Cataract Surgery Numbers

[tm12]

I've been to a number of programs now that boast "great" cataract surgery volume but do not volunteer numbers without asking. Upon asking residents, they say 100-110 cataracts which are supposedly more than enough. (Isn't the bare minimum in the mid 80's?). Sometimes they explain that these are "high quality" cataracts. What does that even mean???

What are your thoughts about what's really a good number of cataract surgeries assuming you will eventually be doing cataract surgery in your practice and won't be doing it in fellowship? What are "high quality" cataracts?

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[200UL]

In general, the more the better. Every resident will need a different amount to feel comfortable. I have seen some residents become very good at 80. Some require 180. I would be suspicious if someone at a program tried to justify their surgical volume by saying, "you only need 50 to feel comfortable anyway." That may be true for them but not for you. To put this another way, I have never met a resident who said, "I wish I had fewer cases." Also - cataract surgery is very different than many other surgical procedures in medicine. It takes many cases to become good at it (ie general surgery residents are not required to complete 80 + appendectomies).

The acgme requires counting of the surgical numbers. Class 1 cases should involve the resident doing the entire case from start to finish. Class 3 cases can be counted if you are assisting. I suspect class 1 vs class 3 can be blurred at some programs.

Finally - even if your dreams involve becoming a one-trick-pony ophthalmologist (cataract surgery only), you should also make sure the programs you interview at offer a diverse surgical experience. 1) You never know how your interests will change. 2)Peds, plastics, cornea, refractive, and glaucoma procedures all involve different skill sets and thought processes. Having experience in these makes you a better overall surgeon.

 

[tm12]

In general, the more the better. Every resident will need a different amount to feel comfortable. I have seen some residents become very good at 80. Some require 180. I would be suspicious if someone at a program tried to justify their surgical volume by saying, "you only need 50 to feel comfortable anyway." That may be true for them but not for you. To put this another way, I have never met a resident who said, "I wish I had fewer cases." Also - cataract surgery is very different than many other surgical procedures in medicine. It takes many cases to become good at it (ie general surgery residents are not required to complete 80 + appendectomies).

The acgme requires counting of the surgical numbers. Class 1 cases should involve the resident doing the entire case from start to finish. Class 3 cases can be counted if you are assisting. I suspect class 1 vs class 3 can be blurred at some programs.

Finally - even if your dreams involve becoming a one-trick-pony ophthalmologist (cataract surgery only), you should also make sure the programs you interview at offer a diverse surgical experience. 1) You never know how your interests will change. 2)Peds, plastics, cornea, refractive, and glaucoma procedures all involve different skill sets and thought processes. Having experience in these makes you a better overall surgeon.

Are all cases where the resident is the "primary surgeon" class 1 cases?

 

[MR1]

First, 100-110 is not "great". I would say that number is acceptable. Yes 86 is the minimum. Now about the "high quality", what they are referring to is a good mix of complicated cataracts probably. If you did 200 straight forward clear cornea cataracts, I would argue that is not very good. You want loose zonules, vitrectomized eyes, eyes with a corneal graft, white rocks, tiny flomax pupils, etc. That measure is harder to judge in programs than just getting a number.

I ended up with 150, ~40 of which were "complicated" and I was happy. I know some programs get more like 200 and have even heard of a couple that do 300-400. I would say though 110ish is probably the average.

Like said before a good mix of other surgeries is essential, dont' get hung up on cataract numbers and forget the other stuff.

Lastly, if you are primary surgeon and did most to all of the case, it is class 1. Obviously this is a subjective term, if you did 60% of the case, is that primary or do you only consider it if you did 90%. Most I think go by the latter.

 

[MstaKing10]

According to my PD, class 1 means you did greater than 50% of the critical components of the case. Not a great definition in my opinion and a grey area up for interpretation.

By pure numbers, 110-130 is solid, less is not as good, more is better. Would not get hung up on pure numbers though, more important is understanding how much of the surgery did they do, if they have solid attendings teaching them, if they get a good mix of pathology, techniques taught/mastered, etc. Also, you want to get a mix of other types of surgery as well including glaucoma, retina etc. A good benchmark would be to ask 3rd years how confident they feel at this point performing surgery and were graduates comfortable enough to go into practice?

 

[taehong81]

I agree with the posts above. Having high number of cataract surgeries is great but also you need to consider the quality/variety of the cataracts and the surgical teaching you get. During residency you should be exposed to the complicated cataracts (white mature, pseudoex, traumatic cataract, post vitrectomy/pkp, etc) and the different methods (divide and conquer, horizontal/vertical chop, etc).

 

[Zorro12]

High quality are likely from paracentesis to hydrating the wound, meaning you do the entire case. In the past occasionally the attending would do the bulk of the case , resident IAs, implants IOL and calls it their case to boost numbers.

As far as "good" numbers I would say over 120. I think the complication curve is quite steep for the first 60-80 then after 200 is pretty flat if that gives you some idea (I think there was an archives paper a few years ago).

Just a small, somewhat tangential, point to add. What you guys are calling complicated cataracts are not complicated they are complex. Complicated is when you break bag, perform a vit, need ACIOL, cause an iridodiaylsis etc... Complex cataracts are IFIS, miosis, mature lenses, etc... You need to identify this potential prior to cataract surgery and it can be billed a 66982, but you need to clearly identify the possibility prior to surgery. If you cause a complication, you cannot bill for a vitrectomy. However, if you identify vitreous in the AC prior to surgery you can also bill for an anterior vitrectomy. Small points that you will need when you start coding your cases.

Lastly, remember the white lens, post-vit eyes are attached to patients. After you are long gone from your residency these patients are going to be dealing with an adverse outcome if it occurs. So while I know it is a challenge to take on a difficult case, and it is great when it works out, make sure you are not operating on someone just for ego/numbers, etc... You need to be sure you have attainted the surgical ability with "routine" cases to give the patient a high probability of an acceptable outcome.

 

[200UL]

Lets face it, if a resident does 150 cataracts in residency, not all are going to be beverly hills cataracts. This is the great advantage to training in places with county or VA hospital rotations - there are built in cases that will require extra steps. ie The VA is full of blue eyed patients on flomax.

Any surgeon will tell you that you often cannot tell how the phaco will go until you get into the eye. For example, zonular weakness is often detected during the start the rhexis.

Decision making ability becomes very important when you are on your own (this may be even more important than surgical skill). This can only be acquired with expert teaching and practice.

Related to this decision making ability, it is important not to focus all your thoughts on the "number of cataracts." Diversity in all ophthalmic procedures is important - look for programs that provide it all.

 

[clayito]

zorro is right, there is a paper on this out there somewhere from the last few years. steep curve for first 80 or so (and at least partially why the minimum bar is set at 86). i think the next tier is 160s and then a plateau after that. so, based on the paper that was published, "great" numbers are in the 160s and above. i would consider 100-110s good numbers but definitely not great.

High quality are likely from paracentesis to hydrating the wound, meaning you do the entire case. In the past occasionally the attending would do the bulk of the case , resident IAs, implants IOL and calls it their case to boost numbers.

As far as "good" numbers I would say over 120. I think the complication curve is quite steep for the first 60-80 then after 200 is pretty flat if that gives you some idea (I think there was an archives paper a few years ago).
QUOTE]

 

[clayito]

http://archopht.ama-assn.org/cgi/reprint/125/9/1215.pdf

zorro is right, there is a paper on this out there somewhere from the last few years. steep curve for first 80 or so (and at least partially why the minimum bar is set at 86). i think the next tier is 160s and then a plateau after that. so, based on the paper that was published, "great" numbers are in the 160s and above. i would consider 100-110s good numbers but definitely not great.

High quality are likely from paracentesis to hydrating the wound, meaning you do the entire case. In the past occasionally the attending would do the bulk of the case , resident IAs, implants IOL and calls it their case to boost numbers.

As far as "good" numbers I would say over 120. I think the complication curve is quite steep for the first 60-80 then after 200 is pretty flat if that gives you some idea (I think there was an archives paper a few years ago).
QUOTE]

 

[Andrew_Doan]

After training residents for six years now, I have seen that 100 primary cataract cases are needed because if a surgeon doesn't "get it" by 100 cases, then it's unlikely the surgeon will "get it" at 200.

This is my personal opinion only as a cataract surgery mentor and faculty because I don't have data to support it.

Let me explain it this way. Doing surgery is similar to athletics, like playing quarterback, which I stink by the way! Some people can pick up a football and throw like Cam Newton their first year of play because they were born with natural talent. There are others who can learn to throw the football given enough coaching and may make it to the pros. However, there is a sub-set of people who will never play professional football because they don't have the natural abilities.

The three classes of surgeons (just my opinion):

1) Born surgeons (minor subset): I have seen these young surgeons pick up the tissue plains, work in the eye seamlessly, and start chopping cases after 50 primary cases.

2) Can be made into surgeons (majority subset): When provided with enough cases, the majority of residents become competent surgeons. I think this number falls at around 100. After 100, the resident's are pretty much ready to operate alone.

3) Cannot be made into surgeons (minor subset): These surgeons can be scary and give staff and everyone high blood pressure and TIAs. No matter how many cases, they struggle with cases.

My advice is the RRC has set minimums that produces competent surgeons. Beyond a 100, it's icing. At Iowa, I had over 150 primaries and assisted over 300 cases. Remember while I was watering the cornea for Thomas Oetting, MD, I was observing how he entered with instruments, chopped, and dealt with complications.

Wishing you all luck because this is an amazing field and I love it!

 

[boanssi]

I know this question is slightly off-topic but what are good surgical numbers in the other areas of ophthalmology (oculoplastics, glaucoma, etc.)? How important is it to get good numbers in these areas by the end of your residency training, as is the case with cataract surgery?

 

[boanssi]

I know this question is slightly off-topic but what are good surgical numbers in the other areas of ophthalmology (oculoplastics, glaucoma, etc.)? How important is it to get good numbers in these areas by the end of your residency training, as is the case with cataract surgery?

So, any thoughts?

 

[DrZeke]

I think it's highly dependent on where you want to practice. I did 130 cases and I feel comfortable, but I had to accept that I would not see or do everything in residency. I think most of your learning continues on the job once you finish even if you do fellowship.

I think having good numbers all around is helpful for exposure. Some programs barely give you your numbers in certain subspecialty areas and if it's due to fellows being present you might still like that subspecialty because they have a strong presence in your residency. But if it's due to a paucity of faculty and therefore limited exposure to that subspecialty taught well by someone you may never get the chance to experience that specialty fully.

So... I think ideally it's nice to have super high cataract volume if you want to do comprehensive, however not at the expensive of lid procedures, glaucoma tube shunts/trabs and exposure to glaucoma post op care and cornea procedures /surgeries.

I would always try and aim for a well rounded program. Just because it can color residency experience one way or the other to lack certain experiences.

However, ophthalmology match is competitive and many programs have a weakness here or there in terms of exposure to certain volume in certain subspecialties. While fellowship isn't necessary and you might feel comfortable doing everything coming out of your program that is rarely required or expected in a private practice in a non rural area.




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[schistosomiasis]

I agree with everyone above. Get in as many cataract cases as possible. But even if you go into retina, this is your one and only chance to learn about cornea, peds etc. Take every advantage of the opportunity! Totally agree some residency programs are better than this than others.

Interestingly enough, there was an article in the blue journal (Ophthalmology) that stated your complication rate drops once you reach 1000 cases. This was very true in my experience; something just "came together" for me at that point.

Obviously, this takes a few if not many years after you're done training. Even if you did 200 cases in residency you'll still be watching videos and asking mentors and friends for help (even those of us with 2500 cases under our belt still do).

So yes it's important to do as many cases in residency as possible. It provides the foundation for clinical and surgical decision making. But don't stress out about it (OK I'll admit that I ignored my own advice and did... )