Cataract Surgery: Complication Rates Stabilize After 100 Cases for Trainees

Cataract surgeons in training appear to reach a point of stabilization in their complication rates after performing approximately 100 procedures, according to research presented at the European Society of Cataract and Refractive Surgeons winter meeting earlier this month. The findings, shared by resident doctor Nikolaos Dimitriadis from General Hospital of Sparta, Greece, underscore the importance of structured training programs and mentorship in ensuring patient safety during the learning curve of cataract surgery.

The retrospective audit analyzed 500 consecutive supervised cataract surgeries performed by Dimitriadis between April 2024 and October 2025. The analysis was broken down into blocks of 100 cases to identify trends in complication rates as the surgeon gained experience. The average patient age was 73.9 years, with nuclear cataracts being the most common type observed in 73% of cases (366 patients). A majority of patients (65.1%) presented with no significant pre-existing ocular conditions, though pseudoexfoliation was noted in 9.2%, glaucoma in 8.4%, and age-related macular degeneration in 4.6% of patients. Age-related macular degeneration is a common condition that causes vision loss.

Early Surgical Decisions and Complication Patterns

Dimitriadis noted an initial preference for temporal incisions during the early stages of his training, driven by uncertainty regarding superior approaches. However, he evolved to consistently assess the axis of astigmatism and became comfortable with superior incisions as his experience grew. This illustrates the iterative learning process inherent in surgical training. The study identified several specific complications, with iris prolapse occurring in 3.8% of cases (19 eyes), vitreous loss in 2.2% (11 eyes), and incomplete capsulorrhexis in 1.8% (9 eyes). Posterior capsular rupture occurred in 1.2% of cases (6 eyes), while zonular dialysis and dropped nucleus were less frequent, at 0.4% (2 cases each) and requiring referral for vitreoretinal surgery.

Corneal edema, potentially linked to endothelial damage and increased ultrasound energy use, was observed in 0.6% of cases (3 eyes). Importantly, the majority of posterior capsule ruptures – all six cases – occurred within the first 100 surgeries performed by Dimitriadis. Six of the eleven vitreous loss cases were directly related to posterior capsule rupture, while two were associated with zonular dialysis due to pseudoexfoliation. The remaining three vitreous loss cases were of uncertain origin, potentially stemming from tension during capsulorrhexis or zonular weakness during irrigation and aspiration.

Incomplete capsulorrhexis, primarily occurring within the initial 100 surgeries, was attributed to factors like slight pupils and dense cataracts that reduced visibility. These were managed intraoperatively without lasting consequences. Wound suturing was required in 39 cases, often linked to intraoperative iris prolapse or larger main incisions (greater than 2.75 mm). Dimitriadis reported a significant reduction in the need for suturing as he refined his technique and consistently achieved smaller, 2.75 mm incisions.

Visual Outcomes and the Learning Curve

the mean visual outcome across the 500 cases was 6.6/10, with 86.8% of patients achieving spectacle independence. This suggests a generally successful surgical outcome despite the learning curve experienced by the resident surgeon. Dimitriadis emphasized his confidence that a recent surgical trainee can stabilize their complication rate after completing around 100 cases, provided they receive adequate mentorship and participate in a well-structured training program.

During the discussion following his presentation, Dimitriadis detailed his training approach, which did not initially involve surgical simulation. He began by practicing viscoelastic injection and intraocular lens (IOL) placement to develop an understanding of eye anatomy and hand positioning. He then progressed through a step-by-step training process encompassing irrigation and aspiration, incision creation, capsulorrhexis, and phacoemulsification.

Implications for Surgical Training and Patient Safety

The findings from Dimitriadis’ audit reinforce the critical role of structured training and mentorship in minimizing complications during the initial stages of a surgeon’s career. The identification of a stabilization point around 100 cases provides a tangible benchmark for assessing progress and tailoring training programs. While the study is retrospective and focused on a single surgeon’s experience, it offers valuable insights into the natural learning curve associated with cataract surgery. It’s important to note that individual learning rates may vary, and ongoing supervision and feedback remain essential throughout the training process.

The study also highlights the importance of addressing specific technical challenges, such as managing small pupils and dense cataracts, which can contribute to complications like incomplete capsulorrhexis. The evolution of Dimitriadis’ incision technique, from a preference for temporal approaches to a more nuanced assessment of astigmatism and comfortable use of superior incisions, demonstrates the value of continuous learning and refinement of surgical skills. Research suggests that additional training can improve practice opportunities and career satisfaction.

What’s Next: Ongoing Evaluation and Refinement of Training Protocols

The European Society of Cataract and Refractive Surgeons (ESCRS) and other professional organizations are continually evaluating and refining surgical training protocols to optimize patient safety and surgical outcomes. Future research may focus on identifying specific training interventions that can accelerate the learning curve and reduce complication rates. Further investigation into the factors contributing to vitreous loss and posterior capsule rupture, particularly in eyes with pre-existing conditions like pseudoexfoliation, could also inform targeted training strategies. The ongoing collection and analysis of data from surgical audits, like the one presented by Dimitriadis, will be crucial for monitoring progress and identifying areas for improvement in cataract surgery training.