Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Comparison of Strabismus Surgical Efficiency and Complications Between Attending Surgeon Versus Supervised Ophthalmology Residents

Alixandra Riddering, MD; Xihui Lin, MD; Kim Le, MD

Abstract

Purpose:

To compare surgical operating times and complication rates in strabismus surgery undertaken by attending surgeons versus supervised residents. Eye muscle surgeries are one of the first operations in which ophthalmology residents can actively participate for a majority of the surgery. These surgeries provide an ideal controlled environment to compare attending surgeon and resident surgical performance.

Methods:

A total of 36 surgeries were included: 19 were bilateral muscle surgeries and 17 were unilateral surgeries. Residents completed a microsurgical course prior to operating. One attending surgeon was present for all surgeries, but there were 10 different residents throughout the cases. Primary outcomes were attending surgeon and resident surgical times and complications.

Results:

On average, residents took 35.5 minutes to perform eye muscle surgeries compared to 19.3 minutes for the attending surgeon (P < .0001). Of the resident surgeries, there was one complication requiring a return to the operating room. There were six minor complications during resident surgeries and one minor complication during attending surgeon surgery.

Conclusions:

As expected, resident operation times were nearly double attending surgeon surgical times. Although there was one significant and several minor complications resulting from resident surgeries, none were vision threatening. This microsurgical course likely contributed to the low number of complications. The longer surgical times and minor complications resulting from resident surgeries require physicians to disclose resident involvement during the consenting process for pediatric strabismus surgeries.

[J Pediatr Ophthalmol Strabismus. 2020;57(4):235–237.]

Abstract

Purpose:

To compare surgical operating times and complication rates in strabismus surgery undertaken by attending surgeons versus supervised residents. Eye muscle surgeries are one of the first operations in which ophthalmology residents can actively participate for a majority of the surgery. These surgeries provide an ideal controlled environment to compare attending surgeon and resident surgical performance.

Methods:

A total of 36 surgeries were included: 19 were bilateral muscle surgeries and 17 were unilateral surgeries. Residents completed a microsurgical course prior to operating. One attending surgeon was present for all surgeries, but there were 10 different residents throughout the cases. Primary outcomes were attending surgeon and resident surgical times and complications.

Results:

On average, residents took 35.5 minutes to perform eye muscle surgeries compared to 19.3 minutes for the attending surgeon (P < .0001). Of the resident surgeries, there was one complication requiring a return to the operating room. There were six minor complications during resident surgeries and one minor complication during attending surgeon surgery.

Conclusions:

As expected, resident operation times were nearly double attending surgeon surgical times. Although there was one significant and several minor complications resulting from resident surgeries, none were vision threatening. This microsurgical course likely contributed to the low number of complications. The longer surgical times and minor complications resulting from resident surgeries require physicians to disclose resident involvement during the consenting process for pediatric strabismus surgeries.

[J Pediatr Ophthalmol Strabismus. 2020;57(4):235–237.]

Introduction

During ophthalmology residency training in the United States, strabismus surgeries are one of the earliest surgeries in which ophthalmology residents can actively participate to a significant degree. In our center, first-year ophthalmology residents often perform a significant portion of these surgeries. Typically, attending surgeons will perform muscle surgery on the first eye with the ophthalmology resident as the primary assistant. Then, the ophthalmology resident becomes the primary surgeon for the second eye muscle surgery with the attending surgeon as the primary assistant.

Because a patient's anatomy, including eye muscles, fornices, conjunctivae, and Tenon's capsules, and overall tissue condition and healing properties are presumed to be symmetrical between the two sides, strabismus surgery creates an ideal controlled situation to compare attending surgeon and resident surgical outcomes. Previous studies have compared operative duration and surgical outcomes between residents in different years of training in the United States1 and Korea.2 Another study compared postoperative complications between residents and attending surgeons in Egypt.3 However, there are no studies comparing outcomes between residents and attending surgeons in the current structure of the U.S. Graduate Medical Education training system. Although Arfeen et al3 demonstrated resident surgeons are slower than attending surgeons, it is unclear how much longer resident operative times are than attending surgeon operative times. The purpose of this study was to compare surgical operating times and complication rates in strabismus surgery undertaken by attending surgeons versus supervised residents.

Patients and Methods

The study was conducted over a 6-month period. Outcome measures included total surgical time, minor surgical complications, and major surgical complications. Prior to the first surgery, PGY-2 residents underwent a strabismus microsurgical course. Didactics included anatomy, surgical instruments, and steps of strabismus surgery. This was followed by wet lab practice using grapes and bacon to simulate eyes and extraocular muscles, respectively. Each resident was required to send photographs of their work to the attending surgeon, completing a total of 25 forehand and 25 backhand simulated scleral passes prior to operating.

The same attending surgeon was present for all surgeries (KL). However, of the resident cases studied, there were 10 different residents performing eye muscle surgeries. The majority of the residents were first-year ophthalmology residents. The ophthalmology residents were not aware that they were being timed during surgery. Surgical cases included bilateral symmetrical eye muscle surgeries and unilateral surgeries. For unilateral recess and resect procedures, recession was completed by the attending surgeon and resection by the resident. Only primary horizontal muscle surgeries were included in the study. Restricted muscles, oblique muscles, and vertical muscles were excluded. Surgical duration was timed from incision to end of conjunctival closure. Major complications were defined as any complication requiring return to the operating room within 90 days of initial operation. Minor complications were defined as additional steps required in surgery.

Statistical analysis was performed using the Student's t and paired t tests.

Results

On average, operating time was 35.5 ± 6.0 minutes for residents and 19.3 ± 4.8 minutes for attending surgeons (P < .0001). Differences in surgical duration between resident and attending surgeon were similar between unilateral recess (attending surgeon) and resect (resident) and bilateral surgeries. The final deviation was 7.65 ± 5.20 prism diopters, measured at the final postoperative follow-up appointment. There was one major complication resulting from a resident eye muscle surgery. There were no major complications resulting from the attending surgeon's surgeries (Table 1). The single recorded major complication was a large suture granuloma, which required excision under general anesthesia within 90 days of the original surgery. The number of major complications was not statistically significant. There were six minor complications during resident eye muscle surgeries and one minor complication during attending surgeon eye muscle surgery (P = .054) (Table 2).

Resident vs Attending Surgeon Strabismus Surgery

Table 1:

Resident vs Attending Surgeon Strabismus Surgery

Minor Complications and Additional Steps Required in Surgery

Table 2:

Minor Complications and Additional Steps Required in Surgery

Discussion

In our center, supervised resident strabismus surgery took longer than attending surgeon surgeries and had more minor complications. These differences are statistically significant. Although there were more complications with resident surgeries, resident strabismus surgeries are overall safe procedures.1,2 Resident surgeries did not result in vision-threatening complications such as scleral perforation, postoperative infections, or severe postoperative misalignment. Additionally, it appears that resident scleral passes are safe as long as they are carefully monitored or guided by the attending surgeon. In our surgeries, the attending surgeon would only allow the resident to participate in eye muscle surgeries if the resident had demonstrated competency in a regimented strabismus surgical technique course that included instrument manipulation, scleral suture pass, and knot tying. Our microsurgical course likely contributed to the low number of complications.

Although resident surgeries are slower and require additional anesthesia time, pediatric patients requiring eye muscle surgery are generally healthy before undergoing surgery, so the risk of additional anesthesia time generally does not increase morbidity. Overall, however, resident strabismus surgeries are not as efficient or of the same quality as attending surgeon surgeries. For true informed consent, a resident's role in surgery likely needs to be mentioned. In fact, previous studies have demonstrated that nearly all parents would like to know that residents will be involved in their child's surgery.4

Supervised resident surgeons took 16.2 minutes longer to perform similar muscle surgeries compared to their supervising attending surgeon. Resident surgeons have more minor complications that do not threaten vision during surgery, but overall surgical outcomes were similar when compared to attending surgeon surgeries.

References

  1. Winter TW, Olson RJ, Larson SA, Oetting TA, Longmuir SQ. Resident and fellow participation in strabismus surgery: effect of level of training and number of assistants on operative time and cost. Ophthalmology. 2014;121(3):797–801. doi:10.1016/j.ophtha.2013.10.004 [CrossRef]
  2. Kim MH, Chung H, Kim WJ, Kim MM. Effects of surgical assistant's level of resident training on surgical treatment of intermittent exotropia: operation time and surgical outcomes. Korean J Ophthalmol. 2018;32(1):59–64. doi:10.3341/kjo.2017.0059 [CrossRef]
  3. Arfeen SA, Fouad HM, Hassanein DH, Esmael AF, Awadein A. Outcomes and complications rate of resident versus attending performed eye muscle surgeries. Semin Ophthalmol. 2019;34(5):347–352. doi:10.1080/08820538.2019.1622024 [CrossRef]
  4. Andrews H, Soni A, Green M, Ely A, Quillen D. Parent attitudes toward resident involvement in their child's strabismus surgery. J AAPOS. 2018;22(4):262–265.e3. doi:10.1016/j.jaapos.2018.03.008 [CrossRef]

Resident vs Attending Surgeon Strabismus Surgery

VariableResident Primary SurgeonAttending Primary SurgeonP
Surgical duration (minutes)35.619.9.0001
Major complicationsa10.99
Minor complicationsb61.054

Minor Complications and Additional Steps Required in Surgery

Attending ophthalmologist (1) :

Buttonholed conjunctiva; required closure

Resident (6):

Suture tied down prematurely, dragged Tenon's capsule into scleral tunnel; required relocking muscle

Laceration of superior conjunctiva; required closure

Poor conjunctiva suturing; required re-suturing

Inferior oblique hooked when trying to hook lateral rectus, muscle slid at insertion; required suturing muscle twice

Tore suture when tying too tightly during ligation; required re-suturing

Prematurely cut muscle; required re-suturing

Authors

From the Department of Ophthalmology, Henry Ford Hospital, Detroit, Michigan (AR, KL); and Kresge Eye Institute, Wayne State University, Detroit, Michigan (XL).

Supported by an unrestricted grant from Research to Prevent Blindness.

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

Correspondence: Kim Le, MD, Department of Ophthalmology, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202. Email: kle3@hfhs.org

Received: December 14, 2019
Accepted: March 30, 2020

10.3928/01913913-20200422-01

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