One of the special goals of California Pacific Medical Center’s Ophthalmology residency training in the mid-1980’s and 1990s was teaching cataract surgery while surgical techniques were undergoing historic improvements. Residents regularly performed between 250 and 350 cataract surgeries over three years, among the highest rates in the country. With the residency staffed by a mostly volunteer clinical faculty, only surgeons with a passion to educate would do so. As a result, the quality of instruction and the surgical outcomes were consistently strong.
First-year residents would have the opportunity to observe cataract surgery done by their chief resident and by the attending surgeon, starting to learn the basic techniques. Textbooks were still the norm in learning the surgical steps, and online video presentations were not yet in existence. At times, a first-year resident would be allowed to assist in faculty cases and continued to learn the essential and most basic steps of cataract surgery.
Before their first cases and as part of their curriculum, residents practiced surgical skills in the surgical wet lab. The wet lab had two antique operating microscopes and a full set of surgical instruments. Residents used porcine eyes to practice corneal laceration repair, wound construction, corneal transplants and extracapsular cataract surgery techniques. The Department lost that space and had no wet lab in which to practice until Dr. Alan Scott volunteered a room at the Smith Kettlewell Eye Research Institute for the purpose. Residents moved the wet lab to that site, and corporate sponsors helped to set up fully modern surgical learning facilities. The Lions Eye Foundation annually donated equipment to keep the lab well-supplied with hand-held microsurgery instruments, suture material and practice eyes, and it has remained available for resident use.
After the opening of the Pacific Vision Foundation (PVF) Eye Institute, several further hands-on wet labs were organized to help teach techniques such as phacoemulsification, pupil expansion, basic suturing, intraocular lens folding, and capsular tension rings. Group wet labs such as these are still on-going, and topics are chosen to meet the immediate needs of the modern eye surgeon.
In 2017, the CPMC Foundation helped to acquire an EyeSi surgery simulator which continues to play an important role in preparing junior residents for surgery. It allows residents to establish a deeper understanding of microsurgical principals and complex cataract surgery steps by providing an approximation to real-life surgery. Studies have found that residents who trained using the simulator had shorter surgery times, lower amounts of surgical trauma and fewer complications in surgery – and that they learned these skills more quickly.
Most residents performed their first cataract surgeries at Oakland’s Highland Hospital, under the watchful eyes of Dr. Richard Imes who ran the Ophthalmology service at this Level I trauma center from 1994 until 2020. There were generally two residents at Highland at a time, on an 8-month rotation. The junior resident at Highland performed one or two cataract surgeries per week, and the senior resident two to three times more. Starting with 5-10 planned extracapsular cataract surgeries with Dr. Imes, residents learned wound construction, “can opener” capsulorrhexis, nucleus expression, cortical clean-up, IOL insertion and cataract wound suturing.
At a later stage, Dr. Imes would guide the residents into phacoemulsification, the most advanced method of cataract surgery. Dr. Imes demanded careful pre-op preparation, fastidious attention to detail and attentive follow-up. He was a highly respected teacher. Residents at this county hospital did their own ultrasound biometry and manual keratometry for intraocular lens calculations. Steven Post who frequently volunteered to attend residents in cataract surgery, was appreciated as the gentlest of teachers. Steven Pascal spent countless mornings in the Highland OR and taught residents advanced surgery techniques that he used in his own East Bay practice. By the end of their Highland rotation, many residents had done over a hundred cataract surgeries and learned to manage complications. More recently, Drs. Phillip Penrose, Barry Snyder, Edie De Niro, Jane Loman, Mira Lim, Vincent Ray and Enoch Nam all worked with the residents to enhance their cataract surgery skills.
In 2020, Dr. Jonathan Hernandez came to replace Dr. Imes as the Chief of Ophthalmology for the Alameda Health System. As an alumnus of the CPMC residency, Dr Hernandez was able to use the many positives of the Highland experience and further build the Ophthalmology service. He updated the phacoemulsification equipment and secured more surgical block time. As a glaucoma specialist, Dr. Hernandez was able to teach the residents to combine their cataract surgeries with minimally invasive or incisional glaucoma surgeries, what the residents came to call a “mini glaucoma fellowship.” He was also able to expand the ophthalmology clinics and reduce wait times for patients.
Residents were encouraged to tackle complex cataract cases, and there was the beginning of an emphasis on “refractive cataract surgery.” Over many decades, cataract surgery (the removal of the lens inside the eye) had the very troubling consequence of leaving the patient without any meaningful focus. This problem was previously addressed by the use of thick and distorting “cataract glasses.” Lens implants to replace the natural but cloudy human lens had been pioneered by British surgeon Sir Harold Ridley, who implanted the first lens in a human eye in 1949. However, it was not until the late 1970’s and early 1980’s that truly safe intraocular lens implants became widely adopted in the U.S. Now, there was finally a way to restore nearly normal vision after recovery from cataract surgery. Lens implant design continued to improve rapidly, and soon pre-operative measurements of the unique anatomy of each patient’s eye became highly refined. Soft, foldable lenses could be implanted through tiny incisions. Astigmatism could be corrected with special lens implants. The cataract surgeon had achieved a level of accuracy that rivaled refractive surgery like LASIK. Surgeons, for the first time ever, had a strong likelihood of restoring clear vision that was not dependent on glasses or contact lenses for distance, intermediate or near vision. Frequently, patients would say within several days of cataract surgery that they had never seen so well – and no longer needed glasses for daily visual activities. Cataract surgeons had started to achieve something that had never been thought possible in any field of medicine and surgery – the restoration of a critical human function to a level that rivaled or even exceeded the quality of vision during youth.
After Highland’s stressful but rewarding environment, residents rotated to Kaiser Hospital in San Francisco, operating side by side with high-volume surgeons like Drs. Monty Pack, Ken Ip, Suketu Sanghvi, Richard Wolitz and others. At the time, residents sometimes acted as primary surgeons for cases supervised by the Kaiser attending. They learned the different techniques favored by each attending surgeon, which expanded their repertoire of techniques and pushed them beyond what they had learned at Highland Hospital.
The Kaiser rotation provided significant surgical experience and was a favorite of residents. It remains a key rotation that teaches residents new techniques. At Kaiser, cataract surgery skills could be polished and surgical techniqueimproved to meet patient expectations.
Once the residency returned to three residents per year in 2003, it afforded the opportunity of 4 months of elective time to focus on areas of interest or to strengthen knowledge and skills in particular subspecialties. Residents could spend time with innovative mentors of their choice. During this time period, residents could also travel abroad to Aravind Eye Hospital in India to observe and perform extracapsular cataract surgery and manual small incision cataract surgery. The experience at Aravind was typically inspiring. Besides learning from some of the most skilled cataract surgeons in the world, residents could also study the organization of health care, especially for those with very limited income and had the opportunity to perform surgery on severe cataracts that were blinding.
By the time residents had reached their final months of training and become Chief Resident, they had exhaustively studied and performed cataract surgery. In their last rotation at CPMC, the Chief Resident supervised the Lions Eye Clinic and performed a wide range of vision saving surgeries.
Almost everyone on the CPMC volunteer faculty had experience doing cataract surgery and teaching it, and residents routinely asked subspecialists to supervise their cataract surgery cases when they were Chief Resident. To residents at the time, calling faculty to ask for help in surgery could be daunting. But in retrospect, it built camaraderie and contributed to strong relationships between residents and their teachers.
Retinal surgeons Wayne Fung and Mike Allen, glaucoma specialists Bob Stamper and Jason Bacharach and later George Tanaka and Patricia Wong were frequently asked to assist the residents with their surgery and seemed to always, to find time. Cornea Chief Dan Goodman was generous with his time and expertise and helped residents with difficult surgeries. In the OR, Karen Oxford taught meticulous surgical preparation and how to be ready for a hundred “what ifs” that had to be seen and successfully dealt with. Roger Husted and Leland Rosenblum traveled from Monterey to help, as often as once a month. Roger taught residents techniques that his students still use today – and teach their own residents. Susan Day occasionally attended cataract operations, as did Alan Scott, who asked thoughtful questions about instrumentation and technique throughout.
Currently, resident surgery blocks with Danny Lin have continued to attract what the residents describe as “interesting cases.” During their final months, chief residents gain experiences in a wide variety of procedures including but not limited to combined cataract surgery with keratoplasty, intraocular lens exchange, sutured intraocular lenses, traumatic cataracts, limbal relaxing incisions and premium intraocular lenses.
Denice Barsness and Marina Soboleva continue to oversee the pre-operative ultrasound biometry and IOL calculations for resident patients, keeping up to date with technologies and formulas for post-refractive surgery cases. Mark Paskvan, Lions Eye Foundation coordinator, supervises the surgery scheduling for CPMC resident surgery cases and provides the interface between patients, the sponsoring Lions Clubs and the Ophthalmology Department.
In addition to the rotations through the various hospitals, residents gained additional cataract and anterior segment surgery exposure with many more surgeons in the Bay Area. Beginning in 2017, residents were given the opportunity to work with Dr. Mark Mandel. His rotation later served as one of their initial foundations of cataract and refractive surgery. As a skilled cornea specialist, Dr. Mandel would frequently share management pearls of both routine and complex cataract cases. He often gave lectures on a multitude of topics ranging from corneal pathology to surgical technique. As residents progressed beyond his rotation, he continued to serve as a resource.
Dr. Kevin Denny, a graduate of Harvard and the New York University School of Medicine, was an alumnus of the CPMC program. As the first formal Chief of Cataract Surgery, he served for 15 years. He was then selected as Chairman of the Ophthalmology program in 2016. During his tenure as Chief of Cataract Surgery and then Department Chair, he guided an endless succession of young ophthalmologists into successful cataract surgery skills.
Dr. Danny Lin was named the Cataract and Anterior Segment Surgery service chief in 2016, after Dr. Denny became the Department Chair. Dr. Lin completed his medical training and residency at Stanford University, followed by a fellowship in Cornea, External Ocular Disease, and Refractive Surgery at the UCLA Jules Stein Eye Institute. Since his arrival at Pacific Eye Associates and CPMC in 2004, Dr. Lin maintained monthly resident surgery blocks at CPMC. In addition to coordinating didactics and grand rounds, Dr. Lin enthusiastically supported the education of CPMC residents with the latest in cataract surgery. CPMC residents now gain exposure and hands-on training with new technologies such as femtosecond lasers, intraoperative aberrometry, iris registration devices and premium intraocular lenses for astigmatism and presbyopia.
CPMC residents have learned and helped develop the extraordinary developments in cataract surgery that occurred over a relatively short period of time. The explosion in quality and many innovations in cataract surgery made it one of the most successful and life-changing surgeries in the world.
There is a long list of Barkan Society ophthalmologists who have contributed to the refinement of this surgery in so many ways. Dr. Wayne Fung helped lead the introduction of phacoemulsification to CPMC and San Francisco when it was still questioned among many surgeons. Drs. Stamper, Fung, Cleasby and Norris promoted the use of and rapid improvement in lens implant technology. Dr. John Campbell, in private practice in San Rafael, was one of two key surgeons who discovered the relationship between commonly used prostate medications and major difficulties in cataract surgery. This finding soon led to a reliable way of overcoming this potentially serious problem.
The CPMC Ophthalmology program has been at the forefront of innovation in cataract surgery. Cataract surgery remains one of the most important and beneficial surgical interventions in the world. The future residents at CPMC will have the opportunity to continue to work in this sub-specialty and continue to find new and better ways to preserve and restore eyesight.