1. Joshua Ki Hu Vanderbilt Eye Institute Ophthalmology, PGY-4 DATE 05.30.08 Vanderbilt Eye Institute

2. Introduction  Cataract surgery is one of the most commonly performed surgeries in the world, with over 1 million performed per year in the United States alone.  Resident education designed accordingly.

3.  In 2002 a resident survey revealed that: - the number of phacoemulsification procedures performed by a single resident ranged from 50 to 300 - the majority perform between 80 and 140 (avg. 120) - 25% performed less than 80

4.  In 2007, the Residency Review Committee of the ACGME increased the minimum number of resident performed phacoemulsification procedures from 45 to 86.  Few studies to date attempt to identify time point/case number for significant improvement in resident performed surgery.

5.  The aim of this study is to identify a time point/case number for which a significant decline in complication rates occurs.  Also as a measure of internal “quality” of Vanderbilt’s residency program.  Are patients being subjected to an acceptable level of complications in the early parts of training?

6. Materials and Methods  Retrospective chart review  VA Hospitals, Nashville, TN, charts from patients who had undergone resident performed phacoemulsification during a 6 year period from July 8, 1999, through June 28, 2005 were reviewed.

7.  The surgical cases were categorized based on the resident surgeon performing the cataract surgery, and then sorted chronologically and given a sequential case number.  The total number of intraoperative complications including posterior capsular tear, vitreous loss, and retained lens fragments were recorded, as well as the case numbers for which they occurred.

8.  The study was powered at 80% with statistical significance set at p = 0.05 to detect a 50% change in complication frequency (estimated to be 15%)  Sample size = 304

9.  The cases were divided into groups spanning every 20 procedures  Statistical analysis was performed - using chi square analysis - calculating 95% confidence intervals

10. Results  19 resident surgeons  Under guidance 23 different attending surgeons  99.4% cases performed on males  51.6% Right eyes, 48.4% Left eyes

11. Number of Cases Sorted by Resident Surgeon N = 1442 Mean: 76 Range: 58 - 115

12. Overall Complication Rate

13. Rate of Posterior Capsular Tear vs. Surgical Case Number

14. p = 0.0710 p = 0.0244

15. Rate of Vitreous Loss vs. Surgical Case Number

16. p = 0.0386

17. Conclusions  There is a statistically significant decrease in intraoperative complications in resident performed phacoemulsification cataract surgery once the surgeon has performed 80 procedures. 61-80 for Posterior Capsular Tears 41-60 for Vitreous Loss

18.  The results of this study are in line with the ACGME recommendation to increase minimum amount of phacoemulsification procedures from 45 to 86.  There was also a trend of continued reduction in intraoperative complication rates with increasing surgical experience.

19. Resident Teaching Institution Number of Cases Posterior Capsular Tear Vitreous Loss Retained Lens Fragment Vanderbilt University144211.2%8.2%0.7% Emory University6804.9%3.4%0.4% New Jersey Medical School7196.7%5.4%1.0% University of California – San Francisco 218-8.7%- Penn State College of Medicine 332-4.8%- Baylor College of Medicine1819.9%5.5%- University of Chicago343-4.7%- University of Arizona136-14.7%- University of Utah396-1.8%- Royal Eye Infirmary, England1025.8%2.9%- Istanbul/Akdeniz University, Turkey 29610.5%6.4%2.4%

20.  Overall, phacoemulsification complication rate 3-4%  Resident performed cataract surgery complication rate has been deemed “acceptably low”  What about the early cases?  Roll of adjunctive surgical learning tools

21. Limitations  Case series subject to limitations of retrospective study.  Accuracy of medical record?  The data included only those procedures performed at the VA Hospital.

22. Acknowledgements  Dr. Amy Chomsky  VA Staff  Vanderbilt Eye Institute Residents and Teaching Faculty

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