Download Strauss MSICS Curriculum

Strauss MSICS
Curriculum ©
Use of MSICS as a Stimulus for
Development
This program is designed to facilitate the development of surgical skills and
leadership capacity. An emphasis is placed on the tools needed for
development of successful indigenous eye teams.
Glenn Strauss, MD
Strauss MSICS Development Curriculum ©
Used by permission Glenn H Strauss, MD revised for 2009-2010
Curriculum Overview
Chapter 1. Why MSCIS?
Pg 3 - 4
A. Efficient technique for addressing the spectrum of surgical
problems associated with end stage cataracts
B. Decreased dependency on advanced technology
C. Safety and improved outcomes of a scleral tunnel procedure
Chapter 2. Curriculum goals
A. Surgeon effectiveness
B. Successful small scale cataract projects
C. Training of trainers
Pg 5 - 6
Chapter 3. Challenges for the transitioning surgeon
A. Transitioning from phacoemulsification to MSICS
B. Transitioning from classic ECCE to MSICS
Pg 7 - 8
Chapter 4. Core MSICS knowledge
Pg 9 - 22
Section 1. Understanding the fundamentals of the MSICS technique Pg 9-12
Section 2. Cataract surgical categories and patient selection
Pg 12-14
Section 3. Associated clinical findings requiring technique modifications
Pg 14-17
Section 4. Managing intraoperative complications in a low tech environment
Pg 17-20
Section 5. Management of postoperative complications
Pg 20-22
Chapter 5. Core MSICS surgical skills
A. Surgical fundamentals
B. Anesthesia options
C. Scleral tunnelling
D. Capsular manipulation
E. Nucleus manipulation
F. Cortical manipulation
G. Management of ocular co-morbidities and surgical
complications
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Pg 23 - 24
Chapter 6. Using MISCS as a stimulus for development of the ophthalmic
community
Pg 25 - 29
Section 1. Developing the disciplines needed for success
Section 2. The vision restoration paradigm
Section 3. Developing a successful MSICS team
Section 4. Foundations for the development of an eye care industry
Chapter 7. Training of trainers
Pg 30 - 31
A. Using the “Head, Hands, Heart” surgical training concept
B. Communication tips
Final notes: The importance of surgeon advocacy
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Pg 31
Chapter 1. Why MSICS?
Since the 1980’s, advances in cataract surgery have benefited patients around the
world. Scleral tunnel techniques combined with high tech tools for phacoemulsification have
contributed enormously to patient safety and the quality of outcomes. Until recently, these
advances have been of little benefit to developing nations.
MSICS has been developed by a number of surgeons applying the principles learned
from modern cataract surgery. MSICS is not second rate surgery for the masses. It is an
advancement in cataract surgery that makes the benefits of scleral tunnel techniques available
to developing nations. When done properly, it is a high quality, elegant procedure.
The benefits of MSICS can be summarized as follows:
Efficient technique for addressing the spectrum of surgical problems associated
with end stage cataracts
Chronic lack of access to surgical eye care has resulted in the development of a
worldwide patient population with what can best be described as end stage cataracts. MSCIS
is proving itself to be the right technique for this patient population. Phaco is designed for the
challenges of cataract removal in developed nations not for the many presentations of end
stage cataracts found in developing nations. These distinct patient pools must be approached
differently but without compromising quality.
Decreased dependency on advanced technology
Historically, advances in cataract surgery have been driven by technology.
However, much of the need for cataract surgery is in nations where use of advanced
technology is currently not sustainable due to the high cost of buying and maintaining the
technology. Developing nations are full of broken or useless medical equipment obtained
with the hope of progress but without a real understanding of the challenges.
It has been shown that phacoemulsification can be used to provide premium service at
a price high enough to partially subsidize service to the indigent. But MSCIS provides a high
quality alternative without the technology and the cost. MSCIS represents advancement in
technique without dependency on technology.
Safety and improved outcomes of a scleral tunnel procedure
In many cultures, cataracts are considered to be a normal consequence of old age.
Blindness is perceived as a fate to be endured rather then corrected. Cataract surgery is a
choice for the desperate not a valued service for the aging.
In such cultures it is critical to offer a procedure that inspires the confidence of the
people. There is a growing body of literature reporting the safety and outcomes of MSCIS.
Comparisons with the gold standard, phacoemulsification, are favourable. But patients
themselves decide the value of a medical procedure. If a patient waits weeks before the
vision improves, they are much less likely to consider the procedure to have been successful
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even if they end up with good vision. MSICS is an important advancement for developing
nations making the operative experience and recovery quick and comfortable.
From the surgeons point of view, improved operative efficiency and decreased
postoperative complications also decreases cost and increases availability of time to generate
more income. Combined with the lower cost of the equipment and consumables, MSCIS has
the potential to improve surgeon satisfaction by increasing income as well as improving
outcomes. Both of these factors are imperative for the development of an eye care industry
sustained by meeting the needs of the population it serves.
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Chapter 2. Curriculum goals
This curriculum is designed for cataract surgeons seeking new skills for addressing
the problem of treatable blindness. It is not a comprehensive curriculum for those who are
just beginning their surgical training. The purpose here is to broaden and refine the skills of
the new or established surgeon, challenging the talented among them to be the foundation for
the next generation of eye care in developing nations. Young surgeons must be encouraged to
stay in developing nations by providing them tools that make their work satisfying and
valued.
Training of cataract technicians may be appropriate in certain circumstances.
Additional curriculum can easily be added for establishing the basics of ophthalmic surgery.
The question of just how much surgical training is required to be safe for the public trust is
beyond the scope of this curriculum.
Goal #1: Surgeon effectiveness
The goal of this curriculum is to produce surgeons who effectively address the
problem of cataract blindness in developing nations. In most cases this means a surgeon
should be able to sustain approximately 2,000 cases per year with 90% of cases achieving
good outcomes defined in this curriculum as 6/24 or better uncorrected vision (note WHO
standard is 90% 6/18 or better). Mastering MSICS skills is an important skill needed to reach
this goal but this curriculum also addresses key leadership elements needed for success.
This curriculum is focused on mentoring the ophthalmic surgeons who must take
responsibility for meeting the needs of their own people. Sadly, ophthalmic surgeons in
developing nations often find themselves serving the needs of visiting surgeons rather then
the other way around. This curriculum is designed to put the emphasis where it belongs.
Goal #2: Successful small scale cataract projects
In developing nations where successes are rare, even small scale successes can have a
major impact. The goal of this curriculum is more than just transferring a technical skill. It is
also designed to produce successful small scale cataract surgery projects using the new
MSCIS skills as the stimulus for change in the ophthalmic community. Hopefully, this
success becomes contagious and produces regional as well as local change.
Goal #3: Training of trainers
The final step in this curriculum is the development of the skills needed to train
others. Communication techniques and training strategies can be taught, the effectiveness of
a trainer also relates to their desire for the success of others. This curriculum assumes that the
trainer is devoted to the success of their trainees: allowing for learning opportunities,
mistakes, and respectfully addressing specific weaknesses. Trainees will imitate much of
what they have experienced as they train others. In developing nations, the relationship that
forms between the trainer and the trainee can become an important factor for ongoing success
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and should not be underestimated. It is the hope of this author that this curriculum will
provide many opportunities for these valuable relationships to develop.
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Chapter 3. Challenges for the transitioning surgeon
Transitioning from phacoemulsification to MSICS
Western surgeons, well trained in phacoemulsification, typically find that the
challenges of end stage cataract pathology frustrate even their best efforts. Their usual
technique and their surgical tricks are insufficient when the prevalence of rock hard nuclei
and zonular pathology is high. While careful case selection can certainly yield good phaco
candidates, this does not address the most desperate cases.
Phaco surgeons typically make the transition to MSICS in a relatively short period of
time. Experienced phaco surgeons typically require only 10 to 12 cases to learn the MSICS
tunnel but they often continue to struggle with the new hydrodynamics of the tunnel for
another 20 to 30 cases.
The main challenge is the wider tunnel. The inner wall of an 8.0 mm inner tunnel is
much more floppy then in the usual 3.0 mm phaco tunnel. Instruments inserted into the
anterior chamber must be delicately balanced on the inner posterior lip of the tunnel to
maintain the chamber. Manual regulation of the anterior chamber pressure adds a new
dynamic to the usual phaco technique not to mention the bimanual technique for cortical
management. Additional challenges include absence of a red reflex during capsulotomy and
manual expression of the nucleus.
These surgeons are often motivated by a desire to help their fellow man. With proper
guidance, they can offer appropriate assistance to address the backlog of cases in the fight
against global blindness.
Transitioning from classic ECCE to MSICS
Surgeons trained in classic extracapsular surgery may not have had the benefit of
comprehensive ophthalmic training. In addition to the challenges faced by the phaco surgeon,
the classic ECCE surgeon must learn the basics of scleral tunnelling and how to handle
unfamiliar instruments. Typically, these surgeons require basic instruction in the proper set
up of the surgical microscope, hand position and support, how to properly hold blades, the
importance of protecting the cornea for improved outcomes, and the concept of bimanual
surgery. Good surgeons can achieve basic proficiency with thirty to forty supervised cases.
Two hundred fifty to three hundred cases are needed for advanced proficiency and the ability
to be a trainer.
Classic ECCE surgeons in developing nations see the potential of MSCIS to increase
their effectiveness. Their normal ECCE surgery time is often around 30 minutes.
Postoperative suture management as well as prolonged healing time make postoperative care
a significant burden on their clinical time. While it is possible to significantly improve a
surgeon’s classic ECCE technique and reduce time and complications, the one day
postoperative results, stability of refraction, and safety cannot match a well done tunnel
procedure. Many classic ECCE surgeons have dealt with the nightmare of intraoperative
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pressure resulting in expulsion and most have experienced postoperative broken sutures with
iris prolapse or IOL expulsion. These issues are virtually non-existent with MSICS.
Case selection is also broadened with MSCIS. Typically, classic ECCE surgeons have
been taught that only the most advanced cataracts have an appropriate risk/benefit ratio.
Many 6/60 or counting fingers candidates for cataract surgery are left unoperated until they
have deteriorated to perception of light. In fact, the classic ECCE surgeon may be
uncomfortable at first with techniques for removal of formed cortex and posterior subcapsular
type cataracts.
In addition, the classic ECCE surgeon’s paradigm may be more about cataract
removal than good one day visual outcomes. Avoiding vitreous loss is the priority,
sometimes without practical concern about protecting the cornea. Biometry and IOL
calculations are considered to be a luxury rather then a basic necessity. Because of the
scarcity of resources, viscoelastics are used sparingly often with serious consequences. The
cost of a poor outcome or long recovery is not considered.
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Chapter 4. Core MSICS knowledge
Trainees should demonstrate mastery of the following didactic information. This
information should be reviewed as training progresses using case illustrations. The trainer
will verify mastery prior to certification of completion of this curriculum.
Section 1. Understanding the fundamentals of the MSICS technique
Training begins as a carefully guided mental exercise. The trainee must begin
to think like an MSCIS surgeon in preparation for hands on training. These principles
are best explained by a knowledgeable trainer one-one-one or in a group interactive didactic
setting before hands on work in the surgical theater. The principles should be repeated as the
trainee progresses.
A. Video and live case observation
A minimum of 20 live cases will be observed through the teaching scope. In
addition, the training video should be reviewed regularly for the first week of training.
During observation, the trainer will narrate actions, explaining the specifics of each case in a
step-wise fashion.
B. Recitation of basic MSICS steps to the trainer
The trainee should be able to smoothly verbalize each critical step of
the procedure in the proper order. Mentally rehearsing the steps in the procedure helps
speed the learning process and reinforces the thought processes needed for good surgical
judgement and decision making. Rote learning is typically quite familiar to developing nation
trainees and is an important first step to building their confidence.
C. Understanding the model using simple line illustrations
The trainer will use simple line drawing illustrations to communicate
important concepts in MSICS.
1. basic tunnel architecture: note the suspension bridge-like
configuration and the limbal straddling
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2. the tunnel as a flap valve: regulating the anterior chamber
pressure
3. the tunnel as a funnel: the only way out of the anterior chamber is
the tunnel mouth making it easy to capture the nucleus
4. the inner edge of the posterior tunnel wall as a fulcrum: note the
principles of using instruments through a flap valve
5. anterior capsular tearing principles: centripetal vs centrifugal
tearing
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6. nucleus dislocation: cantilever manipulation
D. Understanding the difference between a one-handed and a two-handed
technique and how this applies to MSICS
The trainee will imitate each of the following movements as
demonstrated by the trainer. These movements should be practiced at first without a
microscope to allow the trainee to get the feel for proper movement of the fingers,
wrist, arm, and shoulder. The techniques can then be practiced in a wet lab if
available.
1. Making the tunnel
The trainee will learn the feel of fingertip control of the blades, use of the
fixating hand to move the eye for optimal positioning and the paint brush type stroke
used to do the dissection.
2. Holding the cystotome/viscoelastic syringe
The trainee will learn to hold the instrument with two hands and will learn the
wrist movement needed to pivot the cystotome at a point on the shaft of the cannula.
3. expressing the nucleus: various techniques
The trainee will learn to use the lens loop as a glide for the nucleus not a
scoop. Maintaining even pressure on the posterior wall of the tunnel when using a
curved lens loop will be demonstrated. Demonstration will include the importance of
proper wrist action, the use of the fixating hand to roll the eye into optimal position,
and various lens loops including the irrigating vectis. The fish hook technique will be
demonstrated as an option but this curriculum recommends lens loop removal as the
preferred technique.
4. Irrigation/aspiration and cortical manipulation using
equatorial sweeping
The trainee will learn the hand position needed for rapid manipulation of the
syringe as well as finger tip control and wrist position for the cannula. The trainee
should practice rapidly switching from irrigation to aspiration and back again. The
trainee will practice the pivoting of the cannula between two fingers and sweeping
movements while keeping the cannula port upright at all times. The trainee should
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understand the cannula as a vacuum controlled cortical manipulator rather than simply
a device to aspirate cortex.
5. Lens insertion angles
The trainee will learn the proper hand, wrist, and arm movements needed to
insert both rigid and flexible IOLs. The trainee will understand the proper angle to
introduce the IOL into the tunnel, the angle of insertion into the capsular bag, and the
rotation of haptics.
6. Viscoelastic as the “third hand”
The trainee will understand the concept of supporting the corneal dome,
opening the bag, moving the iris or lens, controlling vitreous, and floating a dislocated
lens. The rate of injection, the volume, and the use of the anterior chamber itself to
direct the movement of viscoelastics will be explained.
Section 2. Cataract surgical categories and patient selection
Complete diagnostic exam including dilated indirect ophthalmoscope exam is ideal.
The reality is that MSICS will often be used in the context of mass screening for surgical case
selection. Using clear cornea, the absence of an afferent papillary reflex, and visual acuity of
6/60 to perception of light as the screening criteria, 97% of selected patients will be
appropriate surgical cases. Addition of preoperative slit lamp exam to confirm dense cataract,
the accuracy increases to 99%. The presence of a dense cataract makes it difficult to rule out
pre-existing macular disease that may result in a poor outcome. Evidence of corneal disease,
glaucoma, or trauma makes a poor outcome more likely but these patients may still be
acceptable candidates for surgery depending on their clinical presentation. Helping the
patients understand their situation may be difficult and most are accepting of any
improvement.
MSCIS surgery is adaptable to a variety of surgical challenges. These challenges are
easily categorized and will help the surgeon plan a strategy for each patient. Surgery must
always begin with an assessment of surgical category.
A. Mature black cataract (HM – LP, red reflex absent)
This end stage cataract is often associated with weak zonules, partial
dislocation, and pupil abnormalities. Typically, it requires a slightly larger tunnel and
sphincterotomy if the pupil is poorly dilated. The capsulotomy must be approached
cautiously, taking care to avoid engaging the dense nucleus with the cystotome needle until
the anterior capsule is fully open.
If the nucleus does not glide easily through the tunnel, enlarge and try again.
It is best to minimize the amount of pressure required to express the nucleus. In most cases,
there will be minimal residual cortex.
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B. Mature white cataract (HM – LP, red reflex absent)
1. With nuclear chip
A golden color under the capsule should alert the surgeon to the possibility of this
condition. It is often associated with capsular fibrosis which may require use of micro
scissors for successful cutting and removal.
Always begin capsular tear near the tunnel to provide access into the capsular bag in
the event of bag collapse. The peripheral bag decompresses rapidly after the first tear of the
capsulotomy leaving a golden colored chip that moves freely within the bag. The
capsulotomy must proceed with caution keeping the chip under the cystotome needle at all
times.
The chip must be hydraulically expelled from the bag to prepare for expression of the
nucleus. In most cases, the cystotome cannot be used to effectively manipulate the nucleus
and only increases the risk of accidental capsular bag tears. There will be minimal residual
soft cortex. Occasionally, residual dense cortical debris must be manually expressed from the
peripheral bag as it is not soft enough to engage with the Simcoe cannula.
2. Without nuclear chip
The hypermature cortical cataract is often associated with capsular fibrosis which
may require use of scissors for successful cutting and removal. Always begin the capsular
tear superiorly to provide access into the capsular bag from the tunnel if the bag collapses. If
the capsular bag decompresses completely after the initial tear, use of the cystotome must stop
immediately to avoid accidental tearing of the posterior capsule.
Use viscoelastic to reform the bag, to express remaining liquid cortical material, and
to clear the view. Enlarge the capsulotomy using capsular forceps or scissors if necessary to
create a capsular opening large enough to insert an IOL but do not attempt to complete the
capsulotomy until after the IOL has been inserted. A two handed technique may be needed to
remove the capsular flap using capsular forceps to stretch the capsule and the micro scissors
to cut. If the capsular flap is minimal, the Simcoe cannula may be used to engage the flap and
tear it off with a quick jerk.
C. Typical advanced cataract (6/60 – CF, red reflex dim but present)
Use the standard procedure unless there is associated pathology. Note that
rotating the nucleus to dislocate it shears much of the peri-equatorial cortex loose. This
cortex may be left behind in the tunnel as the nucleus passes through it and can be easily
expressed prior to use of the Simcoe leaving minimal residual cortex.
D. Posterior subcapsular cataract (6/36 – CF, red reflex usually present)
These cataracts are often associated with younger patients and trauma. A
slightly smaller tunnel is adequate for removal of the cataract and will improve control of the
anterior chamber.
The soft nucleus will make it difficult to manipulate with the cystotome.
Anterior capsulotomy must be performed cautiously to avoid pushing the needle through the
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cataract and the posterior capsule. Hydro dissection of the nucleus is required to luxate the
nucleus into the anterior chamber. Expression of as much residual cortex as possible
decreases the time needed for manual aspiration. This decreases risk of posterior capsular
rupture.
E. Juvenile and congenital cataracts
The cornea, capsule, and sclera are more elastic if the patient is under 30
years old. For children under ten, the tunnel should be modified to a smaller, squared off
configuration approximately 4mm by 4mm. After hydrodissection, I&A is used for removal
of the cataract. An alternative is the use of an irrigating cannula sweeping side to side in the
tunnel as fluid is injected to wash the cataract out.
A foldable acrylic lens should be inserted, if available, with the IOL power
modified based on age to allow for normal growth. The following table suggests possible
IOL power adjustments needed but final decision should always be on a case by case basis at
the surgeons discretion. If biometry is not possible, intraoperative retinoscopy may be used to
estimate the IOL power. The aphakic spherical equivalent is multiplied by 1.75 to
approximate the IOL power with an A constant of 118.4. The power must be adjusted for
other A constants in direct proportion to the difference in the A constant.
Age (yrs)
0-1
1-4
5-12
Subtract # of Diopters from IOL power
6
3
1
In patients under 10 years old, primary posterior capsulotomy and mechanical
pars plana core vitrectomy are required to avoid secondary cataract formation. This is best
performed after the IOL is inserted. These patients are more likely to require suturing and in
the case of children under 10, suturing should be done even if the wound is water tight.
Section 3. Associated clinical findings requiring technique modifications
Always begin the surgical case by inspecting for the conditions described below.
Failure to do so will lead to unanticipated complications that may be avoided with planning.
A. Small pupil
Adequate pupillary dilation is essential using cyclopentolate 2% and
phenylephrine 2.5% to assure maximal pharmacologic dilation. Filling the AC with
viscoelastic may cause additional mechanical dilation of the pupil. If the pupil did not
dilate to at least 7 mm, sphincterotomy should be considered. A straight micro
scissor should be used to do at least four 1mm snips evenly distributed around the
papillary margin.
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If the small pupil is associated with posterior synechia, begin with
visco/cannula dissection of the synechia to open a space between the capsule and iris. 4 snip
sphincterotomy may be used to lyse the fibrotic pupil. Refill with viscoelastic to stretch the
pupil open. There should be adequate opening to easily lift the nucleus into the AC. Watch
for zonular dehiscence and remember that the synechia may be all that is holding a dislocated
lens.
B. Zonular dehiscence
Depending on the thoroughness of preoperative assessment, a dehiscence
may not be identified until the surgeon begins the capsulotomy.
If the dehiscence is 4 clock hours or less, use of a PC IOL is possible.
Avoid doing capsulotomy in the quadrant of the dehiscence. If the bag is flaccid, attempting
to tear it only increases the likelihood of further dehiscence and vitreous loss. To dislocate
the nucleus, always push it towards the dehiscence rather then pull away from it.
Once the nucleus has been removed, the capsular bag will roll up towards the
center of the pupil. Do not attempt to remove cortex from this quadrant and avoid engaging
vitreous during aspiration. After removal of cortex from other quadrants, unroll the bag by
injecting viscoelastic under the leading edge of the rolled bag. The final position of the IOL
haptics should be in the bag in the quadrant of the dehiscence. It is generally best to insert the
IOL haptic directly into this quadrant rather then rotating the IOL. If insertion into the bag is
not possible, rotate the lens 90 degrees so that the haptics are in the sulcus away from the
involved quadrant.
If the dehiscence involves more then 4 clock hours, it is best to treat this
case as a dislocated lens and insert an anterior chamber lens. Typically these cases are also
associated with vitreous loss.
C. Dislocated lens
Trauma is a common cause of dislocated lens in developing nations probably
due to a lack of basic safety training and equipment plus a higher likelihood of personal
violence. Homocystinurea and Marfan’s syndrome are also possible causes. Patient histories
are often difficult to correlate with findings.
The extent of dislocation might not be fully appreciated until the patient is
observed under the microscope. Even then, posterior synechial adhesions may mask the full
extent of zonular disruption. Attachment of the lens capsule to the iris may act as the support
system for the lens. Disruption of the attachments may further dislocate the lens or even
result in posterior dislocation.
The cystotome can be used to test the stability of the lens by attempting
capsulotomy. If tears are not possible, convert to intracapsular extraction. Zonulysin is
usually not necessary since the underlying cause is zonular disruption. Expressing the intact
capsule through the tunnel may be done with careful pressure on the tunnel and simultaneous
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injection of viscoelastic underneath the dislocated lens. Generally, a lens loop is required.
Rupture of the capsular bag is common during removal.
The condition of the vitreous impacts surgical management. Liquid vitreous
increases the risk of dropped nucleus but decreases the likelihood of needing vitrectomy.
Dense vitreous may act as a pillow to support the lens and remain intact after removal of the
lens. If the vitreous face is broken, vitrectomy will most likely be necessary before inserting
the anterior chamber IOL. See Section 4 below for description of technique for vitreous
removal.
1. Partial dislocation
Mechanical zonulolysis of remaining anterior and posterior zonules with a 25 gauge
viscoelastic cannula is required. Injecting a small amount of viscoelastic under the lens is
helpful to try to float the lens into the anterior chamber as much as possible. If there is no
formed vitreous this may require excessive use of viscoelastic and should be avoided.
Anterior zonular attachments are broken by sweeping the cannula across the capsule under the
pupil. The cannula is then slipped under the lens and, with pressure against the capsule, is
swept around the lens lifting it above the iris plane. The lens loop is inserted under the lens
for expression in the usual manner.
2. Complete dislocation
If the lens is dipping posteriorly, begin by injecting viscoelastic under the lens in
hopes of stabilizing or even floating the lens into the anterior chamber. Initial shallowing of
anterior chamber may be all that is needed to dislocate the lens into the AC. If not, consider
flipping the lens over with the lens loop rather then trying to scoop out the lens. If available,
a mechanical pars plana approach to cataract removal should be attempted rather than
aggressive attempts to remove the lens with MSICS.
3. Specific considerations for various dislocation orientations
Special problems result if a dislocated lens is hinged superiorly. A second instrument
must be inserted through the pericentesis to lift the inferior portion of the lens into the AC
before a lens loop can be inserted to extract the lens.
If the lens is hinged inferiorly, a cannula can usually be passed under the lens while
injecting a small bolus of viscoelastic to push vitreous away from the cannula tip. The lens is
lifted into the AC for removal.
D. Anterior capsular fibrosis
A thickened or fibrotic anterior capsule presents a variety of challenges.
Small fibrotic bands can usually be broken with the cystotome but broad bands extending to
the equator require cutting with micro scissors. Small central fibrotic plaques are easily
removed since the capsular bag around it can be torn using the plaque as a sort of template.
Capsular forceps are often helpful in managing the fibrotic capsule.
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E. Advanced pterygium
Significant pterygia obscure the view of the anterior chamber making anterior
capsulotomy and cortical cleanup more difficult. These patients have a poor prognosis due to
distortion of the visual axis even if the pterygium is removed. The risk of recurrence should
also be considered.
For these reasons, combined pterygia/cataract removal involving the visual
axis is indicated only for bilateral blindness. Pterygia outside the visual axis can be removed
using the conjunctival peritomy for the cataract operation to free up tissue for a rotational
flap.
.
F. Previous glaucoma surgery or secondary IOL after ECCE
A MSICS tunnel can be made through a well healed classic ECCE incision
after 6 months. A tunnel procedure should be considered if secondary IOL implantation is
planned. The site of previous filtration surgery however, should be avoided. Even a failed
bleb site should be avoided as the scleral anatomy is grossly distorted and/or unstable.
G. Uncontrolled glaucoma
Combined MSICS/trabeculectomy is not discussed in this curriculum.
Patients with uncontrolled glaucoma are not likely to achieve the desired outcomes even
though in selected cases, a combined procedure should be considered.
Section 4. Managing intraoperative complications in a low tech environment
Simple, safe, low tech solutions for surgical complications are as important as the
MSICS technique itself. All surgeons will experience one or more of these complications and
the ability to manage them efficiently reduces stress and improves outcomes. The trainee
must have confidence not just in MSICS but also in strategies for managing the following
complications.
A. Posterior capsular rupture
Capsular rupture initiates a cascading series of events that must be
appropriately handled to maximize the visual outcome. The first priority is to avoid
making the problem worse. All AC irrigation should immediately stop at first
suspicion of posterior capsular tear. This allows the surgeon a moment to assess the
situation without hydrating the vitreous. The size of the hole, the condition of the
remaining capsule, the presence of retained nucleus, the amount of residual cortex,
and the condition of the vitreous are all important factors in deciding the next steps. In
general, the desired outcome is a PC IOL, round pupil, and no vitreous in the AC. A
small amount of retained cortex is acceptable.
Use of a standard protocol is helpful to avoid mistakes that may
worsen the outcome. Once a hole or tear is identified, all intraocular manipulation
17
should immediately stop. A cohesive viscoelastic should be promptly injected to
tamponade the hole. This is accomplished by injecting up into the corneal dome so
that a bolus of viscoelastic forms, pushing directly downward and slightly towards the
tunnel over the hole. Injecting directly into the hole will only enlarge the opening.
The “cohesive” qualities of the viscoelastic (the fact that the bolus holds its shape)
make it possible to manage retained nucleus or residual cortex if the bolus is left
relatively undisturbed. If vitreous is presenting through the hole, this bolus will help
contain the vitreous and push it towards the tunnel for easier cutting. An air bubble
can be used if there is not adequate viscoelastic. Dispersive viscoelastics should not
be used.
The wound is checked for vitreous using a dry sponge or rolled cotton.
The sponge is lifted, applying only enough tension to raise the vitreous off the sclera,
and any vitreous is cut. If there is a significant amount of residual cortex, this may be
safely removed by lowering the irrigation bottle to approximately 40 cm above the
patients head and burying the aspiration port in the cortex before aspirating. If the
hole is small and/or the anterior capsular rim is intact, consider putting a PC IOL in
the capsular bag.
If there is a large amount of vitreous or a large hole, intraocular
acetycholine or carbachol should be promptly injected to constrict the pupil and help
contain the vitreous. Additional viscoelastic is injected into the anterior chamber
angle inferiorly to form a bolus that pushes the vitreous towards the tunnel. A sharp
Wescott scissor is inserted into the tunnel with the blades open as far as the tunnel
allows. A single cut is made with the scissor blades resting on the iris or just slightly
behind the pupil. The closed blades are then withdrawn in one smooth motion and
any vitreous at the tunnel opening is cut. This action is repeated as needed until the
pupil is round. Additional viscoelastic is injected to contain the vitreous behind the
pupil and an anterior chamber lens is inserted. The lens should be rotated to the 3 to 9
o’clock position to facilitate iridectomy at the 12 o’clock position.
Peripheral iridectomy is difficult to perform through the tunnel. The
closed tip of a Colibri forcep is dropped over the central inner edge of the tunnel and
the inner tunnel wall is retracted. Midperipheral iris is grasped and lifted. To avoid
iridodialysis, the scissor is inserted into the AC to cut the iris rather then attempting to
drag the iris out the tunnel. Final wash out of remaining cortex and viscoelastic
should be performed with the bottle height no more then 40 cm.
The tunnel may require support to close properly after vitrectomy.
After a final check for vitreous at the wound, the posterior lip of the external tunnel
groove should be grasped and lifted slightly while BSS is injected through the
pericentesis. The pressure may rise rapidly and care should be taken to avoid over
filling the AC which may result in further vitreous loss. If the chamber does not form,
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a single 10-0 nylon suture is placed tangentially to the limbus through the anterior and
posterior walls of the tunnel. The first triple throw knot is tied with only enough
tension to lay it flat on the sclera. 2 additional knots are placed to secure it.
B. Tunnel complications
Failure to maintain a proper dissection depth is the most common
problem: too shallow results in a button hole in the anterior tunnel wall; too deep
results in premature entry into the anterior chamber. In either case, immediately
withdraw the blade and dissect a new tunnel at the proper depth away from the
problem site. In most cases, the case can proceed normally if the problem site is
carefully avoided. Premature entry or buttonholing the tunnel are relatively minor
complications compared to what happens if these problems are not handled correctly.
Premature entry can result in a posteriorly placed tunnel entrance which predisposes
to iris prolapse and may not be self-sealing. A button hole may become a scleral flap
if it extends.
A leaking tunnel after uncomplicated surgery is rare but if it occurs,
use a single 10-0 nylon placed tangential to limbus. The suture supports the posterior
wall of the tunnel, improving the chance for proper apposition.
Scleral perforation while making the groove or tunnel must be repaired
using 8-0 vicryl to close the gap. Amputations of the external tunnel wall can be
repaired by repositioning the free flap and suturing with 10-0 nylon. Cutting one or
both ends of the inner tunnel wall is repaired using tangential 10-0 nylon passed
through the end of the tunnel through the free flap edge.
C. Flat chamber
The development of a rock hard eye and flat chamber during MSICS
requires prompt intervention. In most cases this is a result of aqueous misdirection.
A 21 gauge needle on a 3 or 5 cc syringe is passed through the pars plana
(approximately 2.5mm to 3.0 mm posterior to the limbus). The needle is directed
towards the center of the eye and liquefied vitreous is aspirated until the pressure is
normalized. The needle is withdrawn and the case is finished if possible.
In general, if the chamber cannot be maintained, it is better to leave
cortex then to risk trauma to corneal endothelium. Infiltrate the paracentesis site with
BSS to seal the cornea. If the pressure is still low, grab the posterior external tunnel
lip and lift while injecting BSS through paracentesis. If unsuccessful, tangential
tunnel suture with 10-0 nylon may be necessary.
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D. Iris prolapse
This complication is generally due to a poorly constructed tunnel,
usually a posteriorly displaced inner tunnel entrance. (See “tunnel complications”
above for how to avoid worsening a premature entry.) Pressure in the AC causes the
prolapse almost immediately after the tunnel is made. Repeat efforts to reposition the
iris only results in loss of iris pigment and shredding of the iris tissue. By carefully
working over the iris tissue, the case may be completed with minimal additional
trauma to the iris. After the IOL is in position and viscoelastic has been removed, the
iris is then repositioned by lowering the AC pressure and sweeping the iris in with the
Simcoe cannula (no fluid running). The AC is slowly deepened by injecting BSS
through the paracentesis taking care to avoid overfilling the AC. If necessary, the
superior iris is swept out of the tunnel using the cannula through the paracentesis.
E. Iridodialysis
Iridodialysis is usually caused by poor technique with the lens loop. If
the iris is pinched between the loop and the nucleus at 12 o’clock, a superior dialysis
occurs as the lens loop is inserted. If the iris is pinched between the lens loop and the
nucleus at 6 o’clock, a dialysis occurs inferiorly as the lens loop is removed.
Carefully floating the nucleus into the tunnel prior to insertion of the lens loop helps
prevent superior dialysis. Passing the lens loop no more the two-thirds of the way
across the nucleus helps prevent the inferior dialysis.
If a superior dialysis results in a hammock pupil blocking the visual
axis, iris suturing should be considered if appropriate sutures are available and the
surgeon has been trained in proper techniques. If not, consider transecting the iris to
make a keyhole pupil.
F. The dropped nucleus
Begin with a manual core vitrectomy and attempt to float the nucleus
up by allowing the anterior chamber to flatten. Irrigation of BSS or viscoelastic may
be used to float the nucleus into the AC. If unsuccessful, it is best to leave the nucleus
in the posterior segment and restrict the patient to rest with the head elevated for at
least one week in the hopes that the nucleus will not damage the macula or cause
retinal detachment.
Section 5. Understanding the management of postoperative complications
In general, postoperative complications are the same as in any anterior
segment surgery. Keep in mind that the tunnel can be easily opened with blunt
dissection for more than two weeks postoperatively. It may be difficult to locate the
original paracentesis.
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A. High IOP with normal anterior chamber
Treat with acetazolmide 500 mg plus timolol 0.5% or paracentesis if
the IOP is > 50mm and does not respond to medications within 2 hours.
B. Flat or shallow chamber with low IOP
Assume there is a wound leak and return to surgery for suturing.
C. Flat or shallow chamber with high IOP
The diagnosis is papillary block and laser or surgical iridectomy is
indicated as soon as possible
D. Hyphema
The hyphema will likely clear on its own. Increase topical steroids and
observe. If there is evidence of corneal blood staining, then wash out is indicated.
E. Stromal edema- focal
Increase topical steroids. Always look for patterns that may suggest
the need for changes in technique.
F. Stromal edema- diffuse
Increase topical steroids. Check for appropriateness of consumables
used intraocularly and review daily patterns. This may represent toxicity from
improper irrigating solutions, improper rinsing after alternative sterilization
techniques using acetone or chlorhexidine, or prolonged surgery.
G. Microcystic edema
Check the IOP and treat if elevated. Artificial tears may be added for
comfort.
H. Dislocated IOL:
If affecting vision, return to the operating theatre to reposition or
replace with an AC IOL.
I. Endophthalmitis protocol
If the patient presents with pain and significant inflammation between
day one and ten, the most likely diagnosis is endophthalmitis. The following
treatment protocol provides the best chance of recovery. If the eye has lost all vision,
palliative treatment is still indicated even if enucleation is being considered.
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CEFTAZIDIME (vial of 1000mg in powder form)
Step one: Inject 4.4 mL of sterile saline to 1000mg vial. Dissolve.
Step two: draw 0.1 mL of this solution in a 1 mL syringe.
Step three: Replace the needle with a new empty needle, and draw 0.9 mL of
sterile saline to make 1 mL.
Step four: Discard all but 0.1 mL containing 2.25mg of Ceftazidime. Ready for
intravitreal injection
PLUS
VANCOMYCIN ( vial of 1000 mg in powder form)
Step one: Inject 10 mL of sterile saline to this vial with 1000 mg of
Vancomycin. Dissolve.
Step two: Draw 0.1 mL of this solution into a 1 mL syringe.
Step three: Using a new needle draw 0.9 mL of sterile saline to make 1mL.
Step Four: Discard all but 0.1 mL of this solution containing 1mg of
Vancomycin, ready for intravitreal injection.
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Chapter 5. Core MSICS surgical skillsTrainees should demonstrate mastery of the following skills. The trainer will verify
mastery prior to certification of completion of this curriculum.
A. Surgical fundamentals
1. Microscope, surgeon, and patient positioning
2. Proper technique for holding blades- the paint brush technique,
proper finger tip control
3. Proper hand support
4. Holding the Simcoe cannula
5. Two-handed technique
B. Anesthesia options and management of complications
1. Deep or equatorial peribulbar, subtenons, anterior conal and
posterior conal retrobulbar, topical
2. Anesthetic considerations: volume and type of anesthetics
3. Management of complications including retrobulbar
hemorrhage, seizures, respiratory arrest, circulatory collapse,
and globe perforation
C. Sclero-corneal tunnelling: the mechanics of slicing
1. Using the crescent blade like a paint brush
2. Groove- demonstrate various techniques
3. Tunnel- demonstrate various techniques
4. Keratome entry- demonstrate various techniques
D. Capsular manipulation- the mechanics of tearing
1. Demonstrate can opener technique- cystotome pulled towards the
center creates capsular tears towards the center. Approximately 35
cuts produces near capsulorhexis quality
2. Demonstrate various capsulorhexis techniques- If the red reflex is
present, convert can opener technique to continuous tear. With
practice, this can be done even without red reflex. Trypan blue may
be used for training purposes to visualize the capsule better.
3. Demonstrate scissors capsulotomy for fibrous capsules
E. Nucleus manipulation- the mechanics of rotation, expression, and sliding
1. Demonstrate the use of nucleus rotation to produce a shearing plane
between nucleus and cortex
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2. Demonstrate the even distribution of forces on the zonules produced
by rotation
2. Demonstrate expression of material from the capsular bag like water
from a surgical glove with a hole in it
3. Demonstrate the funnel effect of the tunnel, driving the nucleus into
the tunnel with irrigation and pressure on the inner wall of tunnel
4. Demonstrate the use of the lens loop as a glide by applying pressure
to the inner wall of the tunnel.
5. Demonstrate proper technique to protect the endothelium
F. Cortical manipulation- the mechanics of shearing and aspiration
1. Demonstrate use of the Simcoe to engage and manipulate cortex
using vacuum as a tool for grasping the cortex
2. Demonstrate efficient manipulation of the cortex using
sweeping movements to engage the equatorial cortex.
2. Demonstrate efficient cortical drag and drop technique using the
tunnel as a funnel for hydroexpression
3. Demonstrate proper Simcoe technique to maintain the chamber by
keeping aspiration port up and using the inner tunnel opening as a
fulcrum
G. Management of co-morbidities and complications
1. Practice the posterior capsular tear drill with and without
vitreous loss
2. Practice tangential tunnel suturing technique for leaking tunnel
closure
3. Practice button hole tunnel recovery technique
4. Practice premature entry recovery technique
5. Practice scissors sphincterotomy
6. Practice visco dissection and hydro dissection
7. Practice various strategies for removal of residual formed cortex
using paracentesis and various cannulas
8. Practice various techniques for managing the prolapsed iris
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Chapter 6. Using MSICS as a stimulus for development of the
ophthalmic community
From the beginning, the trainee should understand that the transition to MSCIS provides
them an opportunity to promote change. A MSICS certificate is just another certificate on the
wall if there is no challenge to seize the opportunity for development of their own institutional
systems. Lasting changes will not come from governments or outside agencies. At best,
these institutions can and should be supportive. Ultimately, the changes must come from
those who are providing the service. A comprehensive plan for leadership development is
beyond the scope of this curriculum but the trainee should demonstrate familiarity with at
least these principles.
Section 1. Developing the disciplines needed for success
In the context of developing nations, success may be as unfamiliar as MSICS.
Tolerance of the status quo is expected and turf and position are jealously guarded.
The trainee must develop the mental skills and disciplines needed for success in this
context. The mentoring relationship is vital for communicating these principles and
encouraging the trainee to persevere.
A. An orientation towards team building
Team building promotes the concepts of unity, mutual respect, human
value, individuality, and the willingness to share information for the greater good, all
of which are crucial for the development of a functioning system. As trust develops,
the team becomes more efficient and adaptable to the many challenges it will face to
keep up high quality, high volume service. Work becomes more energized when
there is a sense of team.
The key team building “technique” in developing nations, is
communicating respect. Including the other team members in problem solving
discussions, team meetings prior to beginning each day so that all are aware of the
goals for the day, recognition of individual accomplishment, and brief team meetings
to communicate important information all communicate respect. Voluntary team
bible study is effective for promoting unity and joyfulness. Team building does not
guarantee success but success is not possible without it.
B. An orientation towards positive goal setting and continuing education
Positive goal setting promotes the concept of incremental change and
the pursuit of excellence. By setting positive goals the trainee learns the simple but
profound principle that success is moving towards what is good not just moving away
from what is bad. This orientation is needed to overcome the fatalistic mentality that
often hinders the pursuit of quality and long term success. Appropriate continuing
25
education must become a routine for the trainee. The trainee and their team must
understand that the goal is not just removal of a cataract, it is restoring the sight of an
individual.
C. An orientation towards compassionate action
Compassion is important for team success because it encourages the
self-sacrifice needed to serve the vulnerable without exploitation or corruption.
Positive goals set the direction, but compassion is the motivation the team needs to
move forward. Monetary reward is seldom sufficient for long term commitment to a
goal. Those who are motivated primarily by their pay checks or status will likely be
unproductive team members.
D. An orientation towards focused action
It is often said that if you are aiming at nothing you can hit it every
time. Intentionality rather then serendipity is a key strategy for success. Many
developing nations have learned to simply wait for outside help to come to their
rescue. Focused action is needed to pursue opportunities and, at the end of the day, to
accept genuine accountability for achieving what was intended. It teaches the value
of perseverance but also letting go when something is not working. The trainee who
is focused on the task of building a successful system will avoid distractions and over
commitment.
E. An orientation towards prayerful action
Surgery offered as a prayer puts the surgeon and the team in exactly
the right frame of mind for a success. Most people in developing nations embrace the
spiritual as a normal part of life. To ignore this because of western secularism misses
an important opportunity to reinforce a proper attitude towards healing. We must all
be reminded that successful results sometimes are more about spiritual realities then
about the surgeon’s knife or technique. Prayer is a reminder of the dangers of pride
and the reality of grace for the humble. A brief group prayer at the beginning of each
day is a simple way to raise awareness of this principle.
Section 2. The vision restoration paradigm
The transition to MSCIS should be used to challenge the trainee’s cataract surgery
paradigm. It must be clear that this curriculum is not just conveying a skill, it is also
promoting a new system for success in their professional life.
A. A patient-oriented understanding of successful cataract surgery
As the trainee comes to understand the quality that is possible with
MSICS, their concept of success should be challenged. Success should not be judged
26
by absence of operative complications or even number of operations. Success should
be defined by the patient experience and their perceptions. Uncorrected vision and
comfort are the patients’ measure of success. And the first or second postoperative
day is often when the patient and their family decide if their money was well spent.
Surgeons who understand this concept will develop the appropriate service orientation
for success.
B. Importance of biometry and IOL power selection
For optimal uncorrected vision, proper IOL selection is critical. If
standardized IOL power is used, a perfect procedure may produce suboptimal results
and patient dissatisfaction. Surgeons should be familiar with how to do biometry
even though they may utilize their staff to do the measurements. Maintaining a
reasonable inventory of IOLs is critical to make full use of biometry.
C. Understanding the importance of auditing outcomes
A surgeon who is committed to patient success must learn how to audit
their own outcomes. There are several strategies and templates available separately
from this curriculum. See
http://www.cehjournal.org/files/globalreview/globalreview_024.pdf .
Audits of postoperative outcomes provide the data to identify opportunity for system
improvements.
Section 3. Facilitating a successful local cataract project
The trainee must learn how to develop their own institution as a platform for
successful cataract surgery. To begin this work, the trainer must be able to confirm
the quality of the trainee’s performance. The staff and administration must know that
the stage is set to try something new and exciting that will benefit their reputation and
their institution. If the trainee is not ready, it is best not to start this process and
surgical training should continue. If it is determined that the surgeon is not a
candidate for a successful project, it is best to move on to other trainees.
A. Assess local conditions, equipment, consumables, and staff
Develop a comprehensive assessment plan with the trainee. Where
will there likely be problems? Can any training be done to assist with these
problems? Is additional equipment needed? Where will the first patients come from?
Is the institution willing to back the start up efforts by offering free use of facilities?
B. Prepare the local team
The surgeon must be prepared to be the leader of the team. This may
require involvement with details not normally part of the surgeon’s tasks. Make sure
27
each team member knows what is going to happen and how their job contributes to
the success of the team.
C. Address political barriers
Most institutions have barriers designed to prevent change. The trainer
can act as an advocate for the team to address these barriers. And once the team has
proven itself, administrators may continue to provide support. Interference from
peers or other medical professionals is common. A willingness to promote their
success will go a long way towards overcoming their resistance.
Section 4. Foundations for developing the local eye care industry
MSCIS can be used to drive development of the local eye care industry. Once a local
team has been successful, doors may begin to open for broader support and corporate
sponsorship. Rather then propping up or trying to improve old systems, the trainee must learn
to challenge existing practices and systems that may be preventing development of
sustainable solutions to treatable blindness. A grasp of the basics economic issues of cataract
surgery care will help the trainee maximize the financial benefit.
A. The basic economics of MSICS: the value of time and satisfaction
↓ surgical time = lower cost/case
↓ postop problems = lower cost/case
↑ patient satisfaction = decreased opportunity cost as
patient demand increases
↑ surgeon satisfaction = decreased recruiting and retention
costs as surgeons develop confidence and improved financial
return
B. Understanding fixed and variable costs/case
The variable cost of consumables is about the same as classic
extracapsular surgery. MSCIS is not about drastically reducing the cost of surgical
supplies. It decreases cost by increasing productivity and reducing complications. The
highest fixed cost is in personnel. The most effective way to decrease cost per case is
by increasing productivity. BUT this must be accompanied by a higher level of team
satisfaction to be accepted.
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C. Quality in cataract surgery drives ophthalmic industry development
Elective surgery in an older population must be high quality to be
successful. The eye care industry in any nation is built on the success of cataract
surgery because this is ophthalmic service with the highest perceived value.
Management of glaucoma, corneal, and vitreoretinal disease are important but must
be built on the foundation of a successful cataract center.
29
Chapter 7. Training surgeons to train others
It should first be said that not all surgeons will make good trainers. Even the most
proficient surgeons sometimes lack the attitudes and skills needed to assist others through the
tedious learning process. The trainer should make sure the trainee has the aptitudes and
desire to be a trainer by observing how they interact with others. Those who are naturally
teachers are usually the best candidates.
Training a surgeon to be a trainer begins with raising awareness of HOW the training
process occurs. Hopefully, the trainee will be able to use their own training experience as a
positive model but they will require help separating training skills from their surgical skills.
One of the main problems a trainer faces is establishing an effective training
connection with the trainee. It takes time for this connection to develop. Everyone learns a
little differently and the most effective trainers are those who know how to identify and use
those differences to establish a connection. Cross-cultural issues and previous bad
educational experiences may have a negative impact on the trainee. Training a trainer requires
helping them overcome their own challenges before they can help others. It may be difficult
for a new trainer to allow room for mistakes, let alone provide guidance on how to address the
mistakes while staying positive and respectful. It is easy to take over too soon if a case
becomes difficult. The patience required may not come naturally to some.
A. Using the “Head, Hands, Heart” surgical training concept
This curriculum is designed to be transferable. It is built around the
idea that good surgeons require a good head, good hands, and a good heart to be
successful. This training is designed to address all three areas in that specific order.
The new trainer should learn this curriculum in detail. Over time, their own
experiences will add the needed depth and conviction.
The new trainer should be reminded that it is appropriate to be
selective in choosing their trainees and that the process of training may be spread out
over a longer period of time then their own training. Emphasize the importance of
both surgical concept and technical patterns: both the “what” and the “why”. Begin
development of fine motor skills early and address bad technique directly and
immediately. Try to avoid letting bad habits get started. Learn to read a trainees
level of stress. When stress is high, learning will decrease. Try to select training
cases where success is likely. There is very little to be learned from painfully
enduring a long, hard case. It is better for the trainer to take over when the learning
value of a case decreases or a patient’s outcome is in jeopardy.
B. Communication tips
Remember that as the trainer, you must know what you are trying to
say and why. Stay purposeful but do not be afraid to be repetitive. In general, it is
helpful to focus on one element of technique at a time. Learning will progress more
30
rapidly if the message is communicated in small bites rather then a deluge of
information or criticism.
Always communicate respect and the importance of the trainee’s
success. Learning increases as confidence builds but false confidence and empty
praise can be destructive. Make sure communication is always two-way. A trainee
may be able to explain what they need if you are listening.
It is helpful to be able to record trainee surgery to allow for step by step
discussion of technique and to document progress. Recordings also help a trainee learn to
critique their own technique. Concepts must be taught from a variety of angles. Overviews,
short talks, drawings, videos, and live demonstrations must all be used.
Remember that the trainer is teaching attitudes as well as facts. Often these
attitudes are caught rather then taught. As the trainer, you must demonstrate the value of
patients and your team.
Final note: The importance of surgeon advocacy
Raising awareness of the tragedy of unnecessary blindness is critical. The 30+ million
who could have their blindness corrected need a voice to make their needs known. But those
surgeons who, in the end, are responsible for addressing that need must have a voice as well.
In developing nations, surgeons do not enjoy the prominence or incomes that are
common in the west. To be sure, there are unscrupulous surgeons in developing nations just
like anywhere else. But my hope is that this curriculum is in the hands of those who will
make the most of it for the sake of the blind. Developing nations are waiting for their own
“beloved physicians” who are willing to say “this is no longer acceptable.” Being an
advocate for these physicians may be one of the most important things we can do.
One final thought: It is my personal conviction and observation that it is not enough
to hate blindness and the poverty that is at the heart of the problem. There seems to be no end
to human suffering and it is easy to be overwhelmed with the need. May I suggest that these
needs point us towards profound realities about our world and our selves, a constant reminder
of how small I am and how, in the end, there must be another solution outside of me to end
this tragedy. I must hold on to a belief that there is a loving God who values every life and
asks us to love as He loves. There is no higher achievement then giving honor to the One
who is the source of all life and well-being. Only this is enough to sustain me in the work.
Glenn Strauss, M.D. 2010
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