Atanas Bogoev M.D.
Learning Phacoemulsification: 101
Updated: Apr 20
I am Atanas Bogoev, a young ophthalmologist currently working in Germany with a particular interest in anterior segment and cataract surgery.
I initially wrote this article about learning phacoemulsification (cataract surgery) for the SOE Young Ophthalmology Newsletter but decided to expand it and share it here.
Personally, like all of you, I aim to be a better ophthalmologist and am always looking to expand my knowledge of phacoemulsification.
I am sharing with you my perspective on using various methods to improve your know-how and skills when it comes to surgery steps, including machine settings, and surgical techniques. After tackling the problem of learning phaco personally, I came to the conclusion that there are a few main points that you must take into account:
I know you want to get started right away and dive right into the surgical process (I felt the same way). But a thorough understanding of the fundamental principles behind phacoemulsification is crucial for a successful surgeon.
You should perfect your knowledge of the anatomy and physiology of the eye and know the surgical steps, IOLs, as well as various machine settings, especially the ones your hospital has available. You should be comfortable with the indications for surgery, know the possible intraoperative and postoperative complications, and how to deal with them.
Next, you should focus on techniques used during surgery. Attending conferences, reading textbooks, and watching instructional videos are effective ways to gain deeper knowledge in this area.
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I suggest going through one fundamental ophthalmology book such as the AAO Basic and clinical science course 11 Lens and cataract.
BCSC Section 11 is an amazing complete resource that covers the anatomy, physiology and pathology of the lens. As well as the diagnostics, evaluation and management of cataracts. It gives a great overview of lens and cataract surgery, including unusual situations.
Once you cover the basics, I recommend checking out the awesome resources that our awesome colleagues have summarised and posted online. One of the best and most comprehensive summaries of cataract surgery from Matt Hirabayashi, MD:
I especially loved the Free PDF books about eye exams and cataract surgery, the IOL Cheat Sheet, and the History of how we came to progress and improve our IOL calculation formulas. Go check it out!
In addition, I recommend that you watch as many surgical videos on standard phaco techniques as possible. Focus on the steps, understand why and how they are performed, and what potential complications can occur at each step.
Here are a few great examples of standard phaco case videos:
CataractCoach 1309: 90% of your cataract surgery cases are routine, Uday Devgan
If you take a look at my personal go-to online learning resources in ophthalmology you will can find great videos, courses, updates, and discussions about cataract surgery:
Cataract Surgery Wetlabs
Cataract Surgery Wetlabs are a great opportunity and an effective way to gain hands-on experience with phacoemulsification in a safe and controlled environment. I attend wetlabs as often as I get the chance!
Many eyecare educational centers have wetlabs available to their residents, and if this is the case with you - use them as much as possible. A significant part of the surgery is building muscle memory and improving hand-eye coordination to be precise in your movements.
Transitioning from wetlabs to real surgery gives you more confidence in your surgical technique, and makes you more aware, not having to develop your hand movements under the microscope from zero. I recommend practicing wetlabs with an experienced mentor, a fellow, or another resident, and giving each other feedback after every “case”.
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Cataract Surgery Simulation
Simulation training is a unique method of learning phacoemulsification. It provides a realistic virtual environment to practice surgery, using advanced technology and software to simulate various surgical scenarios.
There are increasingly more publications in the literature that point out the benefits of simulation training for residents and young ophthalmologists when learning surgery. That makes sense, as simulation learning is practiced in various fields, like aviation, transportation, manufacturing, design, architecture and etc.
"Ophthalmic simulation training reduces the total rate of complications of resident-performed phacoemulsification. It also shortens the learning curve for cataract surgery training, as indicated by the decreased posterior capsule rupture rate in the initial cases of cataract surgery.”
Montrisuksirikun C, Trinavarat A, Atchaneeyasakul LO. Effect of surgical simulation training on the complication rate of resident-performed phacoemulsification. BMJ Open Ophthalmol. 2022 Jun;7(1):e000958. doi: 10.1136/bmjophth-2021-000958. PMID: 36161842; PMCID: PMC9189817.
I got the chance to practice on simulators first after graduating from medical school, but I got close to zero benefits from it, although I was getting high scores on each and every step.
I got to know Dr. Ivo Ferreira online at the beginning of 2020 (during the first wave of COVID-19), and he asked me a question that struck me:
How many hours have you practiced on a phaco simulator with a dedicated mentor by your side, that know how to teach using simulation?
I was fortunate enough to experience this in the Simulation Course of Oftalmo University in person in Mexico City in 2022. I spent a week intensively practicing various steps and complications of phaco for 12-14 hours per day.
Immediately after the course, I was feeling much more confident in the surgical room with real patients, and I was being more aware of what was happening and where I needed to shift my attention to in a certain step.
Finding a mentor who has not only a lot of experience in phacoemulsification, but is also a great teacher can be challenging, but at the same time a real game-changer.
A good mentor can provide you with guidance when learning phacoemulsification, answer questions, and provide key tips and details on how to improve your skills.
Try observing your mentor's surgeries as much as possible, even recording surgical videos. Pay attention to his hands, and feet, and how they handle the surgical instruments. Ask about everything that you have trouble understanding, including hypothetical situations (For example: If you would encounter this complication, how would you deal with it etc.).
You can download and ask your mentor to evaluate you based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment for Cataract Surgery.
We are fortunate enough to live in a time where amazing mentors offer that same thing online through various programs and directly. I highly encourage all of you to travel and participate in exchange programs, conferences, courses, and meetings where you will meet not only amazing mentors but true role models.
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Start with simple cases
Another important factor when learning phacoemulsification is case selection. The right case selection at the beginning of your learning curve is everything. You don't want to start operating on cases where the probability of complications is higher.
Once you start doing surgery on real patients, begin by performing simple, straightforward cases under supervision and gradually progress to more complex surgical cases - avoid very soft, very hard, or white cataracts, PEX, traumatic cataracts, cases with synechia or traumatic cataracts and cases with small pupils.
This will help you build confidence faster and progress faster through your learning curve, as your mentor will have to intervene less. Once you get the basics, moving on to the more challenging cases will be an easier step for you.
Record your surgical videos and seek feedback
Record and review the video recordings of your surgical cases, complications happen in fractions of a second. For me, this is a key step when learning phacoemulsification.
Capture the surgical cases on video, watch them, analyze your mistakes, learn from them, and make sure they don't happen again. Pay attention to your wasted movements, which steps take you longest and seem hardest for you, and try to identify why. Always ask for feedback from your colleagues and mentors on your surgical technique.
I am sharing with you the way I personally document the surgeries that I took part in or performed myself. I find that If you are really dedicated to improving something, the first thing you have to do is to measure it and analyze the data.
I use a simple Excel table and after each surgical day I enter the following information:
Name and surname of the patient
Patient's Birthdate (I find this important as sometimes there are patients with identical names and surnames)
Which eye I operated on or assisted on
What type of surgery was performed
My role in the surgery (Surgeon/assistant)
The mentor that I was assisting or was supervising me during this surgery
Notes for the surgery
Did I record a surgical Video and did I download it later
Feedback to myself (I write this directly on the day after surgery, and once again after reviewing the surgical video at home)
Patience is key
Being patient is extremely important when learning about cataract surgery. Learning phacoemulsification is a gradual process and there is a learning curve that you need to go through. Some of you may find it easier to pick up certain steps, while others may require more time and practice.
In any case, I encourage you never to lose hope and remember, with persistence and patience, you can achieve mastery in everything, including phacoemulsification. What helps me is to enjoy the learning road and celebrate my successes instead of only focusing on my failures.
Last but not least, be a good person and share your acquired skills with younger colleagues. You know how long it takes and how hard it is to acquire them, so give back, teach, mentor, coach, and follow the awesome saying: “Sharing is caring!”
Practice, Practice, Practice
Practice and repetition are essential for young ophthalmologists who are progressing through the steps and climbing the learning curve of phaco. With practice, you can sharpen your skills, become more confident in your hands, trust yourself more, and be brave enough to tackle more complex situations.
Again, developing essential muscle memory when performing cataract surgery under the microscope, getting to know your equipment and instruments, and recognizing difficult situations comes only with multiple repetitions of the same task.
Do you have any notes or comments about learning phacoemulsification?
Tell us about it in the comments down below. Your feedback means a lot!
This article was featured in the SOE YO Newsletter and was expanded further by Atanas Bogoev, MD, FEBO.
Leave a comment here or message me on Instagram: @atanasbogoev