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In ophthalmology, surgical skills
training is challenging for both teachers and resident. Teaching in operation
room is complicated by the fact that the attending faculty is primarily an
observer with limited ability to prevent surgical complications. With the
recent modifications in residency curricula including virtual reality surgical
simulation and wet labs, technical skills and clinical judgment can be taught and assessed without putting patients at
risk. In this review, guidelines are suggested to improve the process of
training during residency and can be applied to all ophthalmic surgical





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Ophthalmology is a medical and
surgical specialty that need to have good exposure in both to achieve
competency. Surgical skills training is still challenging in most of the residency programs because of multiple factors.(1) 
Variability in surgical exposures among residents in training is
existing in different parts of the wards as
phacoemulsification, one of the most common surgical procedures, done during
residency training. Numbers of phacoemulsification varies widely between
residency training programs and even among the same program. In the United States, residents perform an average of
about 113 phacoemulsification cases during residency training, and most perform
between 80 and 140 cases; however, there is significant variability among
programs, with up to 25% of residents performing fewer than 80 cases.(2)


These numbers are different in the United Kingdom,(3) Canada,(4) Saudi Arabia,(5) and
Jordan(6) being 500-600, 200-400, 80-100, 0-30
cases per resident respectively. Also, during a residency,
there are variable surgical competencies that need to be achieved during
training. All that indicates the need for a more structured and focused
surgical training. Although complex and time consuming, sufficient surgical
exposure must be a high priority in any successful residency program.


Modifications in the surgical training
curriculum, caused by limitations to resident work hours, concerns over patient
safety, and limitations in the operating room have obligated
residency educators to keep searching for more ways of teaching surgical


With the development of competency-based
training, comes the need to look to residency outcome and continuously improve
the transfer of surgical skills. Residency training is a team effort
that includes different members to
achieve a superior outcome. In
ophthalmology, there are three main factors that influence success in surgical training;
administration (hospital administration, and program administration), teachers,
and trainees. This review addresses challenges that face residents’ surgical
training related to all the three components of training.



This would include (hospital managers, head of departments, program
directors). The role of the administration
is crucial to the success of surgical training. Understanding the importance of
training and support from them will help to overcome any difficulty and will ensure achievement of training objectives. There
are different challenges that may face hospital administrators regarding resident’s
training, which includes:


1.     Lack of space (mostly operative rooms and to lesser
extent clinics): in most countries, there is a huge demand for medical services. Incorporating
residents training in hospital systems may cause some delay and underutilization of hospital resources when
looking to a number of cases seen or
managed for a given ancillary. Residents, especially
in their junior level, need more time in clinics and operative rooms (OR)
to provide a similar amount of patient
management in comparison with more senior
staff in the system. To overcome these
challenges, hospital administrators may improve utilization by having
clinic and OR expansion if space is allowing. Also, compensating OR staff by doing residents cases after working hours and weekends, after finishing the main OR lists. The other solution would be outreach programs by sending residents with
their mentors to be trained in less crowded centers. Lastly, affiliation with another community hospital where they are
typically having a huge number of
patients and sufficient clinic and OR. These would be done either under the supervision of that center’s faculty staff or by sending staff from the main training
center to supervise residents training. One should stress on the point of close
supervision to avoid any variability in training. That can be done by
explaining the program objectives, ways of assessment, and monitoring to the affiliated
centers’ staff.


2.     Lack of interested supervisors: The ability to teach surgery is a difficult task. The very best surgical teachers
must be recruited to teach residents surgical competencies. These teachers must
be rewarded, compensated, and encouraged. Motivating interested staff varies
among different institutes. These may include time compensation, letters of
appreciations and priority in attending Conferences and leave application.
Putting “interest in teaching” as one of the advantages
during recruitment. Include residents/fellows
teaching as one mission in hospital/department policies and in staff contracts. Finally, financial incentives for
those teachers would help them more and even encourage others to share in


3.     Surgical cases suitable for training: Patient
Recruitment is one of the challenges that
face residency training program especially in tertiary care centers. Cases in
these centers, usually, are complicated and need expert intervention. This
problem can be solved by modifying eligibility criteria to accommodate cases suitable
for training. Affiliation with community hospital where common surgical cases
can be operated by residents-in-training.


4.     Patient willingness to be
done by trainee: This could be included during opening file process. Keeping in
mind that all residents’ cases should be done under the supervision of treating
consultant. This should be explained
during patient consenting for any
surgical intervention. Also, resident’s clinic can solve this problem since
residents will recruit and manage their own patients.

The possibility of the high rate of complications in residents’ cases: With proper supervision and patients’ selections, risk
of complications are not differ from attending staff. Residents performing
phacoemulsification surgery achieved a low overall rate of major complications
(4.7%). Specific features of cataracts, such as mature nuclei and zonular
pathology, carried increased intraoperative risk. Anticipating risk may help to
decrease surgical complications further.(7) Also, surgical skills
foundation, wet labs, and surgical simulators can help to establish a good surgical foundation and increases surgical
safety. It is essential to include wet-laboratory experience early in all
residency training programs. Nowadays, in ophthalmology, there are multiple
methods of simulation-based to improve trainee
learning curve and increase patient safety. Residents who trained using the
simulator had shorter phacoemulsification times, lower percentage powers, fewer
intraoperative complications, and a shorter learning curve.(8)






By teaching a trainee to perform a
better operation, physician   may
have an impact on thousands. The supervision of
trainee is stressful but beneficial. It would give more confidence in
managing difficult cases. Surgical skills transfer from experienced surgeons to
resident surgeons is difficult because the teaching surgeon primarily acts as
an observer rather than directly performing the procedure.(9)


The following points can help in
efficiently teaching residents surgical competencies and optimize this learning


1.     Patients selection: It is well known that not all cases
are teaching cases. Arranging the list
ahead of time is important, so trainee will have the chance to do a good part of it. The ability to identify those
patients who will tolerate resident intervention is crucial. Avoid certain
patients not suitable for beginner, e.g. monocular, small pupils,
pseudoexfoliation, pediatric patients, or patients with low corneal endothelium.
Never attempt procedures or device with which you are not completely familiar.


2.     Operation room time management: To avoid significant delay in your
list, good control of OR environment is needed. Try not to overload your list
with cases especially when training
novice surgeon. During list creation,
identify which cases can be done by trainee based on their experience. If it is the first list; it would be better to
do the first case to show your surgical way. Try to plan the whole training
period; starting with observation, then doing few steps, then simple cases,
then difficult cases. And if time would allow,
residents may share in the supervision of
their junior colleges that will build their ability to teach in the future.
This approach to teaching surgery allows the trainee to progress in a planned
way and avoid overwhelming them with cases that may lead to complications and
poor confidence. The presence of fellow-in-training
would help more in the process of training. With proper arrangement of OR list, fellows shouldn’t compete with
residents in performing surgical cases. The presence of fellows at training
institution, if utilized in an appropriate way, often enhances residents


3.     Good positioning and microscope handling: Appropriate
positioning at the operating microscope is important in teaching case. Awkward
positioning of the teacher will make the surgery more difficult and affect his
ergonomics.(11)  Often time residents’ cases take longer
time and need attention, so neglecting good positioning will lead to musculoskeletal
strain and affect the overall performance of the teaching staff. At beginning
of the case, adjust seat, table, and microscope to accommodate a neutral
posture. When supervising trainee with different stature, avoid the slight
spine tilt and adjust assistant eyepieces
to correct that difference. Arrange cords of the microscope and machine pedals
in a manner that will not conflict with switching position. At least in between
cases, when possible, pause, stand, and perform upper body and back stretches.(12)


4.     Build and reinforce the resident’s confidence: In my opinion, the most crucial step to have a successful
mission is to know when to intervene during surgical cases either with
comments or act. In the beginning, use the most classic way with aides (capsular
staining, hooks, good amount of viscoelastic devices)
to have a smooth case. Try to avoid and manage minor complications like small capsulorhexis
in the beginning of the case. They may
lead to increase in major complications later and decrease success rate by


It may be
necessary for you to switch positions to evaluate the status or to take over.
This should be done in the spirit of cooperation, without emphasizing the
resident’s failure. Mistakes are better addressed and discussed after the
procedure is completed.


5.     Communicate well with your trainee: You need
to explain to the trainees their roles and what they supposed to do. Don’t assume that they know your ways and
protocols. Especially for the beginners, the preoperative
round is important for the medical aspect of cases, special preparation
and also for patient comfort. In OR, review the case, your approach, and your
goals with the resident before starting. I found it useful for them to show
your way in video or in written before touching the patient. There are a lot of
teaching videos residents may review to help them in OR.


Note that
ophthalmic patients are generally awake during surgery, so one must be careful
about communicating in the operating room for patient comfort. Postoperatively,
it is better to be there for the first postoperative visit as teaching
postoperative care is essential and as important as teaching in OR.(14)


For Residents:


They are the main factor for success.
If anyone aspires to learn something, he/she
will achieve it. Surgical techniques are important but there are much more in order to master ophthalmic surgeries. You
need to be aware that the goals of any surgical training program include
increasing the surgical confidence and skills of the resident, enhancing the
resident’s surgical judgment, and preserving the best possible outcome for the patient.(1)


Here are some suggested guidelines to
give the trainee the best outcome out of his/her training period.

Evaluate patient preoperatively and
surgical indications: Attending clinics and OR sessions but not paying
attention to your patients will not qualify
you as a possible surgeon for them. You must understand the patient’s complaint
and evaluate him fully before the surgery. This would include surgical
indications, proper clinical workups and patient’s
expectations.  It is essential to pay
special attention to patient’s anatomy to plan your surgery. Examples are those
deep-seated eyes, patients with pseudoexfoliation, high myopia, post-refractive eyes, and patients with poor
pupil dilation. If you know your patients preoperatively you would work them up properly and thus you will
eliminate most of the intraoperative


Communicate with your attending physician: Discuss
the patient and  planned procedure thoroughly with the treating consultant. Engage
yourself actively in surgical planning, biometry evaluation, and IOL selection. Discuss phacoemulsification
machine parameters and reasons for modifications, the preferred surgical
technique, and instruments. Remember that
being a good assistant, who can anticipate what is needed, is essential to becoming a competent surgeon. Try to arrange
the OR list ahead of time and save more time for your cases. Be familiar with
the planned procedure by watching videos or
other surgeons.


Utilized your time for learning
surgical skills: Surgical training is complicated by the fact that the teaching
surgeon primarily acts as an observer rather than directly performing the
procedure. So, patient safety should be secured all the time. Therefore,
simulator training and wet labs are
utilized to reduce the learning curve of
beginners, which establishes tissue awareness, dexterity and muscle memory.(9)

So, if you don’t have a chance to do a case in an OR list, you can still utilize your time
in learning. Practicing microscope, suturing, and instrumentations all can be
done and will help you in future lists.



Be familiar with early signs of
intraoperative complications and their management: Good
knowledge about complications is needed for any surgical intervention. A good surgeon cannot prevent complications to
occur but will try to prevent them, and if they happen, will manage them in a proper way. Minor complications (e.g. limited
capsular extension) can be reversed with no subsequent sequels if discovered
early. Vitreous loss will happen in some
of your cases and you need to know how to handle it safely. Other major complications
like drop nucleus, suprachoroidal
hemorrhage can occur. In such cases, it is extremely important to know the
initial management to improve the final outcome.


Understanding and participate in
postoperative care: Take time after each case to discuss every
step of the surgery with your attending physician. Learning from postoperative
care is as important as learning in OR. In the early stages of your surgical
training, make sure to do postoperative rounds
with the attending physician. This step is very important in building up
surgical experience.


In conclusions, there is a great need
for improving surgical training during residency programs. With proper utilization of current resources, one can expect improvement in
achieving training objectives. Coordination between the three components of
training (administrators, teachers, and trainee) is crucial to have a successful mission.