Review: Learning Grid for Cataract Surgery

July 1 is the beginning of the academic year for our ophthalmology residents and it is an important time to perform a self-evaluation of surgical skills. This cataract surgery learning grid shows where the resident should be during each year of the residency training program.

During ophthalmology residency, residents are exposed to cataract surgery in steps, starting from the most basic and ending with advanced techniques such as phaco chop. For the past many years we have been using a simplified learning grid as a guideline for our residents. It covers the range of knowledge and hands-on experience that needs to be acquired during each year of training. Each ophthalmology resident from the UCLA / Jules Stein Eye Institute residency program will spend five rotations, each lasting about two months, with me at Olive View-UCLA Medical Center.

In addition, our residents have a full curriculum on the EyeSi surgical simulator which is helpful in developing manual dexterity, hand-eye coordination, and comfort operating through a microscope. The EyeSi simulator training is completed prior to beginning surgery on patients. All resident surgical cases are done under the direct and active supervision of an expert surgeon.

Since many of our readers are from countries around the globe, let me first explain the typical path of education for ophthalmology residents in the United States:

• 4 years for a Bachelor’s degree (typically Bachelor of Science) at a university
• 4 years for medical school to earn an M.D. degree at a university
• 1 year of internship in general surgery, internal medicine, or a combination year
  • called the PGY-1 year (Post-Graduate Year 1)
• 3 years of ophthalmology residency typically at a university
  • PGY-2 year, PGY-3 year, and PGY-4 year
• 1-2 years for an optional fellowship
  • surgical retina 2 years
  • medical retina 1 year
  • orbit / oculoplastics 2 years
  • cornea 1 year
  • glaucoma 1 year
  • pediatric / strabismus 1 year
  • neuro-ophth 1 year
  • less common fellowships 1 year (uveitis, tumor, etc)
• often residents will do additional years before residency to complete a master’s degree (MPH, MS, MBA, etc), a second doctorate degree (typically Ph.D.), or simply a year or two of research.

At our teaching hospital, I typically work with 5 ophthalmology residents at a time:

• 2 “senior” residents who are both PGY-4
• 1 “junior” resident who is PGY-3
• 2 “1st year” residents who are PGY-2
• sometimes we have a medical student and in the future we may have an intern (PGY1)

PGY-2 residents are not expected to know much about the actual surgery when they first start, but by their second block later in the year they should know how to set up the surgery, do the draping, the IOL calculations, and the post-op follow-up.

PGY-3 residents must know how to suture with 10-0 nylon and it is expected that they have practiced this extensively in their wet-lab. The steps of cataract surgery are still being learned and this resident is expected to do about 30 phaco surgeries during the year.

PGY-4 residents will do many surgeries during the year and it is critical that they learn from each and every surgery. Continual improvement and progressing forward in surgical skills are the primary goals. These residents will complete at least 200 phacos during the year and have the ability to do 300.

If you’re a resident or an ophthalmologist in training, I encourage you to work with your mentors and professors and devise a learning grid of your own. It is a good guideline and it can help prevent you from falling behind. The learning curve for cataract surgery is a steep climb and it requires that you are self-motivated to keep at it, step by step, until you have reached a level of proficiency.

Then, after your training, the real learning happens. In my estimation, doing 200 cataract surgeries (via phacoemulsification) is about half-way up the learning curve. There will be far more learning to be done in the first decade of practice after the completion of your formal training.

It is the resident’s responsibility to make sure that progress is being made to sufficiently climb the learning curve. The residents who push themselves to advance their skills and learn from each and every surgery will go on to have illustrious surgical careers. In 20 years of teaching, I have never seen a lackluster or apathetic resident transform into an accomplished surgeon.