PHACOEMULSIFICATION - A SENIOR SURGEONS LEARNING-CURVE

We sought to prospectively document and evaluate the learning curve of an experienced extracapsular surgeon making a supervised transition f rom extracapsular cataract extraction (ECCE) to phacoemulsification. O ver a period of 2 weeks, 51 phacoemulsification procedures using an en docapsular nucleofractis technique were performed by a single senior s urgeon at the Christian Medical College in Vellore, India under the su pervision of a visiting US expert with more than 15 years experience i n the technique. Vitreous loss occurred in seven eyes (six prior to th e stage of cortical aspiration); failure of capsulorhexis necessitated conversion to standard ECCE in four. Injury to the inferior iris duri ng phacoemulsification was cosmetically significant in three eyes. Two eyes had mild persistent localized corneal edema, but there were no i nstances of permanent corneal damage. One eye had intraoperative displ acement of the nucleus into the vitreous. In one eye with vitreous los s, the implanted intraocular lens dislocated into the vitreous cavity. Two patients had clinically detectable cystoid macular edema at 6 wee ks. Eleven patients were lost to follow up after 3 weeks. Six weeks af ter surgery, 36 of the remaining 40 eyes (90%) had achieved a best-cor rected visual acuity of 6/6. We conclude that phacoemulsification requ ires supervised learning, even for an experienced surgeon. Complicatio ns still occurred, but were restricted to the unfamiliar steps of the surgery. Factors identified in the first 2 days of surgery (10 cases) as critical in the smooth transition to phacoemulsification were caref ul selection of initial cases, a successful capsulorhexis, and hydrodi ssection with vigorous nucleus mobilization. Four of the six instances of vitreous loss during the ultrasonic stage of the procedure occurre d in the first 2 days. The subsequent days were spent perfecting the t echniques learned in the first 10 cases. Prior expertise in scleral po cket incisions and capsulorhexis helped speed the successful transitio n to phacoemulsification.