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Figure 1.
Uncorrected visual acuity (UCVA) (A) and best spectacle-corrected visual acuity (BSCVA) (B) outcomes stratified by resident surgical case number. There were no significant differences in average UCVA or BSCVA or in the percentage of eyes achieving a UCVA or BSCVA of 20/20 or 20/40 or better based on resident case number.

Uncorrected visual acuity (UCVA) (A) and best spectacle-corrected visual acuity (BSCVA) (B) outcomes stratified by resident surgical case number. There were no significant differences in average UCVA or BSCVA or in the percentage of eyes achieving a UCVA or BSCVA of 20/20 or 20/40 or better based on resident case number.

Figure 2.
Posterior capsule tear and vitreous loss rates stratified by resident surgical case number. There were significantly fewer cases with vitreous loss and posterior capsule tear toward the end of residency training. Posterior capsule tear and vitreous loss rates appear to plateau after case 160.

Posterior capsule tear and vitreous loss rates stratified by resident surgical case number. There were significantly fewer cases with vitreous loss and posterior capsule tear toward the end of residency training. Posterior capsule tear and vitreous loss rates appear to plateau after case 160.

Figure 3.
Phacoemulsification efficiency, measured as adjusted phacoemulsification time in minutes and stratified by resident surgical case number. Adjusted phacoemulsification times (total phacoemulsification time multiplied by phacoemulsification power used) were significantly lower toward the end of residency training and continued to decline steadily throughout residency across the first 200 resident cases.

Phacoemulsification efficiency, measured as adjusted phacoemulsification time in minutes and stratified by resident surgical case number. Adjusted phacoemulsification times (total phacoemulsification time multiplied by phacoemulsification power used) were significantly lower toward the end of residency training and continued to decline steadily throughout residency across the first 200 resident cases.

Table. 
Cases Excluded From the Final Analysis
Cases Excluded From the Final Analysis
1.
Rowden  AKrishna  R Resident cataract surgical training in United States residency programs. J Cataract Refract Surg 2002;28 (12) 2202- 2205
PubMedArticle
2.
Albanis  CVDwyer  MAErnest  JT Outcomes of extracapsular cataract extraction and phacoemulsification performed in a university training program. Ophthalmic Surg Lasers 1998;29 (8) 643- 648
PubMed
3.
Allinson  RWMetrikin  DCFante  RG Incidence of vitreous loss among third-year residents performing phacoemulsification. Ophthalmology 1992;99 (5) 726- 730
PubMedArticle
4.
Allinson  RWPalmer  MLFante  RStanko  M Vitreous loss during phacoemulsification by residents [letter]. Ophthalmology 1992;99 (8) 1181
PubMedArticle
5.
Blomquist  PHRugwani  RM Visual outcomes after vitreous loss during cataract surgery performed by residents. J Cataract Refract Surg 2002;28 (5) 847- 852
PubMedArticle
6.
Corey  RPOlson  RJ Surgical outcomes of cataract extractions performed by residents using phacoemulsification. J Cataract Refract Surg 1998;24 (1) 66- 72
PubMedArticle
7.
Cotlier  E Phacoemulsification by residents [letter]. Ophthalmology 1992;99 (10) 1481- 1482
PubMedArticle
8.
Cruz  OAWallace  GWGay  CAMatoba  AYKoch  DD Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. Ophthalmology 1992;99 (3) 448- 452
PubMedArticle
9.
Hollander  DAVagefi  MRSeiff  SRStewart  JM Bacterial endophthalmitis after resident-performed cataract surgery. Am J Ophthalmol 2006;141 (5) 949- 951
PubMedArticle
10.
Karp  KOAlbanis  CVPearlman  JBGoins  KM Outcomes of temporal clear cornea versus superior scleral tunnel phacoemulsification incisions in a university training program. Ophthalmic Surg Lasers 2001;32 (3) 228- 232
PubMed
11.
Noecker  RJAllinson  RWSnyder  RW Resident phacoemulsification experience using the in situ nuclear fracture technique. Ophthalmic Surg 1994;25 (4) 216- 221
PubMed
12.
O’Brien  PDFitzpatrick  PKilmartin  DJBeatty  S Risk factors for endothelial cell loss after phacoemulsification surgery by a junior resident. J Cataract Refract Surg 2004;30 (4) 839- 843
PubMedArticle
13.
Prasad  SKamath  GG Phacoemulsification performed by residents [letter]. J Cataract Refract Surg 2000;26 (6) 794- 795
PubMedArticle
14.
Quillen  DAPhipps  SJ Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol 2003;135 (5) 732- 733
PubMedArticle
15.
Randleman  JBSrivastava  SKAaron  MM Phacoemulsification with topical anesthesia performed by resident surgeons. J Cataract Refract Surg 2004;30 (1) 149- 154
PubMedArticle
16.
Sappenfield  DLDriebe  WT  Jr Resident extracapsular cataract surgery: results and a comparison of automated and manual techniques. Ophthalmic Surg 1989;20 (9) 619- 624
PubMed
17.
Smith  JHSeiff  SR Outcomes of cataract surgery by residents at a public county hospital. Am J Ophthalmol 1997;123 (4) 448- 454
PubMed
18.
Snyder  RWDonnenfeld  ED Teaching phacoemulsification to residents and physicians in transition. Int Ophthalmol Clin 1994;34 (2) 191- 199
PubMedArticle
19.
Tarbet  KJMamalis  NTheurer  JJones  BDOlson  RJ Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg 1995;21 (6) 661- 665
PubMedArticle
20.
Tayanithi  PPungpapong  KSiramput  P Vitreous loss during phacoemulsification learning curve performed by third-year residents. J Med Assoc Thai November 2005;88 ((suppl 9)) S89- S93
PubMed
21.
Unal  MYücel  ISarici  A  et al.  Phacoemulsification with topical anesthesia: resident experience. J Cataract Refract Surg 2006;32 (8) 1361- 1365
PubMedArticle
22.
Binenbaum  GVolpe  NJ Ophthalmology resident surgical competency: a national survey. Ophthalmology 2006;113 (7) 1237- 1244
PubMedArticle
23.
Badoza  DAJure  TZunino  LAArgento  CJ State-of-the-art phacoemulsification performed by residents in Buenos Aires, Argentina. J Cataract Refract Surg 1999;25 (12) 1651- 1655
PubMedArticle
24.
Zimmer  DVHarrison  JCCarriere  VM Cataract extraction with lens implantation at Biloxi Veterans Affairs Medical Center: experience of ophthalmology residents. Ann Ophthalmol 1994;26 (2) 47- 49
PubMed
25.
Elman  MJSugar  JFiscella  R  et al.  The effect of propranolol versus placebo on resident surgical performance. Trans Am Ophthalmol Soc 1998;96283- 291; discussion 291-294
PubMed
26.
Yamamoto  AHara  TKikuchi  KHara  TFujiwara  T Intraoperative stress experienced by surgeons and assistants. Ophthalmic Surg Lasers 1999;30 (1) 27- 30
PubMed
27.
Dooley  IJO’Brien  PD Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg 2006;32 (4) 604- 608
PubMedArticle
28.
Prasad  S Phacoemulsification learning curve: experience of two junior trainee ophthalmologists. J Cataract Refract Surg 1998;24 (1) 73- 77
PubMedArticle
29.
Martin  KRBurton  RL The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon. Eye 2000;14 (pt 2) 190- 195
PubMedArticle
30.
Accreditation Council for Graduate Medical Education, Ophthalmology resident operative minimum requirements. ACGME Web site.http://www.acgme.org/acWebsite/RRC_240/240_MinimumsOperativeTable.pdfFebruary 2007
31.
O’Day  DM Assessing surgical competence in ophthalmology training programs. Arch Ophthalmol 2007;125 (3) 395- 396
PubMedArticle
32.
Henderson  BAAli  R Teaching and assessing competence in cataract surgery. Curr Opin Ophthalmol 2007;18 (1) 27- 31
PubMedArticle
33.
Oetting  TALee  AGBeaver  HA  et al.  Teaching and assessing surgical competency in ophthalmology training programs. Ophthalmic Surg Lasers Imaging 2006;37 (5) 384- 393
PubMed
34.
Lee  A Teaching and assessing surgical competency in ophthalmology [letter]. Ophthalmology 2006;113 (12) 2380- 2381
PubMedArticle
35.
Fisher  JBBinenbaum  GTapino  PVolpe  NJ Development and face and content validity of an eye surgical skills assessment test for ophthalmology residents. Ophthalmology 2006;113 (12) 2364- 2370
PubMedArticle
36.
Cremers  SLCiolino  JBFerrufino-Ponce  ZKHenderson  BA Objective Assessment of Skills in Intraocular Surgery (OASIS). Ophthalmology 2005;112 (7) 1236- 1241
PubMedArticle
37.
Saleh  GMGauba  VMitra  ALitwin  ASChung  AKBenjamin  L Objective structured assessment of cataract surgical skill. Arch Ophthalmol 2007;125 (3) 363- 366
PubMedArticle
38.
Osborne  SASevern  PBunce  CVFraser  SG The use of a pre-operative scoring system for the prediction of phacoemulsification case difficulty and the selection of appropriate cases to be performed by trainees. BMC Ophthalmol >December 27 2006;638
PubMedArticle
39.
Cremers  SLLora  ANFerrufino-Ponce  ZK Global Rating Assessment of Skills in Intraocular Surgery (GRASIS). Ophthalmology 2005;112 (10) 1655- 1660
PubMedArticle
40.
Najjar  DMAwwad  ST Cataract surgery risk score for residents and beginning surgeons [letter]. J Cataract Refract Surg 2003;29 (10) 2036- 2037
PubMedArticle
Clinical Sciences
September 2007

The Resident Surgeon Phacoemulsification Learning Curve

Author Affiliations

Author Affiliations: Departments of Ophthalmology (Drs Randleman, Wolfe, Woodward, Cherwek, and Srivastava) and Biostatistics, Rollins School of Public Health (Mr Lynn), Emory University, Atlanta, Georgia.

Arch Ophthalmol. 2007;125(9):1215-1219. doi:10.1001/archopht.125.9.1215
Abstract

Objectives  To analyze outcomes of resident-performed phacoemulsifications and to assess the resident phacoemulsification learning curve.

Methods  Retrospective chart review of resident-performed phacoemulsification cases at the Atlanta Veterans Affairs Medical Center, Decatur, Georgia, from July 1, 1999, through June 30, 2002. Outcomes measured included postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), intraoperative complications, and adjusted phacoemulsification times (total phacoemulsification time multiplied by phacoemulsification power used).

Results  We analyzed 680 cases. Postoperative mean UCVA was 20/39, and mean BSCVA was 20/25 (≥ 20/20 in 44.0% of cases and ≥ 20/40 in 97.8%). There were no differences in visual acuity outcomes over the course of residency training. Intraoperative complications occurred in 34 cases (5.0%), with a significant reduction in vitreous loss rates after the first 80 resident cases (5.1% vs 1.9%; P = .03). Mean adjusted phacoemulsification time was 0.68 minutes, with a significant reduction in adjusted phacoemulsification time after the first 80 cases (0.87 vs 0.52 minutes; P < .001).

Conclusions  Quality visual outcomes after phacoemulsification can be attained throughout residency training; however, surgical competency, when measured by complication rates and phacoemulsification efficiency, continues to improve significantly with increasing surgical experience well beyond the first 80 resident phacoemulsification cases.

Cataract extraction is one of the most common surgical procedures performed in the world. Accordingly, ophthalmology residents in the United States spend a large proportion of their surgical training learning cataract surgery. A 2002 survey of US ophthalmology residency programs indicated that all residents were taught the phacoemulsification technique, although the number of phacoemulsification cases performed by a single resident varied dramatically, from as few as 50 to as many as 300.1 Many studies have examined the outcomes and complication rates associated with cataract surgery performed by residents and have concluded that, overall, the complication rates and outcomes are acceptable.221 However, few of these studies have attempted to identify a time point during training or a surgical case number at which most residents become competent in performing phacoemulsification.

Residents perform an average of just under 120 phacoemulsification cases during residency training, and most perform between 80 and 140 cases; however, there remains significant variability among programs, with up to 25% of residents performing fewer than 80 cases.1 Our group previously reported decreasing vitreous loss rates with increasing resident surgical experience over the course of 200 cases of phacoemulsification,15 and Corey and Olson6 reported decreased complications and improved surgical techniques with greater experience when they compared the first 50 cases to the last 50 cases of 4 residents, all of whom performed approximately 300 cataract phacoemulsification cases during their residency.

The purposes of this study were to analyze outcomes of phacoemulsification performed by residents during their training experience and to determine a resident learning curve for this procedure.

METHODS

The surgical logs from the Department of Ophthalmology at Emory University and from the Atlanta Veterans Affairs Medical Center (Atlanta VA) in Decatur, Georgia, were accessed to identify all phacoemulsification cases performed by residents during a 3-year academic period from July 1, 1999, through June 30, 2002. The charts for all identified cases performed at the Atlanta VA during the study interval were reviewed. The Emory University and the Atlanta VA institutional review boards granted approval for this study.

During the study period, all phacoemulsification at the Atlanta VA was performed by resident surgeons after approval by attending ophthalmologists. There were no differences in criteria for case selection throughout the academic year; thus, there was no significant variability in case difficulty that might affect outcomes.

Phacoemulsification was performed by the residents with relatively uniform technique for all cases. While patients were under topical or local anesthesia, residents created scleral tunnel incisions for a few of the early cases and then began to use oblique clear cornea incisions. A continuous curvilinear capsulorrhexis was performed. The lens was then phacoemulsified, usually with a “divide-and-conquer” technique. When possible, foldable acrylic or silicone intraocular lenses were inserted into the capsular bag. Alternatively, foldable or polymethylmethacrylate lenses were placed within the ciliary sulcus or, when necessary, polymethylmethacrylate anterior chamber lenses were placed in the anterior chamber angle.

Preoperative data collected included patient age, sex, operative eye, best spectacle-corrected visual acuity (BSCVA), manifest refraction spherical equivalent (MRSE), and ocular comorbidities. Operative data obtained for each case (when available) included resident surgeon, attending surgeon, date of operation, adjusted phacoemulsification time (total phacoemulsification time multiplied by phacoemulsification power used), intraoperative complications, and resident case number. The resident case number was established by first sorting all phacoemulsification cases performed at all facilities chronologically for each resident and then assigning each case its sequential number. Thus, the case numbers used for analysis reflect the actual experience of the individual resident performing the surgery rather than the exact sequential order of cases performed at the Atlanta VA during the study period. Intraoperative complications recorded included posterior capsule tear, vitreous loss, retained lens fragments, and Descemet detachments or wound burns. Postoperative information collected included uncorrected visual acuity (UCVA), BSCVA, and MRSE at the 1-month postoperative visit.

Cases were excluded from analysis if there was insufficient information recorded or if the patient had preoperatively diagnosed ocular comorbidities that limited postoperative visual acuity. The statistical methods used for data analysis and comparisons included the unpaired, 2-tailed t test and χ² analysis.

RESULTS

A total of 762 cases were identified; of these, 680 (89.2%) were included in the final analysis. Eighty-two cases (10.8%) were excluded, including 26 (32%) because of insufficient data and 56 (68%) because of ocular comorbidities limiting the final BSCVA. Most of the excluded cases had preoperative retinal abnormalities (Table). Mean (SD) patient age at the time of surgery was 68.9 (10.3) years (range, 40-100 years), and 665 cases (97.8%) were male. Mean preoperative BSCVA was 20/64 (range, hand motions to 20/25), and mean (SD) MRSE was −0.7 (2.7) diopters (D) (range, −25 to +9 D).

There was an even case distribution among residents with regard to patient age, sex, and operative eye. Fifteen residents performed phacoemulsification during the study period under the guidance of 17 attending surgeons, with a relatively even case distribution between residents (mean [SD] number of cases, 45; range, 18-82).

Mean postoperative UCVA was 20/39; UCVA was 20/20 or better in 16.4% of cases and 20/40 or better in 77.0%. Mean BSCVA improved from 20/65 preoperatively to 20/25 postoperatively (P < .001); BSCVA was 20/20 or better in 44.0% of cases, and was 20/40 or better in 97.8%. Mean MRSE improved from −0.7 D to −0.4 D (P = .005). On average, eyes gained 4 lines of BSCVA postoperatively (range, 14 lines gained to 6 lines lost). There was no significant change in cylinder postoperatively (0.86 vs 0.85 D, P = .8). There were no significant changes in UCVA or BSCVA outcomes (Figure 1) during residency training.

Overall, intraoperative complications occurred in 34 cases (5.0%), with some cases experiencing more than 1 complication. These included 33 cases (4.9%) with posterior capsule tear, 23 (3.4%) with vitreous loss, 3 (0.4%) with retained lens fragments, and 3 (0.4%) with wound injury, including wound burns or small Descemet detachments. There were too few cases of retained lens fragments or wound injury to make meaningful comparisons; however, when resident cases 1 through 80 (315 cases) were compared with cases 81 through 207 (365 cases), there were fewer cases with posterior capsule tears (6.3% vs 3.5%; P = .20) and significantly fewer cases with vitreous loss (5.1% vs 1.9%; P = .03) later in training. Posterior capsule tear and vitreous loss rates continued to decrease throughout residency training (Figure 2). There were no significant differences in UCVA (20/48 vs 20/39; P = .15) or BSCVA (20/28 vs 20/25; P = .13) between cases with and without vitreous loss.

Mean (SD) adjusted phacoemulsification time was 0.68 (0.5) minutes. When resident cases 1 through 80 were compared with cases 81 through 207, there was a significant reduction in adjusted phacoemulsification time (0.87 vs 0.52 minutes; P < .001) later in training. Adjusted phacoemulsification times continued to decrease throughout residency training (Figure 3).

COMMENT

Phacoemulsification remains one of the most important skills to master during ophthalmology residency training. Although each surgeon will likely develop these skills at an individualized pace, and although some residents may face great challenges in acquiring fundamental surgical skills,22 ophthalmology residency training programs should have specific training guidelines and provide a realistic number of minimum surgical cases to help residents develop competency in performing phacoemulsification. Based on our study results, good visual outcomes can be attained early during residency training; however, surgical competency, when measured by complication rates and phacoemulsification efficiency, continues to improve with increasing surgical experience and does not plateau during residency training.

VISUAL ACUITY OUTCOMES

Overall, most eyes achieved 20/40 or better UCVA and BSCVA after resident phacoemulsification. These results compare favorably with those of previous reports.3,5,6,10,11,13,14,17,19,21,23,24 We found consistent visual acuity outcomes throughout residency training, with no significant trends over time. This is encouraging when one considers the substantial stress encountered by resident physicians and attending staff, especially during a resident's early cases.2527

COMPLICATIONS

The overall complication rate in this series compared favorably with those of previous reports.5,6,9,10,14,21,23,28 There were no cases of endophthalmitis in our study, and we found decreasing rates of posterior capsule tear and vitreous loss throughout residency training. The overall rate of vitreous loss was equivalent to that reported by Martin and Burton29 during the first 300 cases performed by an experienced surgeon learning phacoemulsification, a rate that dropped precipitously over the course of the first 3000 cases. Our data suggest that the learning curve, as it pertains to posterior capsule complications, extends beyond the first 200 resident cases. However, the vitreous loss rate after the first 80 cases (1.9%) seems quite acceptable; after 160 cases, this rate dropped even further, approaching that of experienced surgeons. Fortunately, vitreous loss did not significantly affect final visual acuity outcomes in our series.

IMPROVED SURGICAL EFFICIENCY DURING RESIDENCY TRAINING

We used adjusted phacoemulsification time as a marker for surgical efficiency during residency training. This seemed appropriate because the case selection and nucleus density remained constant throughout the resident's surgical experience; thus, changes in this variable could be attributed to improved surgical technique. We found significant differences between early and late resident cases, and adjusted phacoemulsification times continued to decrease throughout the study; thus, improvements in surgical efficiency appear to continue beyond the resident's first 200 cases without reaching a plateau.

EFFECT OF THE RESIDENT PHACOEMULSIFICATION LEARNING CURVE

Residency training is clearly a balancing act, with residency programs using their available resources to provide residents with a comprehensive but balanced clinical and surgical experience to optimally prepare them for autonomous practice. Although the length of ophthalmology residency—almost exclusively 3 years of training following an internship year—has remained constant, significant advances in medical and surgical therapies in all areas of ophthalmology require the time and attention of residents during their training. Therefore, it is critical to strike the appropriate balance between teaching phacoemulsification and teaching other clinical and surgical skills. With this in mind, how can residency programs best partition their time?

The Residency Review Committee of the Accreditation Council for Graduate Medical Education30 has recently increased the minimum number of cataract procedures performed by the resident as primary surgeon from 45 to 86; based on our data, this increased minimum seems well justified. In fact, our results indicate that resident skills continue to improve significantly beyond this minimum number, and many programs should try to find ways to maximize their residents' phacoemulsification volume.

FUTURE DIRECTIONS

Many new, evolving models assess and enhance resident surgical competency and may, ideally, improve the quality of the resident training experience.3138 These models include skills-training exercises,35 resident surgical evaluation models,36,37,39 scoring systems for resident case selection,38,40 potential paradigm shifts in conceptual training models,34 and the promise of virtual simulator training.32 All of these approaches may improve the efficiency of resident surgical training and may shorten the learning curve. Nevertheless, there will likely be no substitute for actual operative experience, and ophthalmology residency programs should ensure that their graduates have access to the appropriate number of supervised surgical cases so that they may develop the skills necessary to perform phacoemulsification upon graduation.

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Article Information

Correspondence: J. Bradley Randleman, MD, Department of Ophthalmology, Emory University, 1365B Clifton Rd NE, Ste 4500, Atlanta, GA 30322 (Jrandle@emory.edu).

Submitted for Publication: March 30, 2007; final revision received May 11, 2007; accepted May 17, 2007.

Financial Disclosure: None reported.

Funding/Support: Supported in part by Research to Prevent Blindness, Inc, and core grant P30 EYO6360 from the National Institutes of Health.

References
1.
Rowden  AKrishna  R Resident cataract surgical training in United States residency programs. J Cataract Refract Surg 2002;28 (12) 2202- 2205
PubMedArticle
2.
Albanis  CVDwyer  MAErnest  JT Outcomes of extracapsular cataract extraction and phacoemulsification performed in a university training program. Ophthalmic Surg Lasers 1998;29 (8) 643- 648
PubMed
3.
Allinson  RWMetrikin  DCFante  RG Incidence of vitreous loss among third-year residents performing phacoemulsification. Ophthalmology 1992;99 (5) 726- 730
PubMedArticle
4.
Allinson  RWPalmer  MLFante  RStanko  M Vitreous loss during phacoemulsification by residents [letter]. Ophthalmology 1992;99 (8) 1181
PubMedArticle
5.
Blomquist  PHRugwani  RM Visual outcomes after vitreous loss during cataract surgery performed by residents. J Cataract Refract Surg 2002;28 (5) 847- 852
PubMedArticle
6.
Corey  RPOlson  RJ Surgical outcomes of cataract extractions performed by residents using phacoemulsification. J Cataract Refract Surg 1998;24 (1) 66- 72
PubMedArticle
7.
Cotlier  E Phacoemulsification by residents [letter]. Ophthalmology 1992;99 (10) 1481- 1482
PubMedArticle
8.
Cruz  OAWallace  GWGay  CAMatoba  AYKoch  DD Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. Ophthalmology 1992;99 (3) 448- 452
PubMedArticle
9.
Hollander  DAVagefi  MRSeiff  SRStewart  JM Bacterial endophthalmitis after resident-performed cataract surgery. Am J Ophthalmol 2006;141 (5) 949- 951
PubMedArticle
10.
Karp  KOAlbanis  CVPearlman  JBGoins  KM Outcomes of temporal clear cornea versus superior scleral tunnel phacoemulsification incisions in a university training program. Ophthalmic Surg Lasers 2001;32 (3) 228- 232
PubMed
11.
Noecker  RJAllinson  RWSnyder  RW Resident phacoemulsification experience using the in situ nuclear fracture technique. Ophthalmic Surg 1994;25 (4) 216- 221
PubMed
12.
O’Brien  PDFitzpatrick  PKilmartin  DJBeatty  S Risk factors for endothelial cell loss after phacoemulsification surgery by a junior resident. J Cataract Refract Surg 2004;30 (4) 839- 843
PubMedArticle
13.
Prasad  SKamath  GG Phacoemulsification performed by residents [letter]. J Cataract Refract Surg 2000;26 (6) 794- 795
PubMedArticle
14.
Quillen  DAPhipps  SJ Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol 2003;135 (5) 732- 733
PubMedArticle
15.
Randleman  JBSrivastava  SKAaron  MM Phacoemulsification with topical anesthesia performed by resident surgeons. J Cataract Refract Surg 2004;30 (1) 149- 154
PubMedArticle
16.
Sappenfield  DLDriebe  WT  Jr Resident extracapsular cataract surgery: results and a comparison of automated and manual techniques. Ophthalmic Surg 1989;20 (9) 619- 624
PubMed
17.
Smith  JHSeiff  SR Outcomes of cataract surgery by residents at a public county hospital. Am J Ophthalmol 1997;123 (4) 448- 454
PubMed
18.
Snyder  RWDonnenfeld  ED Teaching phacoemulsification to residents and physicians in transition. Int Ophthalmol Clin 1994;34 (2) 191- 199
PubMedArticle
19.
Tarbet  KJMamalis  NTheurer  JJones  BDOlson  RJ Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg 1995;21 (6) 661- 665
PubMedArticle
20.
Tayanithi  PPungpapong  KSiramput  P Vitreous loss during phacoemulsification learning curve performed by third-year residents. J Med Assoc Thai November 2005;88 ((suppl 9)) S89- S93
PubMed
21.
Unal  MYücel  ISarici  A  et al.  Phacoemulsification with topical anesthesia: resident experience. J Cataract Refract Surg 2006;32 (8) 1361- 1365
PubMedArticle
22.
Binenbaum  GVolpe  NJ Ophthalmology resident surgical competency: a national survey. Ophthalmology 2006;113 (7) 1237- 1244
PubMedArticle
23.
Badoza  DAJure  TZunino  LAArgento  CJ State-of-the-art phacoemulsification performed by residents in Buenos Aires, Argentina. J Cataract Refract Surg 1999;25 (12) 1651- 1655
PubMedArticle
24.
Zimmer  DVHarrison  JCCarriere  VM Cataract extraction with lens implantation at Biloxi Veterans Affairs Medical Center: experience of ophthalmology residents. Ann Ophthalmol 1994;26 (2) 47- 49
PubMed
25.
Elman  MJSugar  JFiscella  R  et al.  The effect of propranolol versus placebo on resident surgical performance. Trans Am Ophthalmol Soc 1998;96283- 291; discussion 291-294
PubMed
26.
Yamamoto  AHara  TKikuchi  KHara  TFujiwara  T Intraoperative stress experienced by surgeons and assistants. Ophthalmic Surg Lasers 1999;30 (1) 27- 30
PubMed
27.
Dooley  IJO’Brien  PD Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg 2006;32 (4) 604- 608
PubMedArticle
28.
Prasad  S Phacoemulsification learning curve: experience of two junior trainee ophthalmologists. J Cataract Refract Surg 1998;24 (1) 73- 77
PubMedArticle
29.
Martin  KRBurton  RL The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon. Eye 2000;14 (pt 2) 190- 195
PubMedArticle
30.
Accreditation Council for Graduate Medical Education, Ophthalmology resident operative minimum requirements. ACGME Web site.http://www.acgme.org/acWebsite/RRC_240/240_MinimumsOperativeTable.pdfFebruary 2007
31.
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