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Indian J Ophthalmol. 2019 Feb;67(2):213-216. doi: 10.4103/ijo.IJO_1133_18.

Perceived difficulties and complications in learners of phacoemulsification: A principal component analysis model.

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Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi, India.



To evaluate the difficulty perceived of each step of phacoemulsification and analyze the factors affecting them.


Overall, 12 trainee residents were allotted 10 cases of phacoemulsification of eyes with senile cataract, under a single observer, and the steps of each surgery were rated from very easy to very difficult with a questionnaire. The completion rates of steps and complications of each surgery were noted. Principal component analysis of the responses to the difficulty level questionnaire was conducted to obtain factors resulting in the perceived difficulty.


The lowest difficulty scores were for initial step of incision creation (1.63 ± 0.84), followed by intraocular lens insertion (2.51 ± 0.8). The most difficult step was divide/chop of the nucleus (3.74 ± 0.97) followed by phacoemulsification (3.32 ± 0.82). Highest completion rates were seen for the initial steps of the surgery and the lowest for divide/chop. We identified two major patterns of difficulty among the trainees - one for steps involving high amount of binocularity and the other, for steps involving high precision of hand control. The rate of complication of our study was within acceptable range.


Although trainees have practiced phacoemulsification steps on simulation, real-life situation may bring in unprecedented level of difficulty and challenges, which may be documented and used for targeted improvement of surgical skills. Stereopsis and hand control training should form a major part of training modules of cataract surgery both on simulation and real-life scenarios.


Factor analysis; perceived difficulty; phacoemulsification; principal component analysis; trainees

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