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224 T. Hammer et al.
of one’s own training are more clearly perceived
in a foreign environment, and on the other hand,
the trainee can also learn from the strengths and
weaknesses of other environments, not least
other surgical techniques (Fig. 21.5).
21.4.1 Assessing the Status
and Progress of One’s Own
Surgical Training
The acquisition of certain skills can be divided
into five phases or competency levels (Dreyfus
1980): novice, beginner, competent, experienced surgeon, and expert. In practice, there
are numerous variations of this classification,
which are helpful for training planning and
evaluation. For example, not only abroad, the
ICO-OSCARS are frequently used, which are
available for the most important ophthalmological procedures (OSCAR, “Ophthalmology
Surgical Competence Assessment Rubric”) [2].
The assessment forms are helpful for internalizing the individual surgical steps and can well
assess the status of surgical training and also
serve one’s own learning control.
With regard to stays abroad, it should be
noted that the timing and content of surgical
training can differ significantly from those the
trainee’s home country, which is why specifying the training year is often not helpful. With
the help of standardized assessment aids such
as the ICO-OSCARS, trainers and mentors are
also able to assess and document the status and
development of surgical skills across national
borders.
Fig. 21.5 Cameroon: Demonstration of regional surgical techniques during a mentor’s visit. (Courtesy of Frank
Wilhelm)
22521 The First Surgeries Are Completed, What Comes Next?
21.4.2 Planning a Stay Abroad
It is important to define fixed goals for planning
and to allocate sufficient time for preparation.
Setting Goals for the Stay Abroad Planning
begins with setting one’s own expectations for
a stay abroad within the framework of surgical
training. Do you want to observe or be practically
active? Learn a specific technique or broaden
your general horizon? Depending on one’s own
training level, different goals are suitable (see also
Table 21.2). Since learning ophthalmic surgery
also significantly involves feedback from colleagues and observing experienced surgeons, both
observations and practical training can be valuable. Especially after a certain basic level of surgical skills has been established, stays in a foreign
environment become increasingly helpful, as the
details of the operation are perceived more differentiatedly and tips can also be implemented
more quickly and easily by the learner. Practical
surgery usually requires a longer familiarization period and mutual acquaintance on site. An
exception is short surgical courses offered for specific operations. These can vary greatly in price,
quality, and adherence to ethical standards. It is
usually worthwhile to first exchange ideas with
colleagues who have recently completed such a
course.
Planning Time for Preparation Performing surgery abroad usually requires a medical license,
possibly additional professional liability insurance,
and a work visa. The costs incurred must usually
be borne by the intern. It is essential to inquire
about the exact regulations on site and to allocate
sufficient time for obtaining all documents. Often,
about a year of lead time is required.
If possible, preparation with surgical videos
in the respective local language is also recommended to learn the relevant technical terms in
advance.
21.4.3 Operating Abroad
Once all the hurdles in preparation are overcome
and one stands for the first time in the new operative environment, a very instructive and enriching time usually begins.
Every eye clinic has its own operating culture,
and abroad, national regulations and customs
additionally determine the atmosphere and procedures in the operating room. This starts with the
size and task distribution of the operating team,
the handling of patients, extends to the way feedback is given, and also includes specific surgical
techniques. National professional societies also
have a significant influence on the frequency and
preference of various surgical techniques. It is
always worthwhile to look beyond the national
horizon, also to learn from the mistakes and successes of others.
A particularly favorable circumstance is
when the mentor and the less experienced
Table 21.2 Different Stages of Surgical Training. There are mixed forms
Competence Definition Aspects
Novice First steps learned, but still
requires constant supervision
Beginner Can independently perform the
entire operation but still frequently needs support
Competent Performs the operation indepen-
dently and rarely needs support
Expert Operates independently with a
lot of experience, teaches other
surgeons
Short internships of a few weeks for general familiarization are
useful. Practical training is most feasible in structured training
programs and should be clearly agreed upon.
Observing various surgeons in different clinics and countries is
useful, as the surgical steps and their fine variations are already
perceived. Practical training is rather difficult, usually requiring
a long stay of 3–12 months.
Practical training is possible during a longer stay to deepen
existing knowledge. Short observations are often sufficient to
learn new techniques and subsequently apply them.
Benefits from observing other experienced colleagues. Acting
as a trainer is possible, especially with regular assignments
conducted over years.
226 T. Hammer et al.
colleague already know each other from mutual
visits. Then the experienced mentor can better
address the regional peculiarities during surgical
training [8].
Examples of different variants of common
surgical techniques are sutureless extracapsular cataract extraction (“sutureless ECCE”) or
releasable sutures in trabeculectomy. In these
cases, adapted ICO-OSCARS can also be used
for teaching and learning control.
Steps of Sutureless Extracapsular Cataract
Surgery
1. Surgical preparation including
peribulbar anesthesia and sterile
draping
2. After inserting the lid speculum, a
superior rectus muscle fixation suture
may be placed, especially in deep-set
eyes
3. Peritomy of the conjunctiva along
the limbus over four clock hours and
21.4.4 Examples of Internationally Common Surgical Variants
hemostasis
4. Scleral incision and preparation of a
scleral corneal tunnel up to 1–1.5 mm
The general course of a specific operation is
usually fixed. However, regarding the small
details, there are often many ways that can
be taken. Since only relatively few of these
individual steps are compared in randomized
studies, much surgical practice is based on experience and traditional knowledge. This knowledge can be expanded through videos, but it
is best learned by observing experienced surgeons or by independent operating under direct
supervision.
into the clear cornea, without opening
the anterior chamber yet
5. Paracentesis, filling the anterior
chamber with viscoelastic
6. Completing the scleral corneal tunnel
into the anterior chamber
7. Capsulotomy with the curved tip of a
26G needle, can-opener or envelope
8. Hydrodissection and dislocation of
the lens nucleus into the anterior
chamber
9. Extraction of the lens, e.g., with a lens
Sutureless Extracapsular Cataract Extraction
loop or in fishhook technique
10. Removal of cortex and epinucleus
remnants with the Simcoe irrigation/
aspiration cannula
Introduction
Sutureless extracapsular cataract extraction (“sutureless extracapsular cataract
extraction“, ECCE) is an advancement of
the classic ECCE. It is widespread in many
countries with a high number of patients
with advanced cataracts. Additionally, the
11. Implantation of the intraocular lens
into the posterior chamber
12. Irrigation and aspiration
13. With correct tunnel construction, it
self-seals in small incision techniques,
so no suture is required. If the tunnel
is not tight, a suture must be placed.
costs of the procedure can be kept low,
as the purchase and maintenance as well
as consumables of a phacoemulsification
unit are eliminated, and PMMA intraocular lenses can be used. The surgical technique is a sensible option for any cataract
surgeon in difficult situations, such as with
a very hard lens nucleus.
Trabeculectomy with Releasable Scleral Flap Sutures
The trabeculectomy is significantly less standardized than cataract surgery (Fig. 21.6). The
application of Mitomycin C, scleral flap sutures,
or conjunctival sutures of the filtering bleb are
performed in various ways in different clinics
and by different surgeons. A globally frequently
22721 The First Surgeries Are Completed, What Comes Next?
used variant in the procedure of trabeculectomy
(Fig. 21.7) is the use of releasable sutures instead
of single knotted sutures to fix the scleral flap.
In this case, a loop is knotted instead of a single thread. One end of this loop runs through the
peripheral cornea. If the intraocular pressure is
too high in the early postoperative phase within
the first month, one or both threads can be easily
pulled at the slit lamp with a needle and forceps,
without the need for a laser and without leaving
thread remnants in the tissue [10, 11].
Fig. 21.6 Tanzania: A mature lens nucleus can be gently removed using sutureless extracapsular cataract
extraction, here with a “lens loop”. (Courtesy of Heiko
Philippin)
Internet Resource For many surgeries performed worldwide, helpful resources can be
found on the internet. Many surgeons offer videos that provide a good overview of surgical
Fig. 21.7 United Kingdom: Observing a trabeculectomy with releasable scleral flap sutures during an international
fellowship. (Courtesy of Heiko Philippin)
228 T. Hammer et al.
techniques and their differences. A free option
for ophthalmological online training in general
and specifically for global surgical techniques
is “Cybersight” by Orbis (www.cybersight.
org). The platform offers courses on, for exam-
ple, phacoemulsification and sutureless ECCE
(“sutureless ECCE”).
References and Further Reading
1. Ahr WM (2021) Frühe Nachsorge nach unkomplizierter Kataraktoperation. Z prakt Augenheilkd
42:83–95; Dreyfus SE (2004) The five-stage model
of adult skill acquisition. Bull Sci Technol Soc
24:177–181
2. Golnik KC, Beaver H, Gauba V, Lee AG, Mayorga
E, Palis G et al (2011) Cataract surgical skill assessment. Ophthalmology 118:427.e1–427.e5
3. Holzwig DH (1997) Irisretraktor, ein Teilschritt
in der Kataraktchirurgie bei engen Pupillen. In:
11. Kongress der Deutschsprachigen Gesellschaft
für Intraokularlinsen-Implantation und refraktive
Chirurgie. Springer, Berlin/Heidelberg, S 232–237
4. Kohnen S (2012) Kataraktchirurgie: Komplikationsmanagement bei Inzision und Kapseleröffnu ng.
Ophthalmo Chir 24:147–154
5. Kohnen S (2016) Komplikationsmanagement in der
Kataraktchirurgie: Linsensubluxation und Zonulolyse.
Ophthalmo Chir 28:117–120
6. Pham DT (2016) Komplikationen bei der
Intraokularlinsen-Implantation. Ophthalmo Chir
28:123–128
7. Pham DT (2017) Spätkomplikationen bei der
Intraokularlinsen-Implantation. Z prakt Augenheilkd
38:64–68
8. Sachsenweger M (1990) Augenheilkunde in den
Tropen. Gustav-Fischer, Stuttgart/New York, S 206s
9. Wirbelauer C, Schmidt S, Puk C (2018)
Mechanische Pupillenerweiterung mit Ringen zur
Kataraktoperation bei enger Pupille. Ophthalmologe
115:329–335
10. Zhou M, Wang W, Huang W, Zhang X (2014)
Trabeculectomy with versus without releasable
sutures for glaucoma: a meta-analysis of randomized
controlled trials. BMC Ophthalmol 14:1–8
11. Khaw PT, Chiang M, Shah P, Sii F, Lockwood
A, Khalili A. Enhanced Trabeculectomy – The
Moorfields Safer Surgery System. Dev Ophthalmol.
2012;50:1–28.