Original Article

Comparison of the Posterior Capsule Rupture Rates

Associated with Conventional (Start to Finish) Versus
Reverse Methods of Teaching Phacoemulsification
Milind Suryawanshi1,2,3, Parikshit Gogate4,5, Anil N. Kulkarni2,3,6, Archana Biradar3, Pooja Bhomaj3

ABSTRACT Access this article online

Website:
Purpose: Comparison of the rates of posterior capsule rupture (PCR) associated with www.meajo.org
conventional versus a reverse method of teaching phacoemulsification. DOI:
Methods: Trainees were taught conventional (start‑to‑finish) phacoemulsification beginning 10.4103/0974-9233.175886
with an incision (tunnel construction) to capsulorhexis, sculpting, nucleus cracking, segment
Quick Response Code:
removal, cortex aspiration, intraocular lens implantation, and viscoelastic removal. In the
reverse method, after incision and capsulorhexis, the trainees were progressively taught
viscoelastic wash, cortex aspiration, segment removal, nucleus cracking, sculpting, and
intraocular lens implantation. Trainees from a Tertiary Eye Care Centre were classified as
“beginners,” for their first 30 cases and then “trainees” for their next 70 surgeries. Data were
collected on posterior capsular rent and vitreous loss during each step of training.
Results: Thirty‑two ophthalmic surgeons learning phacoemulsification surgery on 609 cataracts
cases were supervised by 3 trainers. Fifteen beginners performed 287 surgeries using the
conventional method, and 17 beginners performed 322 surgeries with the reverse method. The
incidence of PCR was 18/287 (6.2%) with the conventional method and 15/322 (4.6%) with the
reverse method (P = 0.38). PCR occurred during cortex aspiration (8/287, 2.8%) and segment
removal (5/287, 1.7%) in the conventional method. PCR occurred during nucleus cracking,
segment removal, and cortex aspiration (4/322 surgeries for each step, 1.2%). In the follow,
70 cases (trainees) there was no difference in PCR with either method (4.7% vs. 4.3%, P = 0.705).
Conclusion: Conventional and reverse method for training phacoemulsification were both
safe in a supervised setting.

Key words: Cataract Surgery, Intra‑Operative Complication, Phacoemulsification, Surgical

Training

INTRODUCTION especially in paid practice settings. 1 Hence, learning the

technique for phacoemulsification is mandatory for beginners

S mall incision cataract surgery (SICS) with phacoemulsification

is the technique of choice for cataract surgeons worldwide,
1
Department of Ophthalmology, Armed Forces Hospital, Muscat,
Oman, 2Department of Ophthalmology, Bharti Vidyapeeth
Medical College, Sangli, 3Lions National Association for the Blind
Eye Hospital, 6Dr. Kulkarni Eye Hospital, Miraj, 4Department of
Ophthalmology, Padmashri D. Y. Patil Medical College, Pimpri,
5
Dr. Gogate’s Eye Clinic, Pune, Maharashtra, India
Corresponding Author: Dr. Parikshit Gogate,
Dr. Gogate’s Eye Clinic, K‑102 Tadiwala Road,
Pune ‑ 411 001, Maharashtra, India.
E‑mail: parikshitgogate@hotmail.com
as well as experienced cataract surgeons who have not adapted
to this procedure. The advantages of phacoemulsification
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and
build upon the work non‑commercially, as long as the author is credited and the new creations are
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For reprints contact: reprints@medknow.com
Cite this article as: Suryawanshi M, Gogate P, Kulkarni AN, Biradar A,
Bhomaj P. Comparison of the Posterior Capsule Rupture Rates Associated
with Conventional (Start to Finish) Versus Reverse Methods of Teaching
Phacoemulsification. Middle East Afr J Ophthalmol 2016;23:163-7.

© 2016 Middle East African Journal of Ophthalmology | Published by Wolters Kluwer - Medknow 163
 Suryawanshi, et al.: Comparison of Reverse and Conventional Method of Teaching Phaco
surgery include excellent potential visual outcome, small corneal
incision, and the possibility to employ premium intraocular
lenses.2,3 However, it is not easy to master the technique due to
its steep learning curve.
The options used to learn phacoemulsification surgery vary from
surgeon to surgeon. Some rely on self‑learning methods such as
videos of expert surgeons or request training from the vendor
of phacoemulsification units who are more than willing to offer
“tips” to beginners.4 Some get trained by practicing on animal
eyes in a wet lab. Although this is a good opportunity to know the
functioning of the machine, human eyes differ considerably from
animal eyes. Due to the difference in the thickness of lens capsule
and lack of a nucleus in the animal lens, phacoemulsification in
animal eyes is not the same as human eyes.
In the most teaching centers, formal training provided to a
beginner who learns the procedure under the supervision of
an expert who intervenes only at if complications occur or
the duration of surgery is too long.4‑6 In a stepwise training
program, phacoemulsification surgery is divided into various
steps and proficiency in one step leads to next step under the
guidance and supervision of an expert trainer.7 Some centers in
the developed world use simulators.8,9 The road to SICS aided
by phacoemulsification is said to be slippery with vitreous.
Numerous studies of resident training focus on preserving
the posterior capsule and limiting vitreous loss.7,10‑13 A novel
technique of “reverse” method of training, in which the final
steps of the surgical technique are taught first, and the initial
steps are taught last was attempted in Brazil.14 However, it
has never been compared to the traditional “start to finish”
supervised method of teaching phacoemulsification surgery. The
aim of the study was to compare “start to finish” or conventional
method to the reverse method of training with regards to
posterior capsular rupture (PCR) in phacoemulsification surgery
at a teaching institute.
METHODS
This study was conducted at the Lions National Association
for the Blind (NAB) Eye Hospital, a Tertiary Referral and
Teaching Center in Western Maharashtra, India. This institute
hospital fellowship program and residency programs. The Ethical
Committee of the hospital approved this study. The incidence of
PCR depends on the level of skill of a surgeon; hence, surgeons
learning phacoemulsification surgery in the institution were
divided into two groups. Those who had done <30 cases of
phacoemulsification surgery were considered “Beginners,” those
who had 30–100 cases were considered “trainee.” The hospital
has an in‑house residency training and fellowship training
program. It also has some doctors enrolling for short‑term
phacoemulsification training (30 days course). These were
ophthalmologists who had done their residency a few years ago
164 Middle East African Journal of Ophthalmology, Volume 23, Number 2, April - June 2016
and had now joined to enhance their skills. “Beginners” were
thus not novice surgeons who were performing cataract surgery
for the 1st time but had some experience with manual SICS and
were now upgrading their skills for phacoemulsification.
Table 1 outlines the 10‑step division of phacoemulsification
surgery. Chronology of steps in which the beginner learned
surgery by “start to finish” or reverse method is demonstrated
serially. From March 2008 to February 2009, beginners learned
the “start to finish” method of teaching were considered
Group A (“start to finish” or conventional), whereas from
March 2009 to February 2010, beginners who learned using
the reverse method were considered as Group B (reverse).
The beginners in both groups were well versed with tunnel
construction, continuous curvilinear capsulorhexis, and hydro
dissection as they were performing manual SICS independently
and with good results. The hospital authorities considered this
criterion for beginning phacoemulsification training as the safest
approach to transition to phacoemulsification, similar to other
centers in India.5,15 Therefore, the first three steps for both
the groups were same. Each beginner from their respective
group was given 3–5 cases to learn a particular step from step
number four. On acquiring adequate skill of the particular step
they were allowed to move to the next step. Beginners from
Group A learned the technique of phacoemulsification surgery
using the conventional method. Beginners from Group B learned
the reverse technique. The fourth step was removing (washing)
viscoelastic material from the anterior chamber in a case that
was being completed by the trainer. The fifth step was the
aspiration of the cortex in a case where the trainer had already
emulsified the nucleus. The sixth step involved emulsification
of nucleus that was already cracked by the trainer. The seventh
step involved the beginner being taught to crack the nucleus that
was already trenched by the trainer. The eighth step involved
teaching the beginner to trenching the nucleus and in ninth
step nucleus rotation was taught. The final tenth step was in the
bag implantation of poly‑methyl‑methacrylate lens with 5 mm
optics. In the reverse method, steps 4–9 were exact reversals
of the conventional method. After the 30th case, the surgeons
Table 1: Order of steps of phacoemulsification taught
Step “Start to finish” technique Reverse technique
1 Limbal and side port incisions Limbal and side port incisions
2 Staining of capsule, viscoelastic Staining of capsule, viscoelastic
injection, capsulotomy injection capsulotomy
3 Hydro dissection and hydro Hydro dissection and hydro
delineation delineation
4 Nucleus rotation Viscoelastic wash
5 Trenching Aspiration of cortex
6 Nucleus cracking Segment removal
7 Segment removal Nucleus cracking
8 Aspiration of cortex Trenching
9 IOL implantation Nucleus rotation
10 Viscoelastic wash IOL implantation
IOL: Intraocular lens
 Suryawanshi, et al.: Comparison of Reverse and Conventional Method of Teaching Phaco
surgery include excellent potential visual outcome, small corneal
incision, and the possibility to employ premium intraocular
lenses.2,3 However, it is not easy to master the technique due to
its steep learning curve.
The options used to learn phacoemulsification surgery vary from
surgeon to surgeon. Some rely on self‑learning methods such as
videos of expert surgeons or request training from the vendor
of phacoemulsification units who are more than willing to offer
“tips” to beginners.4 Some get trained by practicing on animal
eyes in a wet lab. Although this is a good opportunity to know the
functioning of the machine, human eyes differ considerably from
animal eyes. Due to the difference in the thickness of lens capsule
and lack of a nucleus in the animal lens, phacoemulsification in
animal eyes is not the same as human eyes.
In the most teaching centers, formal training provided to a
beginner who learns the procedure under the supervision of
an expert who intervenes only at if complications occur or
the duration of surgery is too long.4‑6 In a stepwise training
program, phacoemulsification surgery is divided into various
steps and proficiency in one step leads to next step under the
guidance and supervision of an expert trainer.7 Some centers in
the developed world use simulators.8,9 The road to SICS aided
by phacoemulsification is said to be slippery with vitreous.
Numerous studies of resident training focus on preserving
the posterior capsule and limiting vitreous loss.7,10‑13 A novel
technique of “reverse” method of training, in which the final
steps of the surgical technique are taught first, and the initial
steps are taught last was attempted in Brazil.14 However, it
has never been compared to the traditional “start to finish”
supervised method of teaching phacoemulsification surgery. The
aim of the study was to compare “start to finish” or conventional
method to the reverse method of training with regards to
posterior capsular rupture (PCR) in phacoemulsification surgery
at a teaching institute.
METHODS
This study was conducted at the Lions National Association
for the Blind (NAB) Eye Hospital, a Tertiary Referral and
Teaching Center in Western Maharashtra, India. This institute
hospital fellowship program and residency programs. The Ethical
Committee of the hospital approved this study. The incidence of
PCR depends on the level of skill of a surgeon; hence, surgeons
learning phacoemulsification surgery in the institution were
divided into two groups. Those who had done <30 cases of
phacoemulsification surgery were considered “Beginners,” those
who had 30–100 cases were considered “trainee.” The hospital
has an in‑house residency training and fellowship training
program. It also has some doctors enrolling for short‑term
phacoemulsification training (30 days course). These were
ophthalmologists who had done their residency a few years ago
164 Middle East African Journal of Ophthalmology, Volume 23, Number 2, April - June 2016
and had now joined to enhance their skills. “Beginners” were
thus not novice surgeons who were performing cataract surgery
for the 1st time but had some experience with manual SICS and
were now upgrading their skills for phacoemulsification.
Table 1 outlines the 10‑step division of phacoemulsification
surgery. Chronology of steps in which the beginner learned
surgery by “start to finish” or reverse method is demonstrated
serially. From March 2008 to February 2009, beginners learned
the “start to finish” method of teaching were considered
Group A (“start to finish” or conventional), whereas from
March 2009 to February 2010, beginners who learned using
the reverse method were considered as Group B (reverse).
The beginners in both groups were well versed with tunnel
construction, continuous curvilinear capsulorhexis, and hydro
dissection as they were performing manual SICS independently
and with good results. The hospital authorities considered this
criterion for beginning phacoemulsification training as the safest
approach to transition to phacoemulsification, similar to other
centers in India.5,15 Therefore, the first three steps for both
the groups were same. Each beginner from their respective
group was given 3–5 cases to learn a particular step from step
number four. On acquiring adequate skill of the particular step
they were allowed to move to the next step. Beginners from
Group A learned the technique of phacoemulsification surgery
using the conventional method. Beginners from Group B learned
the reverse technique. The fourth step was removing (washing)
viscoelastic material from the anterior chamber in a case that
was being completed by the trainer. The fifth step was the
aspiration of the cortex in a case where the trainer had already
emulsified the nucleus. The sixth step involved emulsification
of nucleus that was already cracked by the trainer. The seventh
step involved the beginner being taught to crack the nucleus that
was already trenched by the trainer. The eighth step involved
teaching the beginner to trenching the nucleus and in ninth
step nucleus rotation was taught. The final tenth step was in the
bag implantation of poly‑methyl‑methacrylate lens with 5 mm
optics. In the reverse method, steps 4–9 were exact reversals
of the conventional method. After the 30th case, the surgeons
Table 1: Order of steps of phacoemulsification taught
Step “Start to finish” technique Reverse technique
1 Limbal and side port incisions Limbal and side port incisions
2 Staining of capsule, viscoelastic Staining of capsule, viscoelastic
injection, capsulotomy injection capsulotomy
3 Hydro dissection and hydro Hydro dissection and hydro
delineation delineation
4 Nucleus rotation Viscoelastic wash
5 Trenching Aspiration of cortex
6 Nucleus cracking Segment removal
7 Segment removal Nucleus cracking
8 Aspiration of cortex Trenching
9 IOL implantation Nucleus rotation
10 Viscoelastic wash IOL implantation
IOL: Intraocular lens
 Suryawanshi, et al.: Comparison of Reverse and Conventional Method of Teaching Phaco

were asked to perform surgery by the conventional method Table 2: Comparison of posterior capsular rupture by both
and were graduated to the trainee group. In both groups, the methods of training
new step was preceded with the revision of the previous steps. Type of PCR (%) Total (%) P
Nucleus emulsification was taught with the “divide and conquer” training Yes No
method and irrigation‑aspiration was taught as a bimanual Beginner Start‑finish 18 (6.7) 269 (93.7) 287 (100) 0.38
method. Epinucleus removal was performed during the “cortex (0-30 cases) (15 surgeons)
Reverse 15 (4.6) 307 (95.4) 322 (100)
aspiration” step. (17 surgeons)
Trainee Start‑finish 32 (4.7) 647 (95.3) 679 (100) 0.705
There are a variety of techniques for teaching phacoemulsification, (31-100 cases) (11 surgeons)
Reverse 31 (4.3) 691 (95.7) 722 (100)
the three supervising surgeons used the divide and conquered (12 surgeons)
technique as they were most familiar with this method and
PCR: Posterior capsular rupture
considered it the easiest for the transition. Most trainees had
some experience with manual SICS, and were proficient in
tunnel construction and capsulorhexis and were familiar with Table 3: Steps during surgery where posterior capsular rupture
the nuclear and advanced cortical cataracts that formed the bulk occurred
of the training cases. Suturing of the tunnel was performed if Steps Start‑finish Reverse
technique (%) technique (%)
there was any uncertainty about the integrity of wound closure.
Nucleus rotation 1 (0.4) 0 (0.0)
Trenching 1 (0.4) 1 (0.4)
The outcome measure was the incidence of PCR in each group, Nucleus cracking 1 (0.4) 4 (1.2)
and for “beginners” and “trainees.” Statistical analysis was Segment removal 5 (1.7) 4 (1.2)
Cortical aspiration 8 (2.8) 4 (1.2)
performed with a two‑by‑two Chi‑square test.
Intra‑ocular lens implant 2 (0.7) 2 (0.6)
Total 18/287 (6.2) 15/322 (4.6)
RESULTS

Thirty‑two ophthalmologists learning phacoemulsification (the DISCUSSION

first 100 surgeries) participated in the study. Their average
age was 30 years, and 17 (53.1%) were males. They were
supervised by 3 trainers (2 female), each of whom had an
experience of at least 8000 cataract surgeries, of at least 1000
were phacoemulsification cases. Table 2 presents the results of
PCR with both methods.
Fifteen beginners (first 30 cases) performed 287 surgeries
by with the conventional method and had PCR occurred in
18 (6.2%) cases. Eleven of these beginners later performed
679 surgeries (“Trainee” group next 31–100 cases), and PCR
occurred in 32 (4.7%) cases. Seventeen beginners performed
322 surgeries using the reverse method and PCR occurred in
15 (4.6%) cases (P = 0.38, Chi‑square test for comparison
between “beginners” of the two groups). Twelve surgeons taught
with the reverse method later performed 722 phacoemulsification
surgeries (“Trainee” group, next 31–100 cases) and PCR
occurred in 31 (4.3%) cases (P = 0.705, Chi‑square test for
comparison between “trainees” of the two groups).
Table 3 presents that 18 cases had PCR with the conventional
training method and PCR occurred while aspirating cortex in
8 (2.8%) cases followed by rupture during emulsification of
nuclear fragments in 5 (1.7%) cases. Of 15 cases of PCR with
the reverse training method, PCR occurred during nucleus
fragmentation, emulsification, and cortical aspiration in
4 (1.2%) cases each.
The transition from SICS or conventional extracapsular cataract
extraction (ECCE) to phacoemulsification is a steep learning
curve.11,12 This is akin to new driver who initially has poor
hand‑foot‑eye‑brain coordination while learning to drive a car.
Similarly, a lack of coordination is faced by beginner learning
phacoemulsification surgery. The use of a foot switch is new
to these individuals and requires some experience. Judicious
use of ultrasound energy, vacuum, and flow rate is learned with
experience. Therefore, PCR can occur at various steps of surgery.
In the developed world, some centers use a virtual surgery
simulator for training residents in phacoemulsification surgery.
Those who were trained on simulators had less intraoperative
complications and shorter learning curves.9 Hand and foot
activated surgical tools in simulated ophthalmic surgery are also
used to assess dexterity.8
In reverse training method, the transition to the new technique
was gradual. A study assessing the difficulty of the various steps
of phacoemulsification surgery reported an incidence of PCR
of 9%.16 The most difficult steps were phacoemulsification of
the nucleus and capsulorhexis.16 The steps considered most
challenging that carried the greatest risks were emulsification
of the nucleus and cortex aspiration. In the current study, these
steps were taught towards the end of the training once the other
steps were adequately performed. While washing viscoelastic as
the first step of conversion, the trainee surgeon was familiarized

Middle East African Journal of Ophthalmology, Volume 23, Number 2, April - June 2016 165
 Suryawanshi, et al.: Comparison of Reverse and Conventional Method of Teaching Phaco
with the use of the foot switch and gained experience in the
nuances of foot pedal control. Cortex aspiration without use
of ultrasound energy, emulsification of already divided nucleus,
cracking of already divided nucleus helped build the confidence
of the surgeons. Epinucleus aspiration was considered a part of
the cortical aspiration step.
The reverse training method resulted in almost a third lower
incidence of PCR in beginner group compared to conventional
“start to finish” training method. In “trainee” groups (31–100
learning cases), the incidence of PCR was similar. In the cortical
aspiration step, the incidence of PCR decreased more than 50%
in the reverse method compared to conventional method. In
nucleus cracking step, the incidence of PCR was >0.89% in
reverse method compared to the conventional method. However,
these differences were not statistically significant (two proportion
Z‑test). The decreased incidence of PCR could be due to the
trainer surgeons performing the initial steps (e.g., continuous
curvilinear capsulorhexis, hydro‑dissection, and rotation of the
nucleus) more diligently. The trainer surgeons were experienced
and left a clean and clear field for the trainees to operate on,
thus decreasing the chance of the capsular damage.
The “beginners” in the current study were already trained in
SICS. However, they experienced difficulty in cortical aspiration
and nucleus fragment emulsification likely due unfamiliarity with
using a foot switch. Thomas observed two residents in early stage
of learning phacoemulsification and noted an incidence of PCR
of 10% although they were familiar with SICS.13
Hennig stated that in unsupervised learning, formal training, and
stepwise formal training the incidence of PCR was 15%, 10%,
and 4.8%, respectively; thus advocating stepwise formal training
for beginner.4 Studies of complications during surgical residency
training from Germany and USA reported an incidence of PCR
of 3.8% and 3.1%, respectively during phacoemulsification
training.7,10 Reports from Taiwan and USA evaluating the
learning curve of phacoemulsification in resident surgeons
reported an incidence of PCR of 4.9% and 5.1% respectively.11,12
The US study noticed that the incidence of PCR decreased from
5.1% to 1.9% after 80 surgeries indicating safety and efficiency
improved with experience. Our study had comparable results
although the “reverse” technique made the training safer in
terms of PCR.
The Brazilian Council of Ophthalmology, in partnership
with Alcon Brazil, used the reverse method to teach
phacoemulsification surgery. The module used by Fischer
et al. was slightly different where the progress of three 2nd‑year
resident surgeons was monitored at five “checkpoints.” The
incidence of PCR in this study was 13.1%.14 India has a large
pool of young ophthalmologists who need phacoemulsification
training.17 The feedback from residency training programs
166 Middle East African Journal of Ophthalmology, Volume 23, Number 2, April - June 2016
showed that surgical training for residents was considered
inadequate by many of the respondents.18 One reason is that
the residency chief believed surgical teaching may compromise
on the quality of patient care.19,20 Many young ophthalmologists,
therefore, seek special phacoemulsification training after the
completion of their residency and fellowship programs. The
reverse method may offer a new, safer method of mastering
phacoemulsification.
The limitations of this study include that nonrandomized
design and that data from a single center are reported. A larger
comparison with multiple centers would help refute or validate
the relatively greater safety of the reverse method in preserving
the posterior capsule. In addition, our “beginners” were
surgeons with some experience in manual SICS and not residents
performing cataract surgery for the 1st time or those who were
only familiar with ECCE.
CONCLUSION
This study revealed that both stepwise, supervised “start
to finish” conventional and reverse methods of training
phacoemulsification were safe and effective. However, the
reverse method showed a nonsignificant trend toward lower
PCR.
Acknowledgment
Dr. Shailbala Patil, Director of Education and Training and
Dr. Ashok Mahadik, Medical Director, Lions NAB Eye Hospital,
Miraj, India. Mrs. Gogate, Statistician, Bharti Vidyapeeth
Medical College, Sangli, India; Shrivallabh Sane, Data Clinic,
Pune, India for statistical analysis.
Financial support and sponsorship
Lions NAB Eye Hospital, Miraj, Maharashtra, India.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Chang DF. Tackling the greatest challenge in cataract surgery.
Br J Ophthalmol 2005;89:1073‑4.
2. Riaz Y, Mehta JS, Wormald R, Evans JR, Foster A, Ravilla T,
et al. Surgical interventions for age‑related cataract. Cochrane
Database Syst Rev 2006;4:CD001323.
3. Minassian DC, Rosen P, Dart JK, Reidy A, Desai P, Sidhu M,
et al. Extracapsular cataract extraction compared with small
incision surgery by phacoemulsification: A randomised trial.
Br J Ophthalmol 2001;85:822‑9.
4. Hennig A, Schroeder B, Kumar J. Learning phacoemulsification.
Results of different teaching methods. Indian J Ophthalmol
2004;52:233‑4.
5. Khanna RC, Kaza S, Palamaner Subash Shantha G, Sangwan VS.
Comparative outcomes of manual small incision cataract
 Suryawanshi, et al.: Comparison of Reverse and Conventional Method of Teaching Phaco
surgery and phacoemulsification performed by ophthalmology
trainees in a tertiary eye care hospital in India: A retrospective
cohort design. BMJ Open 2012;2. pii: E001035.
6. Quillen DA, Phipps SJ. Visual outcomes and incidence of
vitreous loss for residents performing phacoemulsification
without prior planned extra capsular cataract extraction
experience. Am J Ophthalmol 2003;135:732‑3.
7. Rutar T, Porco TC, Naseri A. Risk factors for intraoperative
complications in resident‑performed phacoemulsification
surgery. Ophthalmology 2009;116:431‑6.
8. Podbielski DW, Noble J, Gill HS, Sit M, Lam WC. A comparison
of hand‑and foot‑activated surgical tools in simulated
ophthalmic surgery. Can J Ophthalmol 2012;47:414‑7.
9. Belyea DA, Brown SE, Rajjoub LZ. Influence of surgery simulator
training on ophthalmology resident phacoemulsification
performance. J Cataract Refract Surg 2011;37:1756‑61.
10. Briszi A, Prahs P, Hillenkamp J, Helbig H, Herrmann W.
Complication rate and risk factors for intraoperative
complications in resident‑performed phacoemulsification
surgery. Graefes Arch Clin Exp Ophthalmol 2012;250:1315‑20.
11. Lee JS, Hou CH, Yang ML, Kuo JZ, Lin KK. A different approach
to assess resident phacoemulsification learning curve: Analysis
of both completion and complication rates. Eye (Lond)
2009;23:683‑7.
12. Randleman JB, Wolfe JD, Woodward M, Lynn MJ, Cherwek DH,
Srivastava SK. The resident surgeon phacoemulsification
Middle East African Journal of Ophthalmology, Volume 23, Number 2, April - June 2016 167
learning curve. Arch Ophthalmol 2007;125:1215‑9.
13. Thomas R, Naveen S, Jacob A, Braganza A. Visual outcome
and complications of residents learning phacoemulsification.
Indian J Ophthalmol 1997;45:215‑9.
14. Fischer AF, Pires EM, Klein F, Siqueira Bisneto O,
Soriano ES, Moreira H. CBO/ALCON teaching method of
phacoemulsification: Results of Hospital de Olhos do Paraná.
Arq Bras Oftalmol 2010;73:517‑20.
15. Haripriya A, Chang DF, Reena M, Shekhar M. Complication
rates of phacoemulsification and manual small‑incision cataract
surgery at Aravind Eye Hospital. J Cataract Refract Surg
2012;38:1360‑9.
16. Dooley IJ, O’Brien PD. Subjective difficulty of each stage of
phacoemulsification cataract surgery performed by basic
surgical trainees. J Cataract Refract Surg 2006;32:604‑8.
17. Thomas R, Dogra M. An evaluation of medical college
departments of ophthalmology in India and change following
provision of modern instrumentation and training. Indian J
Ophthalmol 2008;56:9‑16.
18. Gogate P, Deshpande M, Dharmadhikari S. Which is the best
method to learn ophthalmology? Resident doctors’ perspective
of ophthalmology training. Indian J Ophthalmol 2008;56:409‑12.
19. Gogate PM, Deshpande MD. The crisis in ophthalmology
residency training programs. Indian J Ophthalmol 2009;57:74‑5.
20. Grover AK. Postgraduate ophthalmic education in India: Are
we on the right track? Indian J Ophthalmol 2008;56:3‑4.