Cataract surgery (phacoemulsification and aspiration: PEA) is the most frequently performed ophthalmic surgery in developed countries, including Japan. In Japan, ophthalmic surgeries account for nearly 20% of all surgical procedures, and cataract surgery is positioned as the first surgery that resident physicians should learn.
Cataract surgery requires not only technical skills but also cognitive skills, judgment, and experience to manage unexpected intraoperative complications 2). The risk of complications from improper surgery can exceed the side effects of drug therapy, making safe and efficient surgical education a global challenge.
For many years, ophthalmic surgical education has been based on Halsted’s methodology. This approach centered on a “quantitative” philosophy, where competence was considered achieved only after performing a certain number of surgeries.
However, this method has the following problems.
Variability in training opportunities: Acquired skills vary depending on the training facility and timing.
Patient risk: Inexperienced surgeons operating directly on patients may cause adverse events.
Difficulty ensuring uniformity of ability: Even if the required number of procedures is completed, actual skill levels vary greatly among individuals.
To overcome these challenges, modern training methods using VR simulators and wet labs are becoming more widespread.
Currently, a competent surgeon is defined as someone who can appropriately demonstrate specialized knowledge, skills, and attitudes. To objectively assess cataract surgery skills, the International Council of Ophthalmology (ICO) developed the “ICO-Ophthalmology Surgical Competency Assessment Rubric: Phacoemulsification (ICO-OSCAR: Phaco).”
ICO-OSCAR is recommended as a tool for monitoring the learning progress of residents. However, many countries still use only the number of procedures performed as a proficiency indicator.
Cataract surgery training requirements vary significantly by country.
Region/Organization
Summary of Requirements
United States (ACGME)
86 cases per resident over 3 years
Brazilian Council of Ophthalmology
150 or more total ophthalmic surgeries
Europe (EBO member countries)
Decentralized system delegated to each country
A 2019 survey in sub-Saharan Africa found that the average number of procedures performed by second-year ophthalmology residents was zero. Despite technological advances, global uniformity in education remains remarkably low.
QHow much training is needed to safely learn cataract surgery?
A
The required number of cases varies greatly among individuals, and the number alone cannot guarantee competence. The US ACGME mandates 86 cases over three years, but competency-based assessments such as ICO-OSCAR are recommended for objective evaluation of skills.
2. Surgical Techniques to Master and Complications During Training
Cataract surgery consists of multiple steps. The basic techniques that beginners should learn step by step are shown below.
Anterior Segment Techniques
Incision creation: Performed via sclerocorneal incision, corneal incision, or single-plane sclerocorneal incision. The wound width is typically around 2.4 mm.
Ophthalmic viscosurgical device (OVD) injection: Maintains the anterior chamber and ensures safe intraocular manipulation. Proper use of dispersive and cohesive types is important.
Continuous curvilinear capsulorhexis (CCC): The first critical step of the surgery. A complete circular shape is required, and attention should be paid to the vector flowing outward.
Phacoemulsification (PEA): The nucleus is fragmented and aspirated using an ultrasound tip. The divide-and-conquer technique is the basic method for beginners.
Cortical aspiration (I/A): Residual cortex is removed using an irrigation/aspiration tip. Careful manipulation is required to avoid damaging the posterior capsule.
Wound closure check: Confirm self-sealing. Suturing is required in pediatric cases.
The divide-and-conquer (D&C) technique is a safe method that allows processing while confirming the depth of the nucleus, and is recommended as the basic technique for beginners to learn first. After gaining proficiency, transitioning to the phaco chop technique improves the efficiency of nuclear fragmentation.
Intraoperative Complications Common During Training
Capsulorhexis runaway: The capsulotomy extends peripherally, resulting in an incomplete continuous curvilinear capsulorhexis. This can be prevented by additional injection of ophthalmic viscosurgical device.
Surge phenomenon: A sudden drop in intraocular pressure during aspiration causes anterior displacement of the posterior capsule. This is managed by appropriate machine settings and careful technique.
History of diabetes, atopy, or glaucoma attack: Can cause small pupils or zonular weakness.
QWhat is the most important preparation before performing cataract surgery for the first time?
A
Establishing a routine of preoperative evaluation (checking pupil dilation, nuclear hardness, and zonules) and prior practice on a simulator or in a wet lab are important. Repeatedly observing the surgeries of an instructor and reviewing one’s own surgical videos are also essential for skill acquisition.
The software automatically records resident performance and provides scores and feedback. Programs at the University of Montreal and UNESP (Brazil) only allow patient surgery after achieving specified benchmarks on the Eyesi simulator.
A systematic review by Ahmed et al. (2020) in BMJ Open Ophthalmology analyzed 10 of 165 articles from 2012–2019 that met inclusion criteria and concluded that training on the Eyesi (VRmagic) is effective in reducing surgical complication rates3).
A retrospective cohort study by Ferris et al. (2009–2015, 29 UK NHS sites) reported that first- and second-year residents who received Eyesi training had a 38% lower rate of posterior capsule rupture4).
Staropoli et al. compared residents at the same institution between a simulator-trained group (n=11) and a non-trained group (n=11), with complication rates of 2.4% and 5.1%, respectively5).
A wet lab is a practice room where surgical techniques are practiced using biological materials, effective for acquiring basic motor skills and learning instrument handling. The ACGME common program requirements identify surgical training in a simulated environment as essential for ophthalmology resident education.
Porcine eyes: Easily obtainable from butcher shops or slaughterhouses. The most evidence-supported model for PEA training. However, the anterior capsule from young animals has high viscosity and elasticity, providing a feel similar to pediatric eyes. The lens is naturally clear, so cataracts must be induced chemically or physically.
The habit of reviewing surgical videos, asking instructors questions, and identifying differences from the instructor’s surgery is essential for improving overall ophthalmic surgical skills. The following points are emphasized for skill acquisition.
Meticulous incision creation: Precise incisions that minimize induced astigmatism.
Completion of a continuous circular capsulorhexis: The first hurdle that determines the difficulty of all subsequent procedures.
Reliable nuclear division: Divide the nucleus sufficiently before phacoemulsification.
Elimination of impatience: Unnecessary impatience to shorten surgery time leads to unexpected complications.
QCan the same instruments used on animal eyes in the wet lab be used in actual surgery?
A
Use is strictly prohibited. Instruments used on animal eyes are biologically contaminated and pose a risk of transmitting infections such as iatrogenic Creutzfeldt-Jakob disease (CJD). If synthetic eyes are used, the instruments can be reused.
4. Latest research and future prospects (reports at the research stage)
Real-time analysis of surgical videos using AI is being researched as a new method for training support 1).
Real-time surgical phase recognition: Neural networks (NN) recognize each phase of cataract surgery (e.g., CCC, phacoemulsification) in real time. The goal is to automatically send warnings or advice to inexperienced surgeons 1).
Automatic surgical tool detection: Systems using CNN (convolutional neural network) and RNN to automatically detect instruments from each frame of surgical videos have been reported 1).
Automated skill assessment and feedback: Surgical videos are divided into constituent phases, and recommendations for the next surgical step or complication warnings are automatically presented 1).
There is research that uses NN to perform real-time phase segmentation of cataract surgery videos, extracting two important phases: continuous curvilinear capsulorhexis (continuous anterior capsulotomy) and nucleus extraction. The aim is to apply this to complication prevention through skill assessment of inexperienced surgeons 1).
The CATARACTS Challenge (2017) evaluated the accuracy of automatic annotation for 21 types of surgical instruments using over 9 hours of cataract surgery videos from 50 cases. The deep learning methods proposed by 14 teams achieved accuracy comparable to manual annotation by experts1).
The VeBIRD (Video-Based Intelligent Recognition and Decision) system automatically tracks the surgical process and can automatically control the amount of ultrasonic energy released according to nuclear hardness1).
Research on application to robotic surgery is also progressing, with attempts to quantify the range of motion of each instrument during the five main stages of cataract surgery using electromagnetic tracking and to use this data in the design of robotic assistance systems1).
Femtosecond laser-assisted cataract surgery (FLACS) may improve the circularity and centration of continuous curvilinear capsulorhexis, enhance the precision of corneal incisions, and reduce the amount of ultrasonic energy required2). However, at present, it has low cost-effectiveness, and its risk profile and refractive outcomes have not been shown to surpass those of standard phacoemulsification2).
The impact of FLACS on the training environment is a topic for future research.
Tognetto D, Giglio R, Vinciguerra AL, et al. Artificial intelligence applications and cataract management: a systematic review. Surv Ophthalmol. 2022;67(3):817-829. doi:10.1016/j.survophthal.2021.09.004.
American Academy of Ophthalmology Preferred Practice Pattern Cataract/Anterior Segment Panel. Cataract in the Adult Eye Preferred Practice Pattern. Ophthalmology. 2022;129(1):P1-P126.
Ahmed TM, Hussain B, Siddiqui MAR. Can simulators be applied to improve cataract surgery training: a systematic review. BMJ Open Ophthalmol. 2020;5:e000488. doi:10.1136/bmjophth-2020-000488.
Ferris JD, Donachie PHJ, Johnston RL, Barnes B, Olaitan M, Sparrow JM. Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees. Br J Ophthalmol. 2020;104(3):324-329. doi:10.1136/bjophthalmol-2018-313817. PMID:31142463.
Staropoli PC, Gregori NZ, Junk AK, et al. Surgical simulation training reduces intraoperative cataract surgery complications among residents. Simul Healthc. 2018;13(1):11-15. doi:10.1097/SIH.0000000000000255. PMCID:PMC5799002.
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