696
LETTERS
patient selection for femtosecond laser–assisted cataract surgeries is still advocated. We are once again thankful to Dr. Pardianto for sharing his knowledge and thoughts on these important issues.dNafees Baig, FHKAM, FCOphthHK, Clement C.Y. Tham, FRCS
Two techniques for managing posterior polar cataracts: Traditional phacoemulsification versus femtosecond laser–assisted cataract surgery I commend Drs. Alder and Donaldson1 for good outcomes in their posterior polar cataract cases. I agree that inadvertent hydrodissection was likely performed during nuclear removal in the femtosecond laser–assisted cataract cases, causing posterior capsule rupture. It is also possible that posterior adhesions between the capsule and lens were never lysed by hydrodissection or hydrodelineation because the surgeons had a poor view from the cavitation bubbles. Manipulation of an attached posterior capsule during nuclear disassembly would also cause a hole in the posterior capsule in this case. As the authors mention, because of a potentially weak posterior capsule in posterior polar cataracts, hydrodelineation without hydrodissection should be performed instead to minimize this risk. I wonder, however, that had the authors instead performed a cruciate nuclear fractis without a grid pattern whether isolated hydrodelineation could have been more easily performed, which would have decreased the risk for posterior capsule blowout. I also agree that increasing the width of the posterior safety zone would be helpful. Ian Gorovoy, MD Fort Myers, Florida, USA REFERENCE 1. Alder BD, Donaldson KE. Comparison of 2 techniques for managing posterior polar cataracts: traditional phacoemulsification versus femtosecond laser–assisted cataract surgery. J Cataract Refract Surg 2014; 40:2148–2151
Training in the prevention of surgical errors in ophthalmology We read with interest the article by Chen et al.1 that described residents' perspectives of training in the prevention of surgical errors in ophthalmology. Surgical errors have devastating consequences. Apart from economic costs arising from work productivity losses, corrective surgeries, and insurance
claims, errors also result in emotional pain and sufferingA given the importance of eyes to daily living. More importantly, as pointed out, many of these errors are preventable, which highlights the importance of adequate training. The majority of respondents (205/309 [66.0%]) believed that hands-on experience with guidance from attending physicians was the most effective method of training to avoid surgical errors. Studies have emphasized the importance of role models and mentors in surgical training,2 which underscores the importance of identifying good mentors in ophthalmology and giving them key roles in the training of junior physicians. We agree with the authors that a weakness of this system is the variability of the quality of teaching among surgeons, who may differ in clinical knowledge and adherence to safety protocols. In this light, attending ophthalmologists should be acutely aware of their responsibility to assume responsibility for the safety culture of their department and recognize that they influence the behavior of junior residents. It is difficult for anyone to remain chronically uneasy about erring.3 The responsibility falls on everyone, especially the seniors, to remind and help the juniors to practise safely. Unsurprisingly, only 2.6% (8/309) of respondents believed that merely observing the attending physician is effective. This highlights the importance of hands-on practical training, as opposed to theoretical teaching, in imparting patient safety knowledge similar to other aspects of surgical training. Programs can consider group case discussions, interactive sessions, and scenario training for this purpose.A In addition, we noted the majority of respondents (237/323 [73.0%]) indicated that there was no formal assessment of knowledge in preventing surgical errors after receiving training. We agree that resident competency should be objectively assessed.B If this is not done, it will be unclear whether the residents have the requisite competency to practice. Educators might make the case for formative or summative assessments through reflective portfolios and “Objective Structured Clinical Examinations.”2 The results can be used to guide remediation if necessary. An additional advantage is that it could be used to evaluate the strengths and weaknesses of the residency program with an eye toward improvement. Lastly, it would also be interesting to know whether, apart from training residents to avoid errors, programs should also train residents to manage errors. Because preventing errors will never be completely effective, creating systems to mitigate the aftermath of errors is also part of the qualityassurance process in hospitals. Residents can be particularly vulnerable during the transition to
J CATARACT REFRACT SURG - VOL 41, MARCH 2015
LETTERS
patient selection for femtosecond laser–assisted cataract surgeries is still advocated. We are once again thankful to Dr. Pardianto for sharing his knowledge and thoughts on these important issues.dNafees Baig, FHKAM, FCOphthHK, Clement C.Y. Tham, FRCS
Two techniques for managing posterior polar cataracts: Traditional phacoemulsification versus femtosecond laser–assisted cataract surgery I commend Drs. Alder and Donaldson1 for good outcomes in their posterior polar cataract cases. I agree that inadvertent hydrodissection was likely performed during nuclear removal in the femtosecond laser–assisted cataract cases, causing posterior capsule rupture. It is also possible that posterior adhesions between the capsule and lens were never lysed by hydrodissection or hydrodelineation because the surgeons had a poor view from the cavitation bubbles. Manipulation of an attached posterior capsule during nuclear disassembly would also cause a hole in the posterior capsule in this case. As the authors mention, because of a potentially weak posterior capsule in posterior polar cataracts, hydrodelineation without hydrodissection should be performed instead to minimize this risk. I wonder, however, that had the authors instead performed a cruciate nuclear fractis without a grid pattern whether isolated hydrodelineation could have been more easily performed, which would have decreased the risk for posterior capsule blowout. I also agree that increasing the width of the posterior safety zone would be helpful. Ian Gorovoy, MD Fort Myers, Florida, USA REFERENCE 1. Alder BD, Donaldson KE. Comparison of 2 techniques for managing posterior polar cataracts: traditional phacoemulsification versus femtosecond laser–assisted cataract surgery. J Cataract Refract Surg 2014; 40:2148–2151
Training in the prevention of surgical errors in ophthalmology We read with interest the article by Chen et al.1 that described residents' perspectives of training in the prevention of surgical errors in ophthalmology. Surgical errors have devastating consequences. Apart from economic costs arising from work productivity losses, corrective surgeries, and insurance
claims, errors also result in emotional pain and sufferingA given the importance of eyes to daily living. More importantly, as pointed out, many of these errors are preventable, which highlights the importance of adequate training. The majority of respondents (205/309 [66.0%]) believed that hands-on experience with guidance from attending physicians was the most effective method of training to avoid surgical errors. Studies have emphasized the importance of role models and mentors in surgical training,2 which underscores the importance of identifying good mentors in ophthalmology and giving them key roles in the training of junior physicians. We agree with the authors that a weakness of this system is the variability of the quality of teaching among surgeons, who may differ in clinical knowledge and adherence to safety protocols. In this light, attending ophthalmologists should be acutely aware of their responsibility to assume responsibility for the safety culture of their department and recognize that they influence the behavior of junior residents. It is difficult for anyone to remain chronically uneasy about erring.3 The responsibility falls on everyone, especially the seniors, to remind and help the juniors to practise safely. Unsurprisingly, only 2.6% (8/309) of respondents believed that merely observing the attending physician is effective. This highlights the importance of hands-on practical training, as opposed to theoretical teaching, in imparting patient safety knowledge similar to other aspects of surgical training. Programs can consider group case discussions, interactive sessions, and scenario training for this purpose.A In addition, we noted the majority of respondents (237/323 [73.0%]) indicated that there was no formal assessment of knowledge in preventing surgical errors after receiving training. We agree that resident competency should be objectively assessed.B If this is not done, it will be unclear whether the residents have the requisite competency to practice. Educators might make the case for formative or summative assessments through reflective portfolios and “Objective Structured Clinical Examinations.”2 The results can be used to guide remediation if necessary. An additional advantage is that it could be used to evaluate the strengths and weaknesses of the residency program with an eye toward improvement. Lastly, it would also be interesting to know whether, apart from training residents to avoid errors, programs should also train residents to manage errors. Because preventing errors will never be completely effective, creating systems to mitigate the aftermath of errors is also part of the qualityassurance process in hospitals. Residents can be particularly vulnerable during the transition to
J CATARACT REFRACT SURG - VOL 41, MARCH 2015
