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Trends in cataract surgery training

Mona Lotfipour, MS, Ramunas Rolius, MD, Erik B. Lehman, MS, Seth M. Pantanelli, MD, MS,
Ingrid U. Scott, MD, MPH

Purpose: To evaluate trends in cataract surgery training curricula trainees at 91% of programs. More than two thirds (71%) of
and factors affecting timing of resident participation as a primary program directors indicated that their program had a cataract
surgeon. surgery training curriculum designed to transition residents
gradually to the operating room. These curricula included
Setting: Pennsylvania State College of Medicine, Hershey, Penn- structured wet laboratory (92%) and lecture (89%) components.
sylvania, USA. Inadequate resident knowledge and surgical skill base (57%) and
anticipation of increased surgical complication risk (37%) were
Design: Cross-sectional study of anonymous survey results. the most commonly reported factors impeding earlier exposure
to phacoemulsification in residency.
Methods: A description of the study and link to an online survey
was e-mailed to program directors of each ophthalmology resi-
Conclusions: Results show that residents today begin surgical
dency training program accredited by the Accreditation Council
training with phacoemulsification rather than ECCE, perform a higher
for Graduate Medical Education (ACGME).
number of phacoemulsification surgeries than is required by the
ACGME, and begin performing phacoemulsification as early as their
Results: Fifty-one (44%) of the 116 program directors completed
first or second year of residency. Despite these evolutions, 29% of
the survey. First-year, second-year, and third-year residents
respondent ACGME-accredited ophthalmology residency programs
performed a mean of 2, 25, and 155 phacoemulsification
reported not having a formal cataract surgery training curriculum.
surgeries, respectively, as a primary surgeon. Only 1 program
(2%) required residents to perform extracapsular cataract J Cataract Refract Surg 2017; 43:4953 Q 2016 ASCRS and ESCRS
extraction (ECCE) before performing phacoemulsification. Clear
corneal phacoemulsification was the first technique taught to Supplemental material available at

In 2002, Rowden and Krishna3 surveyed program direc-

ataract surgery is the most commonly performed
ophthalmic surgical procedure and is, therefore, tors regarding cataract surgery training. At that time, ECCE
an important component of residency training in experience was a near ubiquitous requirement before tran-
ophthalmology.1,2 The Accreditation Council for Graduate sitioning to phacoemulsification and scleral tunnels were
Medical Education (ACGME) requires that graduating more commonly used than clear corneal incisions. In
residents perform a minimum of 86 cataract surgeries as 2013, Yeu et al.,4 collected data from residents regarding
the primary surgeon.A However, the ACGME refrains the number of cataract surgeries performed and perceived
from specifying which techniques (ie, extracapsular cata- adequacy in phacoemulsification training. They found
ract extraction [ECCE] or phacoemulsification or ap- that most residents believed that their exposure was
proaches [scleral tunnel or clear corneal]) should be adequate to be independent surgeons. Since then, to our
mastered during residency training. There are also no spe- knowledge, there have been no published studies docu-
cific requirements with respect to cataract surgery training menting the current trends in phacoemulsification training.
curricula and when residents should begin performing To better understand the current state of cataract surgery
phacoemulsification as a primary surgeon. training with regard to technique and volume, training

Submitted: August 24, 2016 | Final revision submitted: October 19, 2016 | Accepted: October 23, 2016
From the Department of Ophthalmology (Lotfipour, Rolius, Pantanelli, Scott) and Department of Public Health Sciences (Lehman, Scott), Pennsylvania State College of
Medicine, Hershey, Pennsylvania, USA.
Mona Lotfipour, MS, and Ramunas Rolius, MD, contributed equally to this work.
Supported by the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through grant UL1 TR000127. The content is solely the
responsibility of the authors and does not necessarily represent the official views of the NIH, Bethesda, Maryland, USA.
Corresponding author: Seth M. Pantanelli, MD, MS, Pennsylvania State M.S. Hershey Medical Center, 500 University Drive, HU19, Hershey, Pennsylvania 17033-0850,
USA. E-mail:

Q 2016 ASCRS and ESCRS 0886-3350/$ - see frontmatter

Published by Elsevier Inc.

curricula trends, timing of resident participation, and fac- Cataract Surgery Volume and Technique
tors impeding incorporation of resident-performed phaco- Figure 1 shows the frequency and distribution of phaco-
emulsification into residency training earlier, we performed emulsification volume across training programs. As re-
a Web-based survey of program directors. To our knowl- ported by program directors, residency graduates
edge, this is the first survey of program directors to evaluate completed a mean of 182 phacoemulsification surgeries
factors impeding implementation of earlier resident- (median 169) as primary surgeons. One program director
performed phacoemulsification surgery. (2%) reported a resident-performed phacoemulsification
volume less than 101, 15 program directors (29%) reported
a volume between 101 and 150, and 35 program directors
MATERIALS AND METHODS (69%) reported a volume greater than 150. These cases
The Human Subjects Protection Office of the Pennsylvania State were distributed as follows: the mean number of resident-
College of Medicine determined that this study protocol was
performed phacoemulsification surgeries was reported to
exempt from approval by the Institutional Review Board.
be 2 (range 0 to 15) for first-year residents, 25 (range 0 to
90) for second-year residents, and 155 (range 80 to 350)
Data Collection for third-year residents.
An anonymous Web-based survey was constructed using Survey- Most residents began performing phacoemulsification as
monkey.B The survey consisted of multiple choice and Likert-scale a primary surgeon during their second year. However, high
questions regarding the resident phacoemulsification experience variability existed in the distribution of initial exposure as
in each year of residency, phacoemulsification training curricula, first assistant and primary surgeon (Figure 2). In the most
and factors impeding earlier resident-performed phacoemulsifica-
tion (Appendix 1, available at An e-mail conservative programs, the opportunity for a phacoemulsi-
containing an explanation of the study, an invitation to partici- fication first assistant was withheld until the final year of
pate, and a link to the survey was sent to the program director residency (1 program [2%]). In contrast, 17 programs
of each of the 116 ACGME-accredited ophthalmology residency (33%) reported first-year residents were performing phaco-
programs in the United States. Follow-up reminder e-mails were emulsification as primary surgeons; however, as noted
sent to the program directors during the subsequent 1 week and
3 weeks. Surveys were completed in October and November 2015. above, the mean number of cases performed by first-year
residents was only 2.
Thirty-three program directors (67%) reported that the
Statistical Analysis majority of resident-performed phacoemulsification sur-
Responses to the survey were recorded, and frequency data were geries were in patients with public insurance or in Veterans
used for descriptive analysis. All other analyses were performed Administration (VA) hospitals, 4 program directors (8%)
with SAS software (version 9.4, SAS Institute, Inc.), and statistical reported that the majority of resident-performed phaco-
significance was set at a P value less than 0.05. The distribution of emulsification surgeries were performed in patients with
cases was assessed using a histogram, normal probability plot,
Shapiro-Wilk test for normality, and boxplots. Because the private insurance, 8 program directors (16%) reported an
outcome was not distributed normally, a Wilcoxon rank-sum equal mix of patients with private and public insurance,
test was used to compare the median number of resident- and 4 program directors (8%) specified patients were
performed phacoemulsification surgeries at programs that derived derived from a resident clinic without information
volume from private rather than public insurance populations. regarding the insurance status of these patients. The
mean number of phacoemulsification cases performed by
RESULTS residents when the majority of patients had private versus
Fifty-one (44%) of the 116 program directors completed the public insurance was 148 and 188, respectively (P Z .215).
survey. Only 1 program director (2%) reported a requirement for
residents to perform ECCE before attempting phacoemulsi-
fication. Roughly one half (24 program directors [47%])

Figure 2. First exposure for residents as assistant or primary sur-

Figure 1. Frequency distribution of the total number of phacoemul- geon in phacoemulsification cataract surgery, divided by residency
sification procedures completed during residency. year (PGY Z postgraduate year).

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reported that residents begin learning phacoemulsification on the department. Four program directors responded in
with 1 particular technique. Of the programs that begin prose with other potential factors, and these included (1)
training with 1 technique, 21 program directors (91%) re- manual skills are best learned in high frequency, repeti-
ported that residents are initially taught clear corneal inci- tively performed settings, (2) better for the resident to
sions for wound construction; at 2 remaining programs become more attuned to medical ophthalmology before
(9%), residents are initially taught scleral tunnel incisions. tackling surgeries, (3) variability of appropriate cases for
All started with divide-and-conquer for nucleus disas- first time surgeon, and (4) potential for lawsuit due to
sembly. Twenty-seven other program directors (53%) re- higher rate of complications.
ported that their residents learned several techniques in
parallel from different surgeons. DISCUSSION
In the current study, program directors reported a mean
Training Curricula resident phacoemulsification volume of 182 (median
Thirty-six program directors (71%) reported that their pro- 169), which is more than double the minimum number
gram had a formal cataract surgery training curriculum required by the ACGMEA and similar to the 176 cases
(Figure 3). Of these, 33 (92%) reported using supervised ac- logged by residents and reported to the ACGME in
cess to a wet laboratory and 32 (89%) reported lectures to 2015.C The volume of cases reported in this study is a
train residents. Twenty-three programs (63%) also pro- 60% increase over the mean of 113 reported by Rowden
vided unsupervised access to a wet laboratory in which res- and Krishna in 2002.3 In the current study, 69% of program
idents practiced cataract surgery techniques. Twenty-one directors reported that their residents performed more than
programs (59%) also provided unsupervised access to a vir- 151 phacoemulsification surgeries, whereas only 42% re-
tual reality simulator and 19 (53%) provided supervised ac- ported the same in a study by Yeu et al.4 In addition to per-
cess to one (Eyesi, VRMagic GmbH). forming a higher number of phacoemulsification surgeries,
residents are also performing their first phacoemulsifica-
tion surgeries earlier in training than in previous years.
Factors Impeding Early Resident-Performed
Yeu et al.4 found that 18% and 79% of first-year and
second-year residents, respectively, performed phacoemul-
Table 1 shows factors impeding early resident-performed
sification as a primary surgeon. In contrast, our study found
phacoemulsification. Twenty-eight program directors
that 33% and 90% of first-year and second-year residents,
(55%) reported that residency year was a determining factor
respectively, performed phacoemulsification as a primary
for deciding when residents perform their first phacoemul-
surgeon. Although a higher phacoemulsification volume
sification surgery as a primary surgeon, whereas 33 (65%)
does not necessarily translate into greater competence as
reported that satisfactory achievement of training mile-
a phacoemulsification surgeon, the trend toward higher
stones determined resident readiness. Nineteen program
volumes suggests that residents graduating today might
directors (39%) and 4 program directors (8%) believe that
be more comfortable with phacoemulsification than those
surgical complication rates associated with resident-
graduating 15 years ago.
performed phacoemulsification would be higher if residents
Resident training programs closely affiliated with a VA
started operating in the first or second year of residency,
hospital or major university, where the proportion of resi-
respectively, rather than in the third year of residency.
dents surgical patients with public insurance is higher,
The most commonly reported factors impeding earlier
had a higher resident phacoemulsification volume than
resident-performed phacoemulsification included inade-
quate resident knowledge and surgical skill base, anticipa-
tion of increased surgical complication risk, no perceived Table 1. Perceived barriers to implementation of resident-
benefit to resident education, concern about taking volume performed phacoemulsification cataract surgery earlier dur-
away from senior residents, and the effects of cost and time ing residency training.
Perceived Barrier PDs, n (%)

Inadequate knowledge and surgical-skill base 29 (56.86)

Anticipation of increased complication rates 19 (37.25)
No perceived benefit 16 (31.37)
Negatively affect experience of senior residents 15 (29.41)
Increased cost and limited OR time 10 (19.61)
Faculty resistance because of other factors 10 (19.61)
Insufficient patient base 9 (17.65)
None 8 (15.69)
Other 4 (7.84)
Figure 3. Approaches to cataract surgery training in programs with
an existing curriculum. OR Z operating room; PDs Z program directors

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training programs unaffiliated with either of the above (182 curriculum. Although 90% of program directors reported
versus 142, respectively). This difference was not statisti- residents began their training as primary surgeons in their
cally significant (P Z .215), possibly because of the limited first 2 years of residency, first-year and second-year resi-
power of the current study given the relatively small num- dents performed, on average, only 2 and 25 phacoemulsifi-
ber of survey respondents. cation surgeries, respectively, per year. In the current study,
Cataract surgery technique has evolved substantially over 19 program directors (39%) believed that surgical compli-
the past 13 years (Figure 4). In the 2002 study by Rowden cation rates would be higher if residents began phacoemul-
and Krishna,3 73% of residents began their surgical training sification as a primary surgeon as a first-year rather than
with ECCE. A study by Chen et al. in 20105 found that 26% third-year resident. In comparison, only 4 program direc-
of programs trained residents to perform ECCE before tors (8%) believed the same when comparing second-year
phacoemulsification. The current study found that only 1 to third-year residents. These beliefs might be unfounded;
program (2%) began its cataract training with ECCE. In studies10,11 have shown that complication rates associated
2015, graduating residents logged an average of only 2 cases with resident-performed phacoemulsification are higher
(range 0 to 32) of ECCE.B Clearly, ECCE is no longer a with the first 40 to 80 cases performed; however, there is
training priority at the vast majority of U.S.-based residency no evidence to suggest that complication rates would be
training programs. Although some might argue that this higher if these first cases were performed earlier as opposed
renders new surgeons inadequately prepared to deal with to later in residency training. A previous study12 found that
dense cataracts, it is also important to remember that the resident participation as a primary surgeon is associated
phacoemulsification technology has improved significantly. with increased operative times and costs during the first
What would have been unmanageable with a phacoemulsi- half, but not the second half, of the academic year. However,
fication machine 20 years ago is often quite manageable no study has assessed whether the increased costs associ-
today. ated with resident-performed phacoemulsification are asso-
The ACGME requires that ophthalmology training pro- ciated with year of residency.
grams have a surgical-skills development resource. This The current study has several limitations. First, only 44%
requirement is often fulfilled by providing residents with of program directors completed the survey. The response
access to a wet laboratory in which to practice. However, rate is lower than in other recent studies that surveyed pro-
provision of a wet laboratory, in and of itself, is not neces- gram directors; therefore, it is possible the responses ob-
sarily sufficient; previous studies69 have shown that tained are not representative of all U.S residency training
combining access to a wet laboratory with a structured sur- programs.13,14 There is concern about a nonresponse bias
gical training curriculum results in significant reductions in because program directors had the option to take part in
cataract surgery complications and a less steep learning the study. It is possible that program directors who chose
curve. Despite this, 29% of program directors surveyed in not to participate have programs that place a different
our study reported that their programs do not have a formal emphasis on surgical training than the ones found in this
cataract surgery training curriculum. Barriers to imple- study. Second, only program directors were questioned
menting such curricula could include lack of faculty time regarding residents' training. It is possible that residents
and/or commitment, lack of financial resources to support at these programs might have reported their experience
a wet laboratory with a virtual surgery simulator and/or differently. Results might have also been different if we
model eyes, the perception that virtual surgery simulation had surveyed all faculty involved in resident training of
and/or model eyes are inadequate to sufficiently mimic a cataract surgery. Third, the anonymous nature of this study
true-to-life operating experience, and the perception that prevented the evaluation of factors such as whether regional
an apprentice-type style of teaching cataract surgery ne- differences exist in practice patterns or whether residency
gates the need for a formal cataract surgery training program size influences cataract training curricula. Last,
whereas some of the questions in the survey were modeled
closely after the survey questions from Rowden and
Krishna's study3 so that results could be directly compared,
other questions pertaining to factors impeding earlier
phacoemulsification were validated internally only. Using
an externally validated questionnaire might have decreased
the risk for misinterpretation by the program directors.
Residents graduating from U.S.-based ophthalmology
training programs are learning phacoemulsification earlier
during residency and performing a higher number of
phacoemulsification cases than they were a decade ago.
Although most ACGME-accredited ophthalmology resi-
dency training programs have a formal structured cataract
Figure 4. Changes in cataract surgery training over the last 13 years.
Data from the current study are compared with data collected by surgery training curriculum, 29% do not. A Web-based
Rowden and Krishna in 20023 (ECCE Z extracapsular cataract cataract surgery training curriculum, including such com-
extraction). ponents as written study materials, slide presentations,

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