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Ophthalmology. 2018 Nov;125(11):1692-1699. doi: 10.1016/j.ophtha.2018.04.033. Epub 2018 May 31.

Residents' Learning Curve for Manual Small-Incision Cataract Surgery at Aravind Eye Hospital, India.

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Johnson Graduate School of Management, Cornell University, Ithaca, New York.
Cataract Services, Aravind Eye Hospital, Chennai, India.
Cataract Services, Aravind Eye Hospital, Madurai, India.
LAICO-Aravind Eye Care System, Madurai, India.
Chairman, Aravind Eye Hospital, Madurai, India. Electronic address:



The goal of this study was to document the resident learning curve for manual small-incision cataract surgery (MSICS) and to identify implications for the design of ophthalmology residency programs aimed to train surgeons for developing countries.


Hospital-based retrospective cohort study.


All 38 residents entering 2 postgraduate residency programs at Aravind Eye Hospital, Madurai, in 2012 and 2013.


Surgical complications and reoperations for all MSICSs performed by residents during the residency training period were evaluated using a computerized patient database. Multivariate logistic regression models were used to estimate the effect of the cumulative number of surgeries performed on incidence of intraoperative complications, postoperative complications, and reoperations, controlling for covariates.


Incidence of intraoperative and first-day postoperative complications of Oxford Cataract Treatment and Evaluation Team (OCTET) grades II and III and the incidence of reoperations. Analyses controlled for patient-, resident-, and residency program-level covariates.


The study evaluated 13 159 surgeries performed by the 38 residents between October 15, 2012, and August 24, 2016. The mean number of surgeries performed by a resident was 346.3 (standard deviation, 269.4). Three hundred forty-two eyes (2.60%) with at least 1 intraoperative complication, 234 eyes (1.78%) with at least 1 first-day postoperative complication, and 154 reoperations (1.17%) were observed. After controlling for baseline covariates, increasing surgical experience was associated with reduced risk of intraoperative and postoperative complications, as well as reoperations. The odds decreased by 17% (intraoperative complications), 12% (postoperative complications measured 1 day after surgery), and 7% (reoperations) per 100 additional surgeries performed. Patient-level factors such as older age, left eye surgery, and lower preoperative uncorrected visual acuity were found to be associated with higher risk of intraoperative complications (P < 0.01 for all).


The risk of surgical complications and reoperations in MSICS decreased steadily with surgical experience gained by resident surgeons. We recommend that ophthalmology residency programs in developing nations teaching MSICS provide opportunities to perform 300 surgeries or more by residents so as to achieve rates of intraoperative and postoperative complications of less than 2%.

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