Extracapsular cataract extraction to phacoemulsification: why and how?

To determine what factors influence a decision to move from extracapsular cataract extraction to phacoemulsification as the cataract removal technique of first choice, and to investigate how the transition is managed.

Questionnaire surveys were carried out in 1996 and 1997 of consultant ophthalmologists in the former Oxford Region.

'Evidence of clinical benefit' was the strongest factor influencing a decision to change technique, but 'fear of becoming a dinosaur' and 'peer pressure' were also important factors. Beliefs about advantages of phacoemulsification were little changed with increasing experience, but personal contraindications to phacoemulsification diminished with time. Hard nuclei, mature cataracts and poor zonular support remained relatively strong contraindications to phacoemulsification by the second survey. Only 46% of 14 respondents had performed phacoemulsification under supervision before 'going solo', but 64% felt well or adequately prepared for their first solo phacoemulsification. Influence of non-clinical factors such as equipment availability on the choice of technique did not diminish significantly between surveys. Increasing experience of phacoemulsification appeared to reinforce beliefs about its advantages.

Respondents appear to have adopted phacoemulsification with careful preparation, and enthusiasm for the technique has been reinforced by increasing experience. Courses and wet-labs provide limited preparatory experience, but peer supervision is difficult to arrange for consultants. Respondents generally felt that learning phacoemulsification had been stressful, but not as difficult as feared. Implications for the introduction of new surgical techniques into ophthalmological practice in the future are discussed.