Ophthalmic Education:

Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist: Chapter 4. Cataract and Lens

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• Basic Level Goals: PGY-2
  
  
• Standard Level Goals: PGY-3
  
  
• Advanced Level Goals: PGY-4

General Educational Objectives:

1. Describe the evaluation and management, indications for and intraoperative and postoperative complications of cataract surgery and related anterior segment procedures.
   
   
2. Perform the complete preoperative ophthalmologic examination of cataract patients.
   
   
3. Formulate the differential diagnoses of cataract and evaluate the normal and abnormal lens.
   
   
4. Perform optimum refraction of the post-cataract surgery patient.
   
   
5. Develop and exercise clinical and ethical decision-making in cataract patients.
   
   
6. Develop good patient communication techniques regarding cataract surgery.
   
   
7. Perform routine and advanced cataract surgery and intraocular lens (IOL) placement.
   
   
8. Manage basic and advanced clinical and surgical cataract problems.
   
   
9. Effectively diagnose and manage intraoperative and postoperative complications of cataract surgery.
   
   
10. Work effectively as a member of the medical care team.
    
    
11. Develop teaching skills about cataracts for instructing junior trainees and students.

Basic Level Goals: PGY-2

A. Cognitive Skills

1. Identify the most common causes and types of cataract (e.g., anterior polar, cortical nuclear sclerotic, posterior subcapsular).
   
   
2. List the basic history and examination steps for pre-operative cataract evaluation.
   
   
3. Describe the steps in cataract surgical procedures.
   
   
4. Define the elementary refraction or contact lens fitting techniques to obtain best corrected vision prior to considering cataract extraction.
   
   
5. Describe the major etiologies of dislocated or subluxated lens (e.g., trauma, Marfan's syndrome, homocystinuria, Weill-Marchesani syndrome, syphilis).
   
   
6. Familiarity with the techniques of intracapsular cataract extraction, extracapsular cataract extraction, and phacoemulsification.
   
   
7. Describe the following:
   1. Basic ophthalmic optics as related to cataracts
   2. Types of refractive error in cataract
   3. Retinoscopy techniques for cataracts
   4. Subjective refraction techniques for cataract patients
   5. Types of IOLs; IOL power calculation
      
      
8. Identify and describe the principles and mechanisms of the following instruments in the evaluation of cataracts:
   1. Lensometer
   2. Autorefractor
   3. Retinoscope
   4. Phoropter
   5. Keratometer
   6. Slit lamp biomicroscope
   7. Glare and contrast testing devices
   8. Potential acuity meter

B. Technical/Surgical Skills

1. Perform basic slit lamp biomicroscopy, retinoscopy, and ophthalmoscopy.
   
   
2. Evaluate and classify common types of lens opacities.
   
   
3. Perform subjective refraction techniques and retinoscopy in patients with cataract.
   
   
4. Perform direct and indirect ophthalmoscopy pre- and post-cataract surgery.
   
   
5. Perform basic steps of cataract surgery (e.g., incision, wound closure) in the practice lab.
   
   
6. Assist at cataract surgery and perform patient preparation, sterile draping, anesthesia.
   
   
7. Perform the following steps of cataract surgery in the practice lab or under direct supervision, including any or all of the following:
   1. Wound construction
   2. Anterior capsulotomy/capsulorrhexis
   3. Instillation and removal of viscoelastics
   4. Extracapsular and phacoemulsification techniques (e.g., sculpting, divide & conquer, phaco - chop)
   5. Irrigation and aspiration
   6. Cortical clean-up
   7. IOL implantation (e.g., anterior and posterior)

Standard Level Goals: PGY-3

A. Cognitive Skills

1. Describe the less common causes of lens abnormalities (e.g., spherophakia, lenticonus, ectopia lentis).
   
   
2. Describe the preoperative evaluation of the cataract patient, including:
   
   
   1. The systemic diseases of interest or relevance to cataract surgery.
   2. The relationship of external and corneal diseases of relevance to cataract and cataract surgery (e.g., lid abnormalities, dry eye).
   3. The relationships of glaucoma, uveitis and capsular opacities related to cataract surgery.
      
      
3. Describe glare analysis testing for cataract surgery.
   
   
4. Describe the use of A- and B-scan ultrasonography in cataract surgery.
   
   
5. Describe the instruments and techniques of cataract extraction, including extracapsular surgery and phacoemulsification (e.g., trouble-shooting the phacoemulsification machine, altering the machine parameters).
   
   
6. Describe the types, indications and techniques of anesthesia for cataract surgery (e.g., topical, local, general).
   
   
7. Describe indications, techniques, and complications of surgical procedures, including:
   1. Extracapsular surgery
   2. Intracapsular surgery
   3. Phacoemulsification
   4. Paracentesis
   5. IOL placement
      
      
8. Describe history and techniques of basic IOL implantation.
   
   
9. Correlate the level of visual acuity with the lens or capsular opacities.
   
   
10. Describe the common complications of cataract and anterior segment surgery (e.g., intraocular pressure elevation, hyphema, endophthalmitis, cystoid macular edema, retinal detachment, intraocular lens dislocation, lens-induced glaucoma and uveitis).
    
    
11. Describe the indications for, principles of, and techniques of YAG laser capsulotomy, and to understand the proper timing of YAG laser capsulotomy.

B. Technical/Surgical Skills

1. Perform local injections of corticosteroids, antibiotics, and anesthestics.
   
   
2. Implement the basic preparatory procedures for cataract surgery (e.g., obtaining informed consent, identification of instruments, sterile technique, gloving and gowning, prep and drape, other preoperative preparation).
   
   
3. Use the operating microscope for basic cataract surgery.
   
   
4. Perform extracapsular surgery in a practice setting (e.g, animal or practice lab) and then in the operating room under supervision, including mastery of the following skills:
   1. Wound construction
   2. Anterior capsulotomy/capsulorrhexis
   3. Instillation and removal of viscoelastics
   4. Extracapsular technique
   5. Beginning phacoemulsification techniques (e.g., sculpting, divide & conquer, phaco-chop)
   6. Irrigation and aspiration
   7. Cortical clean-up
   8. IOL implantation (e.g., anterior and posterior, special IOLs)
      
      
5. Perform paracentesis of the anterior chamber.
   
   
6. Perform the appropriate steps in cataract surgery, assist in cataract surgery, and perform more advanced steps in patient preparation and anesthesia.
   
   
7. Describe the more advanced applications of viscoelastics in surgery (e.g., control of iris prolapse, elevation of dropped nucleus, viscodissection, aspiration of residual/retained viscoelastic).
   
   
8. Perform basic postoperative evaluation of the cataract patient.
   
   
9. Recognize and refer or treat common postoperative complications of cataract surgery (e.g., endophthalmitis, elevated intraocular pressure, cystoid macular edema, wound leak, uveitis).

Advanced Level Goals: PGY-4

A. Cognitive Skills

1. Define the more complex indications for cataract surgery (e.g. better view of posterior segment), describe the performance of and describe the complications of more advanced anterior segment surgery (e.g., pseudoexfoliation, small pupils, mature cataract, hard nucleus, black cataract, post-traumatic, zonular dehiscence), including more advanced procedures (e.g., secondary IOLs and indications for specialized IOLs, capsular tension rings, iris hooks, use of indocyanine green staining of the anterior capsule).
   
   
2. Describe the instruments and techniques of cataract extraction, including extracapsular surgery and phacoemulsification (e.g., trouble-shooting the phacoemulsification machine, altering the machine parameters).
   
   
3. Describe the indications for, techniques of, and complications of cataract extraction in the context of the subspecialty disciplines of glaucoma (e.g., combined cataract and glaucoma procedures, glaucoma in cataractous eyes, cataract surgery in patients with prior glaucoma surgery), retina (e.g., cataract surgery in patients with scleral buckles or prior vitrectomy), cornea (e.g., cataract extraction in patients with corneal opacities), ophthalmic plastic surgery (e.g., ptosis following cataract surgery), and refractive surgery (e.g., cataract surgery in eyes that have undergone refractive surgery).
   
   
4. Independently evaluate complications of cataract and IOL implant surgery (e.g., posterior capsular tears, vitreous prolapse, intravitreal dislocation of cataractous fragments, choroidal effusions).
   
   
5. Understand indications for and technique of intracapsular surgery (e.g., rare cases may require this procedure; or patients may have had the procedure performed previously).
   
   
6. Describe indications for and instrumentation and techniques used to implant foldable and non-foldable IOLs.
   
   
7. Describe the evaluation and management of common and uncommon causes of postoperative endophthalmitis.
   
   
8. Perform repositioning, removal, or exchange of IOLs.
   
   
9. Assist in the teaching and supervision of basic and standard level learners (i.e., first and second year residents).
   
   
10. Describe the government and hospital regulations that apply to cataract surgery.

B. Technical/Surgical Skills

1. Describe the principles, indications for, mechanics of, and performance of A-scan ultrasonography and calculation of IOL power.
   
   
2. Perform phacoemulsification in a practice setting (e.g, animal or practice lab) and then in the operating room, including mastery of the following skills:
   
   
   1. Wound construction
   2. Anterior capsulotomy/capsulorrhexis
   3. Viscoelastics
   4. Intracapsular, extracapsular and phacoemulsification techniques (e.g., sculpting, divide & conquer, phaco-chop, stop and chop)
   5. Instrumentation and techniques of irrigation and aspiration
   6. IOL implantation (e.g., anterior and posterior, special IOLs)
   7. IOL repositioning, removal or exchange
      
      
3. Perform implantation of foldable and non-foldable IOLs.
   
   
4. Perform intraoperative and postoperative management of any event that may occur during or as a result of cataract surgery, including:
   
   
   1. Vitreous loss
      
      
   2. Capsular rupture
      
      
   3. Anterior or posterior segment bleeding
      
      
   4. Positive posterior pressure
      
      
   5. Choroidal detachments
      
      
   6. Expulsive hemorrhage
      
      
   7. Loss of anesthesia
      
      
   8. Elevated intraocular pressure
      
      
   9. Use of topical and systemic medications
      
      
   10. Astigmatism
       
       
   11. Postoperative refraction (simple and complex)
       
       
   12. Corneal edema
       
       
   13. Wound dehiscence
       
       
   14. Hyphema
       
       
   15. Residual cortex
       
       
   16. Dropped nucleus
       
       
   17. Uveitis
       
       
   18. Cystoid macular edema (CME)
       
       
   19. Elevated intraocular pressure and glaucoma
       
       
   20. Postoperative early and late intraocular infection

Next: Chapter 5. Contact Lens

Also see: Table of Contents of the Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist