgery. "The laser has the capability to complete certain steps of the surgery, so if a resident is having difficulty manually performing any of these steps, such as constructing the wound, creating the capsulorhexis or fragmenting the lens, I have the laser do it for him," he says. "The resident will continue to practice the manual technique in the wet lab to perfect it, but by having the laser do that part of the surgery, we don't put a patient at risk of complications. Nor do we decrease the number of surgeries we're doing, and we don't delay the process of learning other parts of the surgery. We're not changing the way our residents do surgery, we're just giving them another option."

A survey of cataract surgeons training in Europe several years ago found the most difficult steps in the surgical procedure were capsulorhexis and nuclear division.¹ Dr. McCulley says he would add a third difficult step: creating consistent, self-sealing, watertight corneal incisions. "The LenSx Laser accomplishes all three of those steps in a more predictable manner than manual surgery."

The faculty is using the laser at UT, and Dr. McCulley expects to begin training residents shortly. "My intention with our training program is to have residents begin learning phacoemulsification cataract surgery and IOL implantation by using the LenSx Laser," he says. "Once they're proficient with the laser, I'll have them perform the entire procedure manually. That way, when they finish their training, they'll be proficient with both methods."

Although their approaches differ, both Dr. McCulley and Dr. de la Cruz want to ensure that surgeons who've been through their programs will have the skills necessary to perform cataract surgery, even if they don't have access to a femtosecond laser or if they have patients who aren't candidates for the laser.

Minimal Learning Curve

Dr. de la Cruz had some concerns that residents who were just learning to perform cataract surgery would face a steep learning curve when the femtosecond laser was introduced. He was pleasantly surprised. "Imagine you're learning to perform a surgery and then someone throws in a new technology," he says. "My initial thought was the residents might be resistant to it and have difficulty, but in fact, it was the opposite. The learning curve was almost nonexistent. The residents were able to adapt to this new technology very well early on, and we didn't put anyone at risk. Nor was there a greater burden on the residents with regard to their education."

Not only did residents adapt, but they embraced the new technology. "For the residents, it's exciting to add a component of technology," Dr. de la Cruz says. "Of course, with their initial cases, they were cautious, but once they entered fully into it, they enjoyed it. They really appreciate being able to have a perfect capsulotomy. They enjoy being able to place their wounds wherever they want them with exact precision as to depth and thickness. They found their outcomes were much more predictable and reliable."

Confidence Builder

According to Dr. de la Cruz, residents and fellows using the LenSx Laser are implanting toric and multifocal lenses with more confidence. "I've noticed a change in how our residents advise patients," he says. "In the past, they were more likely to offer patients advanced technology IOLs later in the year. Now, they're comforable offering them to patients as early as August, which is the beginning of their third year. Seeing that they're more confident providing this kind of care early in their training, I believe they'll be more confident offering it to their patients when they go into practice."

Dr. de la Cruz notes his own confidence has increased. "Now that I have the LenSx Laser system, I feel my outcomes are more predictable, particularly when positioning the lenses," he says. "I've been more comfortable and confident offering advanced technology lenses to my patients. In fact, my practice has become much more focused on refractive cataract surgery, because I can offer extra precision to patients with the laser and the addition of advanced technology IOLs now."

High Expectations

Cataract surgery is increasingly becoming a refractive procedure, and patients' expectations reflect that shift. As Dr. McCulley notes, "With monofocal and astigmatism-correcting lenses, patients expect to see well at distance. With presbyopia-correcting lenses, they expect to see well at all distances. What's more, patients want their cataracts removed with a laser, because they have the perception that lasers are more precise and safer."

In addition, they were excited to have the surgery partially done with a laser. That's very attractive to patients. ▪

Reference

1. Dooley IJ, O'Brien PD. Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg. 2006;32:604-608.