Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Comparison of Pediatric Cataract Surgical Techniques Between Pediatric Ophthalmology Consultants and Fellows in Training: A Video-Based Analysis

Akshay Badakere, FRCS; Preeti Patil Chhablani, DNB; Anjali Chandrasekharan, MS; Mohammad Hasnat Ali, MBA; Ramesh Kekunnaya, FRCS

Abstract

Purpose:

To compare intraoperative technique and quality of surgical steps in pediatric cataract surgery between pediatric ophthalmology consultants and fellows in training.

Methods:

In a video-based analysis by two fellowship-trained pediatric ophthalmologists, 42 surgical videos of pediatric ophthalmology consultants and 34 videos of fellows in training were graded based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). Six steps in surgery were analyzed: wound construction, anterior continuous curvilinear capsulorrhexis, irrigation and aspiration, intraocular lens implantation, primary posterior capsulorrhexis with anterior vitrectomy, and wound suturing. Cohen's Kappa was used to rate inter-observer agreement.

Results:

Cohen's Kappa scores ranged from 0.6 to 0.8. The median scores for surgical steps for both analyzed groups were similar. The mean duration of surgery was shorter for consultants (24 minutes, range: 10 to 45 minutes) than for fellows (40 minutes, range: 15 to 70 minutes). The median age of patients operated on by consultants was younger (24 months, range: 2 to 180 months) than fellows (58 months, range: 10 to 150 months).

Conclusions:

The quality of the surgical steps performed by pediatric ophthalmology consultants and fellows in training was similar.

[J Pediatr Ophthalmol Strabismus. 2019;56(2):83–87.]

Abstract

Purpose:

To compare intraoperative technique and quality of surgical steps in pediatric cataract surgery between pediatric ophthalmology consultants and fellows in training.

Methods:

In a video-based analysis by two fellowship-trained pediatric ophthalmologists, 42 surgical videos of pediatric ophthalmology consultants and 34 videos of fellows in training were graded based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). Six steps in surgery were analyzed: wound construction, anterior continuous curvilinear capsulorrhexis, irrigation and aspiration, intraocular lens implantation, primary posterior capsulorrhexis with anterior vitrectomy, and wound suturing. Cohen's Kappa was used to rate inter-observer agreement.

Results:

Cohen's Kappa scores ranged from 0.6 to 0.8. The median scores for surgical steps for both analyzed groups were similar. The mean duration of surgery was shorter for consultants (24 minutes, range: 10 to 45 minutes) than for fellows (40 minutes, range: 15 to 70 minutes). The median age of patients operated on by consultants was younger (24 months, range: 2 to 180 months) than fellows (58 months, range: 10 to 150 months).

Conclusions:

The quality of the surgical steps performed by pediatric ophthalmology consultants and fellows in training was similar.

[J Pediatr Ophthalmol Strabismus. 2019;56(2):83–87.]

Introduction

Learning the skills to perform a safe and technically sound cataract surgery is a prerequisite to any good training program in ophthalmology. This mandates that the programs have good assessment and monitoring tools that can enhance learning and surgical outcomes.1 In 1997, the Accreditation Council for Graduate Medical Education (ACGME) instituted six requirements for competency in residency programs: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning, and systems-based learning. The American Board of Ophthalmology added a seventh requirement: surgical competency in residency training.2

Historically and currently, the quality of surgical skills has been assessed either subjectively or objectively, using scoring systems such as the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR), Objective Assessment of Skills in Intraocular surgery (OASIS), and Global Rating Assessment of Skills in Intraocular Surgery (GRASIS).2 Microsurgical techniques have a steep learning curve and the pediatric age group has its own challenges. Thus, the purpose of our study was to compare the intraoperative technique and quality of every step in pediatric cataract surgery between consultants and fellows.

Patients and Methods

This study was conducted at the L. V. Prasad Eye Institute in Hyderabad, India, and was approved by the ethics committee and institutional review board. This was a video-based analysis of each surgical step done by two blinded observers. The two observers are fellowship-trained pediatric ophthalmologists proficient in performing and skill transfer in pediatric cataract surgery.

Two groups of unedited videos were analyzed. The first group (consultants) consisted of 50 surgeries performed by fellowship-trained pediatric ophthalmologists, with at least 2 years of post-fellowship experience. The second group (fellows) consisted of 50 surgeries, which were performed by fellows in various stages of a structured pediatric ophthalmology fellowship. All surgeries were uncomplicated pediatric cataract surgeries and included patients with congenital, developmental cataract. Patients younger than 14 years were included in the study. The surgeries were performed under general anesthesia. Only one eye was operated on in one sitting. All patients underwent lens aspiration with a primary posterior capsulotomy and anterior vitrectomy. Intraocular lens (IOL) implantation was performed in patients with a corneal diameter of 10.5 mm or greater, based on the surgeon's discretion and the presence of other intraoperative complications. Inthe-bag IOL implantation using a foldable, hydro-phobic acrylic IOL was preferred; however, whenever this was not possible, a three-piece IOL with polypropylene haptics was implanted in the sulcus.

The ICO-OSCAR for pediatric cataract surgery was used to grade each surgical step.3 The ICO-OSCAR for pediatric cataract surgery has the following scoring system: 2 = novice; 3 = beginner; 4 = advanced beginner; and 5 = competent.

Statistical Analysis

Statistical analyses were performed using R Core Team software (R Foundation for Statistical Computing, Vienna, Austria). Cohen's Kappa was used to rate the inter-observer agreement.

Results

Of 100 analyzed surgical videos, 50 were performed by consultants and 50 were performed by fellows. Incompletely recorded videos were excluded, thereby resulting in 42 videos in the consultant group and 34 videos in the fellows group. In the consultant group, 21 surgeries were performed on children younger than 2 years. In the fellows group, two surgeries were performed on children younger than 2 years. The six key surgical steps considered for analysis were wound construction, continuous curvilinear capsulorrhexis, irrigation and aspiration of the lens, IOL implantation, primary posterior capsulotomy and anterior vitrectomy, and wound suturing.

The inter-observer agreement and Cohen's Kappa for anterior capsulorrhexis were 95.72% and 0.84, wound construction were 98.36% and 0.83, IOL implantation were 96.54% and 0.82, irrigation and aspiration of the lens were 92.11% and 0.77, primary posterior capsulotomy and anterior vitrectomy were 96.07% and 0.68, and wound suturing were 90.07% and 0.71, respectively (Figure 1).

The pattern of agreement between the two observers for (A) anterior continuous curvilinear capsulorrhexis (CCC), (B) wound construction, (C) intraocular lens (IOL) implantation, (D) irrigation and aspiration (I&A), (E) primary posterior capsulotomy (PPC), and (F) wound suturing. The dark gray zone shows the area of agreement and the light gray zone shows the area of disagreement.

Figure 1.

The pattern of agreement between the two observers for (A) anterior continuous curvilinear capsulorrhexis (CCC), (B) wound construction, (C) intraocular lens (IOL) implantation, (D) irrigation and aspiration (I&A), (E) primary posterior capsulotomy (PPC), and (F) wound suturing. The dark gray zone shows the area of agreement and the light gray zone shows the area of disagreement.

The consultants operated on younger children (median age: 24 years, IQR [interquartile range]: 12 to 41 months, range: 2 to 180 months) and had a shorter surgical time (median time: 22 minutes, IQR: 15.5 to 30 minutes, range: 10 to 45 minutes) than the fellows (median age: 58 months, IQR: 38 to 72 months, range: 10 to 150 months; median time: 39 minutes, IQR: 25 to 51 minutes, range: 21 to 76 minutes). Complications included 1 posterior capsule tear for consultants and dropped lens matter in 1 eye and 1 eye in which the haptic of the IOL was partially cut during implantation for fellows. Table 1 lists the median scores of the individual surgical steps that were performed.

Summary of Median Scores of Steps Performed by Consultants and Fellows

Table 1:

Summary of Median Scores of Steps Performed by Consultants and Fellows

Discussion

The authors chose the ICO-OSCAR because the scoring system provided specific feedback for each step of surgery.4 Learning from experienced preceptors may aid the trainee by sharing the preceptor's vast experience, but has not been shown to reduce complication rates and give formative feedback to trainees. On the other hand, objective methods are transparent, formative, and can help a trainee identify his or her strengths and weaknesses in each surgery performed.1,2 They can also be used to assess inter-examiner reliability and validity.1

Adequately transferring microsurgical skills is one of the challenges faced by residency programs. Over the years, various time-tested techniques have been used to transfer skills and evaluate the quality of surgery performed. These vary from subjective models (eg, preceptor and apprenticeship model and regular audits looking into outcomes) to objective methods (eg, ICO-OSCAR, OASIS, and GRASIS scoring systems).1,2

We studied the proficiency of pediatric cataract surgery as performed by trained pediatric ophthalmologists in comparison with surgery performed by fellows in various phases of their training. Pediatric cataract surgery has traditionally been considered more complex and requires greater skill in comparison with routine adult cataract surgery. To have a structured assessment, we divided the surgery into six easily gradable steps.

Our study showed that there was no statistically significant difference in the grading of the surgical steps performed by fellows and consultants. Although this was not entirely expected, we suspect that the age of the patients in each subgroup may cause this result. The median age of patients was 22 months in the consultant group and 58 months in the fellows group. The complexity and level of difficulty of pediatric cataract surgery is linked to the age of the patient, so surgery is easier with older patients. This may explain why we did not observe a difference in the scores in the two groups, despite a difference in the level of training. Additionally, the groups only included patients with uncomplicated cataracts; cases requiring a greater level of skill (eg, traumatic cataract or cataract after vitreoretinal or other intraocular surgery) were not included.

This study is the first to examine the quality of surgery in a pediatric age group. Previously published studies were on the quality of surgeries performed by trainees in vitreoretinal procedures, glaucoma filtering surgeries, and a comparison of cataract surgery techniques performed by trainees.5,6

A limitation of this study is that it was primarily a video-based analysis. Consequently, it was difficult to know the complexity of the surgical case, which could influence scores. Newer trainees start with older patients and relatively simpler cases, whereas more experienced trainees and faculty perform the complex procedures.

The transfer of safe microsurgical skills from preceptors to trainees is a challenge. Using structured scoring systems, simulators, and video-based assessments can help trainees and can be useful for a systematic assessment of skill levels.

References

  1. Saleh GM, Gauba V, Mitra A, et al. Objective structured assessment of cataract surgical skill. Arch Ophthalmol. 2007;125:363–366. doi:10.1001/archopht.125.3.363 [CrossRef]
  2. Puri S, Sikder S. Cataract surgical skill assessment tools. J Cataract Refract Surg. 2014;40:657–665. doi:10.1016/j.jcrs.2014.01.027 [CrossRef]
  3. Swaminathan M, Ramasubramanian S, Pilling R, et al. ICO-OSCAR for pediatric cataract surgical skill assessment. J AAPOS. 2016;20:364–365. doi:10.1016/j.jaapos.2016.02.015 [CrossRef]
  4. Casswell EJ, Salam T, Sullivan PM, Ezra DG. Ophthalmology trainees' self-assessment of cataract surgery. Br J Ophthalmol. 2016;100:766–771. doi:10.1136/bjophthalmol-2015-307307 [CrossRef]
  5. Wilkinson JT, Richards AB, Choi D, Robertson JE Jr, Flaxel CJ. Incidence of retinal detachment after fellow-performed primary pars plana vitrectomy. ISRN Ophthalmol. 2013;2013:353209.
  6. Sharpe RA, Kammerdiener LL, Wannamaker KW, Fan J, Sharpe ED. Comparison of outcomes of resident-performed Ahmed valve implantation vs trabeculectomy. J Curr Glaucoma Pract. 2016;10:60–67.

Summary of Median Scores of Steps Performed by Consultants and Fellows

MedianQ1, Q3Range
Consultants
  CCC54, 53 to 5
  Wound construction55, 53 to 5
  Lens aspiration55, 53 to 5
  IOL implantation54, 53 to 5
  PPC & AV55, 53 to 5
  Wound suturing55, 53 to 5
Fellows
  CCC54.5, 53 to 5
  Wound construction55, 53 to 5
  Lens aspiration55, 53 to 5
  IOL implantation54, 52 to 5
  PPC & AV55, 52 to 5
  Wound suturing55, 53 to 5
Authors

From the Child Sight Institute, Jasti V. Ramanamma Children's Eye Care Centre (AB, PPC, RK), and the Department of Clinical Epidemiology and Biostatistics (MHA), L. V. Prasad Eye Institute, Hyderabad, India; and the Sadhuram Eye Hospital, Hyderabad, India (AC).

The authors have no financial or proprietary interest in the materials presented herein.

The authors thank Dr. Shoba Mocherla and Mr. Rajashekhar Chanti from the audiovisual team for their help in retrieval of videos.

Correspondence: Akshay Badakere, FRCS, Child Sight Institute, Jasti V. Ramanamma Children's Eye Care Centre, L. V. Prasad Eye Institute, Road Number 2, KAR Campus, Banjara Hills, Hyderabad, Telangana 500034, India. E-mail: akshaybadakere@gmail.com

Received: September 16, 2018
Accepted: November 08, 2018

10.3928/01913913-20190122-03

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