Transcript Comparison of Endothelial Cell Loss After

Comparison of Endothelial Cell Loss After
Phacoemulsification Performed by Third Year
Residents and Anterior Segment Surgeons
Alexandra Braunstein, MD
Eric Wolf, MD
Columbia University Harkness Eye Institute
New York, New York
.
Neither author has any financial interest in the
material presented.
Purpose
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To present a case series of endothelial cell loss secondary to
uncomplicated phacoemulsification with posterior chamber
intraocular lens implantation performed by third year residents
at various points in their training and anterior segment surgeons
at a university teaching hospital in order to examine the rate at
which resident surgical skills approach that of attendings
Background
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Adequate function of the endothelial cells is necessary for a
perfectly clear cornea. It is thought that if a critical number of
cells do not remain the lose of function will result in pathology
such as edema and bullous keratopathy.
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Specular microscopy helps to estimate the morphology and cell
count of the corneal endothelium in vivo long before clinical
signs of decompensation occur.
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Endothelial Cell count has utility in the selection of eyes for
intraocular surgery and for evaluating donor corneas.
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It is generally accepted that there is a gradual decline in
endothelial cell count with age. The average child has ~3500
cells/mm2. The average adult has ~ 2400 cells/mm2 (15003500).
Methods
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Prospective Case Series
Fifteen patients who underwent uncomplicated
phacoemulsification with PCIOL from July 2008 thru December
2008.
11 surgeries were performed by third year residents and 4 by
an anterior segment attending.
There was no randomization or masking of patients.
Resident cases were selected from patients at the resident
clinic with visually significant cataracts.
The attending cases were selected from his private practice.
Methods
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Patients had endothelial cell counts
performed prior to surgery and at
three months post-operatively.
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Cell Density was used to calculate
data.
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Endothelial cell loss in each eye was
analyzed and an average number
was obtained for all cases, as well
as, an average over predetermined
time period of three two month
blocks for the residents.
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Block One: July and August 2008
Block Two: September and October 2008
Block Three: November and December
2008
Exclusion Criteria:
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History of corneal disease in the studied eye.
History of prior ocular surgery in the studied eye.
Patients who had additional surgery performed at the time of
cataract extraction, such as glaucoma filtering surgery or
vitrectomy.
Complications during the surgery, such as posterior capsule
tears.
Use of iris expansion devices during surgery, such as iris
hooks.
Results
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Average endothelial cell count loss for the attending physician
was 701
Average of all resident case endothelial cell count loss was
566.32
Avg.
ECL
Block One
Block Two
Block Three
874.3
648
364.6
Trend of ECL over six months
900
800
700
600
500
Attending
Residents
400
300
200
100
0
1st Tri
2nd Tri 3rd Tri
Total
Study Limitations
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Small sample size
Classification and severity of cataracts extracted were not taken
into account.
The residents endothelial cell counts were obtained from a
different specular microscope than the attending.
Specular microscope operator variability.
Type of IOL was not taken into account. (ie. Accommodative v.
toric)
Polymegethism and Pleomorphism were not taken into account.
Limited follow up time of three months.
Conclusions
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The sample size was too small to provide statistically significant
data.
The study did demonstrate a trend that residents
showed a considerable decrease
in the loss of endothelial cells as they
gained surgical experience
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Further studies with longer follow up, larger sample size and
more detailed analysis of patient variability is needed to support
the trend of improvement noted in this study.
References
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Effect of age on the endothelial cell count in the normal eye.R S Wilson
and M J Roper-Hall, Br J Ophthalmol. 1982 August; 66(8): 513–515.
Changes in the corneal endothelial cell count as a function of age. Panda
A, Venkataswarlu K, Angra SK, Mohan M. Indian J Ophthalmol 1985;33:221-3
Normal Endothelial Cell Density Range in Childhood Paolo Nucci, MD;
Rosario Brancato, MD; Marilyn B. Mets, MD; Steven K. Shevell, PhD Arch
Ophthalmol. 1990;108(2):247-248.
Risk factors for endothelial cell loss after phacoemulsification surgery
by a junior resident, ,Journal of Cataract & Refractive Surgery, Volume 30,
Issue 4, Pages 839-843
Comparison of endothelial cell loss and phacoemulsification energy
during endocapsular phacoemulsification surgery Zetterstrom C., Laurell
C.-G. Journal of Cataract & Refractive Surgery, 1995, vol. 21, no1, pp. 55-58