Hands-on Cataract Training: My Journey at Agarwal’s Eye Hospital
- Martina Milkovska, FEBO
- Aug 10
- 7 min read
A couple of years ago, I was seriously considering buying myself a car. My parents even offered to help pay for it. Naturally, I took the opportunity... and used the money to fly to India to learn cataract surgery at Dr. Agarwal’s Eye Hospital instead.
Since then, I’ve been refining my surgical skills and perfecting the art of catching the bus to work.
At the time, I had just entered the final year of my ophthalmology residency. I had performed a few cataract surgeries independently under supervision, but most of my experience came from extensive wet lab training.
First Impressions of India
I landed in Chennai in mid-August. The first thing that hit me was the heat. Not just hot, but intensely humid and suffocating. Outside felt like a steam room, while inside, the air conditioning was so strong the windows were sealed to keep the moisture out. It took some time to adapt to the new scene. I stayed for 12 days, 10 of which were spent in the hospital, operating every day.
The Agarwals: Living and Breathing Ophthalmology
Prof. Amar Agarwal is both an inspiring and unforgettable figure – a world-class surgeon, a passionate teacher, and a tireless worker. He arrives at the hospital before everyone else, starts operating at 7 a.m., and stays late into the night.
Afterward, he works on papers and presentations, often sleeping only 2 to 4 hours. He joked that he has no life outside the hospital. And in many ways, it was true: his wife and sons also work there, and his friends are his colleagues.
Amidst the intense surgical schedule, we had one evening off, and Prof. Agarwal made it special. He invited all the trainees to dinner at a local restaurant. It was a chance to step away from the operating room and get to know him beyond the role of surgeon and mentor.
Over delicious local food, he shared stories about his journey in ophthalmology, his passion for innovation, and the philosophy that drives his relentless work ethic. The atmosphere was relaxed and fun. We laughed, asked questions, and connected not just as trainees and mentors, but as colleagues from different parts of the world.Â
Dr. Ashvin Agarwal, his son, is another remarkable surgeon. Watching him operate was a privilege; he’s calm, precise, and completely unfazed by complications. In fact, he seemed to thrive on them, using every challenge as an opportunity to apply his full range of skills. Answering my questions, he shared many surgical pearls.
Inside the OR: Training at Agarwal’s
I would arrive at Agarwal’s Eye Hospital around 8 a.m., change into scrubs, and head straight to the main operating theatre, where Prof. Amar Agarwal had already completed several surgeries. Despite the packed schedule, he always greeted me warmly and invited me to observe.
Watching him operate was a masterclass in itself. He didn’t just perform surgery, he explained every step, welcomed questions, and was clearly happiest when surrounded by curious trainees. He had a unique ability to break down complex maneuvers into digestible lessons, even pausing mid-surgery to point out an anatomical detail or technique.
After observing a few surgeries, I’d head downstairs to the trainees’ operating theatre: an organized space with three operating tables, three experienced nurses, and one attending surgeon supervising all cases. There was no lengthy pre-op discussion.
I’d be told whether the case was extracapsular cataract extraction (ECCE) or phacoemulsification, and the patient’s age, particularly important for younger patients, where a more elastic capsule makes capsulorrhexis more challenging.
The pace was fast. As soon as I finished one surgery, the next patient was already being prepped. I’d scrub out, reset mentally, and scrub in again for the next case. There was no time to dwell on the previous surgery. Only time to stay focused, adjust quickly, and keep improving with each case.
But afterwards, there was always time to reflect. I often stayed back to talk with the attending surgeon, asking about specific steps, challenges, or decisions from my cases. Some days, I’d even head back up to the main ORs to discuss techniques with the senior surgeons or catch a few more cases being performed. The openness and availability of the faculty made it easy to learn far beyond the operating table.
What struck me most was the competence of the nurses. In most cases, their help alone was enough to complete a surgery safely. I remember one trainee from Italy who had never performed a cataract surgery before. He didn’t even know the steps.
Yet, with one nurse’s step-by-step guidance, he completed his first case successfully. Watching her guide him so effortlessly was something I’ll never forget. What made the experience even more striking was how the nurses guided us without a microscope of their own. They watched the surgery on a flat screen, yet still gave incredibly precise, confident instructions.
Their depth perception, timing, and intuition were so sharp that they could walk us through every step. From incision to IOL implantation, as if they were seeing everything firsthand. It was a testament to how skilled the support staff were in this high-volume environment.
Extracapsular cataract extraction (ECCE): A Skill Worth Keeping
While at Agarwal’s, I performed both phacoemulsification and ECCE.
Despite phaco being the modern standard, I made it a point to train in ECCE. Both because of its practical value and because I genuinely enjoy the technique.
In Bulgaria, where I work, it’s not uncommon to encounter patients with dense, brunescent cataracts. Cases where phacoemulsification isn’t always the safest or most efficient option. ECCE still has a place, and I wanted to be fully confident with it.
Around my 10th case, I felt I had good control over the technique. In my hands, it feels safe and predictable.
Compared to small-incision cataract surgery (SICS), ECCE has a gentler learning curve. Of course, it comes with higher postoperative astigmatism, which is why I reserve it for eyes with dense cataracts and comorbidities where a good visual outcome isn't expected.
Mastering Phacoemulsification
Phacoemulsification is undeniably the more complex and demanding procedure. On one hand, you must master the phaco machine, understanding its fluidics, and settings. Hand-eye coordination, instrument handling in a confined space, and the ability to troubleshoot intraoperative complications all come into play.
Each step requires focus and control, and there's little room for error. It’s a long learning curve. Every step must be executed with precision, and complications can escalate quickly. But it’s also incredibly rewarding. With experience, phacoemulsification becomes an elegant, efficient, and minimally traumatic surgery – and remains the gold standard for a reason.
One of the most interesting aspects of my time at Agarwal’s was seeing how phacoemulsification was approached, both by Prof. Agarwal himself and the rest of the surgical team. The technique they consistently used involved flipping and tilting the nucleus into the anterior chamber, followed by emulsification outside the capsular bag.
The surgeons there were exceptionally skilled. Their technique was so refined that they used minimal ultrasound energy and completed cases with impressive speed. It was clear that this method had become their preferred choice because in their expert hands, it was both efficient and safe.
In my opinion, however, this technique may not be the best starting point for beginners. For those still building confidence and precision, working within the capsular bag offers a more controlled and forgiving environment, especially when dealing with denser nuclei or when endothelial protection is a concern.Â
Some Surgical Pearls I Gained During My Training at Agarwals Hospital
Hydrodissection Technique
It should be performed gently, and ideally not directed at the 6 o’clock position. Instead, aim to inject fluid just to the left and right of the main incision. A useful trick is to gently lift the edge of the anterior capsule with the cannula tip to ensure correct positioning below the anterior capsular edge. After each fluid wave, lightly tapping the nucleus in the center helps properly distribute the fluid throughout the capsular bag.
Nucleus Prolapse with Hydrodissection
With a correctly sized capsulorhexis, it is possible to prolapse the nucleus into the anterior chamber during hydrodissection, especially if planning to emulsify the nucleus away from the posterior capsule. This technique offers more control and reduces the risk of posterior capsular damage.
ECCE and the Envelope Capsulotomy
When performing ECCE, using an "envelope" type capsulotomy rather than the "can-opener" type facilitates in-the-bag IOL implantation. Staining the anterior capsule with trypan blue improves visualization, and the envelope technique allows smoother expression of the nucleus from the capsular bag. Once the nucleus is removed and the IOL is implanted, the anterior capsular flap should be cut using Vannas scissors.
Learning to SutureÂ
A valuable reminder I received was that you don’t need a patient – or even a microscope – to learn how to suture. Practicing routinely outside of surgery is essential. Every cataract surgeon should feel confident and competent in wound closure.
Pupilloplasty in Selected Cases
In patients with significant preoperative corneal aberrations, a 4-throw pupilloplasty technique can be considered after IOL implantation. It may help reduce postoperative dysphotopsias and improve visual quality.
Final Thoughts
Looking back, my time at Agarwal’s Eye Hospital was the most transformative experience in my surgical training. It challenged me, sharpened my skills, and exposed me to high-volume, high-efficiency ophthalmology at its best.
The hands-on approach, the pace, the support from experienced nurses, and the generosity of the surgeons in sharing their knowledge all created an environment that was intense, immersive, and deeply rewarding. I returned home more confident not just in my technical ability, but in my ability to adapt, make surgical decisions, and grow as an independent ophthalmologist.
For any trainee looking to accelerate their learning and gain real surgical experience, I wholeheartedly recommend this kind of focused, immersive training. It was more than worth the trip, even if it meant postponing the car.
ABOUT THE AUTHOR
Martina Milhovska, M.D., FEBO, is an ophthalmology specialist from Bulgaria with a strong commitment to patient care and continuous professional development. She has trained both locally and internationally, participating in specialized courses and clinical observerships to enhance her expertise.