IntraOP complications in phaco surgery in Hungary

·Clinical Research·

Intraoperative complication rates in cataract surgery

performed by resident trainees and staff surgeons in a
tertiary eyecare center in Hungary
Márton Magyar, Gábor László Sándor, László Ujváry, Zoltán Zsolt Nagy, Gábor Tóth

Department of Ophthalmology, Semmelweis University, ● KEYWORDS: cataract; intraoperative complications;

Budapest 1085, Hungary resident; phacoemulsification; staff surgeon
C o r re s p o n d e n c e t o : G á b o r T ó t h . D e p a r t m e n t o f DOI:10.18240/ijo.2022.04.10
Ophthalmology, Semmelweis University, Mária u. 39.,
Budapest 1085, Hungary. [email protected] Citation: Magyar M, Sándor GL, Ujváry L, Nagy ZZ, Tóth G.
Received: 2021-07-03 Accepted: 2021-11-24 Intraoperative complication rates in cataract surgery performed by
resident trainees and staff surgeons in a tertiary eyecare center in
Abstract Hungary. Int J Ophthalmol 2022;15(4):586-590
● AIM: To compare the incidence of intraoperative
complications during primary phacoemulsification (phaco) INTRODUCTION
surgery between resident surgeons (residents) and staff
surgeons (specialists) and to objectively determine the
difficulty of stages in phaco surgery.
C ataract surgery is one of the most commonly performed
ophthalmic surgeries worldwide. Thus, learning to
perform cataract surgery with phacoemulsification (phaco
● METHODS: This retrospective study included cases of surgery) is an essential part of ophthalmology training
phaco cataract surgery performed between January and programs[1]. Because of the increasing availability of surgical
December 2019. There were no exclusion criteria. For each devices and technical advancement, complication rates are
patient, demographics, clinical history, case complexity, type decreasing. However, intraoperative complication rates may
of surgeon, and operative details were reviewed. Primary differ between staff surgeons (specialists) and resident trainees
outcomes included intraoperative complication rates and (residents)[2-3]. Only a few large-scale studies have compared
the objective measure of difficulty in the steps of the surgery intraoperative complication rates between specialists and
performed by residents and specialists. residents[4-6], and differences between these studies may be
● RESULTS: A total of 3272 cases were included; 7.4% due to different structures in residency trainings. Thus, it is
(n=241) of cases were performed by residents. The overall important to gain insight from different countries with different
complication rate was 5.4% (n=177). The intraoperative education systems to develop more effective training methods.
complication rate was significantly higher (P<0.001) in Although residency programs should provide trainees with
residents (n=33, 13.7%) than in specialists (n=144, 4.8%). the opportunity to improve their surgical skills, patient safety
The most frequent complications were posterior capsule is always the most important aspect of the procedure. This
tear (n=85, 2.6%), anterior capsule tear (n=50, 1.53%), duality poses a great dilemma in residency training programs.
zonular fiber loss (n=45, 1.38%), and dropped nucleus Phaco surgery is a single-surgeon operation, during which
(n=15, 0.46%). Objectively, the most difficult steps during the specialist can supervise, leading the resident through the
surgery were phaco in 66 (60.0%), capsulorhexis in 21 surgery verbally, and in case of intraoperative difficulty or
(19.1%), irrigation/aspiration in 13 (11.8%), hydrodissection complication, possibly take over and finish the surgery to
in 9 (8.2%), and intraocular lens (IOL) implantation in 1 ensure patient safety[5,7-8]. Phaco surgery is a highly complex
(0.9%) case. procedure with well-differentiated unique steps. Several
● CONCLUSION: Intraoperative complication rates studies have attempted to determine the difficult stages of
are higher in residents than in specialists. The order of phaco surgery for residents, albeit subjectively[9-10]. However,
objective difficulty in phaco surgery steps is in line with to our knowledge, no study has objectively analyzed this issue.
the subjective findings of other surveys, revealing that the The primary aim of this study was to determine the incidence
most challenging parts of phaco surgery are phaco and and types of intraoperative complications in phaco surgery
capsulorhexis. in a tertiary eyecare center in Hungary and to compare these
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Tel: 8629-82245172 8629-82210956 Email: [email protected]

complications between residents and specialists. The secondary Table 1 Complexities during cataract surgeries
aim was to objectively assess the order of difficulty of phaco Complexity n (%)
surgery steps for residents. Earlier vitrectomy 156 (4.8)
High axial myopia 114 (3.5)
SUBJECTS AND METHODS
Corneal scar, dystrophy, or keratoconus 107 (3.3)
Ethical Approval The study was conducted at a tertiary
Narrow angles 74 (2.3)
eyecare center in Hungary. The study was approved by the Pseudoexfoliation or zonular fiber compromise 53 (1.6)
Regional and Institutional Committee of Science and Research Small-pupil intraoperative floppy-iris syndrome 50 (1.5)
Ethics of Semmelweis University, Hungary (No.121/2021). Special cataract (posterior polar, traumatic, or 30 (0.9)
hypermature)
The study was performed in accordance with the Declaration
Inadequate cooperation during surgery 28 (0.9)
of Helsinki Guidelines for Human Research. Written informed Earlier glaucoma filtration surgery 19 (0.6)
consent was obtained from the patients. Earlier keratoplasty 17 (0.5)
This retrospective review included 3272 consecutive patients Posterior synechiae 10 (0.3)
who underwent primary phaco surgery performed by residents Anatomical differences in the body habitus 2 (0.06)
and specialists over a period of 1y, from January 1, 2019, to Other complexities 6 (0.2)

December 31, 2019, at the Department of Ophthalmology,

Semmelweis University, Budapest, Hungary. For each subject, residents and specialists.
the clinical data were reviewed, which included patient There were 2675 (81.8%) simple and 597 (18.2%) complex
demographics (sex, age, and eye laterality), clinical history cataract surgeries. The most common complexities (Table 1)
(earlier intraocular surgeries), preoperative and postoperative were patients with earlier vitrectomy (n=156, 4.8%), high
ophthalmological status (case complexity), and operative axial myopia (n=114, 3.5%), corneal scar, corneal dystrophy
details (usage of trypan blue dye staining, iris hooks, and or keratoconus (n=107, 3.3%), narrow angles (n=74, 2.3%),
intraoperative complications). pseudoexfoliation or zonular fiber compromise (n=53, 1.6%),
The factors contributing to the replacement of residents by and small pupil or intraoperative floppy-iris syndrome (n=50,
specialists during phaco surgery were noted to objectively 1.5%).
analyze which surgical steps were the most challenging for Altogether, 2379 (72.7%), 816 (25.0%), and 77 (2.3%)
residents. Thirty-one specialists and 9 residents performed surgeries involved topical, retrobulbar, and general anesthesia,
the phaco surgeries. One resident was in the second, 3 in the respectively. Trypan blue dye staining of the anterior capsule
third, 3 in the fourth, and 2 in the fifth year of the residency. was performed in 120 (3.7%) cases and iris hooks were used
All surgeries included clear corneal incisions, continuous in 92 (2.8%) cases. Specialists (n=573, 96.0%) performed
curvilinear capsulorhexis, and hydrodissection. Phaco significantly more complex cataract surgeries (P<0.001) than
techniques were performed in descending order as follows: residents (n=24, 4.0%).
phaco-crack (n=1338, 40.9%), stop-and-chop (n=780, 23.8%), The overall intraoperative complication rate was 5.4% (n=177;
phaco-chop (n=659, 20.1%), divide-and-conquer (n=436, Table 2).
13.3%), and unclassifiable (n=59, 1.8%). The intraoperative complication rate was significantly higher
Statistical analysis was performed with statistica 8.0 (StatSoft (P<0.001) among residents (n=33, 13.7%) than among specialists
Inc., Tulsa, OK, US). Data are expressed as the mean±standard (n=144, 4.8%). The complication rate in simple cases was
deviation (SD). The Chi-square test was used to analyze the 5.3% (n=127), with intraoperative complication rates being
differences in the proportions of categorical variables. P<0.05 significantly more common (P<0.001) in residents (n=29,
was considered statistically significant. 13.4%) than in specialists (n=98, 4.0%; Table 3).
RESULTS The complication rate in complex cases was 8.4% (n=50) and
The study included 3272 consecutive cases. There were was not significantly different (P=0.13) between residents
1261 (38.5%) men and 2011 (61.5%) women in the study (n=4, 16.7%) and specialists (n=46, 8.0%). The most common
population. The mean patient age was 69.8±11.1y (range, intraoperative complications were posterior capsule tear (PCT;
17mo-98y). Of these patients, 1659 (50.7%) underwent surgery n=85, 2.6%), PCT with vitreous loss (n=54, 1.65%), anterior
on the right eye and 1613 (49.3%) underwent surgery on the capsule tear (ACT; n=50, 1.53%), and zonular fiber loss (n=45,
left eye. There were 3158 (96.5%) corticonuclear, 80 (2.5%) 1.38%) in the whole study population. Anterior vitrectomy was
mature, 22 posterior polar (0.7%), 8 (0.2%) traumatic, and 4 performed in 58 (1.8%) cases and pars plana vitrectomy in 21
hypermature (0.1%) cataract cases. (0.6%) cases.
Of the surgeries, 3031 (92.6%) were completed by specialists Among 241 surgeries performed by residents, 110 were
alone and 241 (7.4%) were performed by residents or by completed with the involvement of a specialist (Figure 1).

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The replacement of residents by specialists during phaco

surgery occurred during phaco in 66 (60.0%), capsulorhexis in
21 (19.1%), irrigation/aspiration in 13 (11.8%), hydrodissection
in 9 (8.2%), and IOL implantation in 1 case (0.9%).
Anterior vitrectomy and pars plana vitrectomy were more
frequently (P<0.001) among resident cases (n=12, 5.0% and
n=6, 2.5%, respectively) than in specialist cases (n=46, 1.5%
and n=15, 0.5%, respectively).
In the whole study population, IOL was implanted in the
capsular bag in 3169 (96.9%) and in the ciliary sulcus in 62
(1.9%) persons. Iris-claw IOL was fixed on the iris in 9 cases
(0.3%), and 32 patients (0.9%) were left aphakic after the
Figure 1 Resident-specialist distribution of cataract surgeries in
primary surgery. Significantly more patients (P<0.01) were left
the whole study population.
aphakic after the primary surgery performed by residents (n=7,
2.9%) when compared to primary surgery by specialists (n=25, Table 2 Intraoperative complications during cataract surgery in
0.8%). the whole sample, in resident trainees, and in staff surgeons n (%)
DISCUSSION Total Resident Staff surgeon
Complication
Cataract is a leading cause of visual impairment and phaco (n=3272) trainee (n=241) (n=3031)
Posterior capsule tear 85 (2.60) 15 (6.22) 70 (2.31)
surgery is the most frequently performed intraocular surgery
Without vitreous loss 31 (0.95) 5 (2.07) 26 (0.86)
worldwide[11-12]. Almost 4.2 million phaco procedures were With vitreous loss 54 (1.65) 10 (4.15) 44 (1.45)
performed in Europe in 2015[13]. With dropped nucleus 15 (0.46) 5 (2.07) 10 (0.33)
Cataract is usually an unavoidable side effect of aging[14]. Anterior capsule tear 50 (1.53) 14 (5.81) 36 (1.19)
Zonular fiber loss 45 (1.38) 8 (3.32) 37 (1.22)
Nearly one-third of people aged 65 years and over have
Intraocular lens dislocation 3 (0.09) 1 (0.41) 2 (0.07)
visually significant cataract in Europe[15]. Phaco surgery is Hyphema 2 (0.06) 0 2 (0.07)
a relatively safe routine procedure with a low complication Broken intraocular lens haptic 1 (0.03) 0 1 (0.03)
rate[13]. However, complications do occur and can cause severe Expulsive bleeding 1 (0.03) 0 1 (0.03)

visual impairment[16-17].
Table 3 Intraoperative complications during cataract surgery in
We analyzed the intraoperative complication rates for phaco
all simple cases and in simple cases for resident trainees and staff
surgery performed by specialists and residents and objectively
surgeons n (%)
determined the difficulty of each stage of the surgery at a tertiary
Simple cases Resident Staff surgeon
Complication
eyecare center in Hungary. To the best of our knowledge, this is (n=2675) trainee (n=217) (n=2458)
the first study to objectively report the order of difficulty in Posterior capsule tear 66 (2.47) 15 (6.91) 51 (2.07)
Without vitreous loss 26 (0.97) 5 (2.30) 21 (0.85)
phaco surgery steps for residents. This is also the first study to
With vitreous loss 40 (1.50) 10 (4.61) 30 (1.22)
report on intraoperative complication rates for primary phaco
With dropped nucleus 13 (0.49) 5 (2.30) 8 (0.33)
surgery, comparing specialists and residents in Hungary. Anterior capsule tear 37 (1.38) 12 (5.53) 25 (1.02)
The overall intraoperative complication rate was 5.4% and was Zonular fiber loss 26 (0.97) 6 (2.76) 20 (0.81)
higher than that reported by other studies in Sweden (0.9%), Intraocular lens dislocation 1 (0.04) 0 1 (0.04)
Canada (1.8%), Portugal (4.1%), and Australia (4.9%)[4-6,18].
Intraoperative complication rates for residents in this study and that of Oliveira-Ferreira et al[6] found significantly higher
was much higher (13.7%) compared to that reported by Low complication rates among residents during phaco surgery.
et al[5] in Canada (2.7%), Briszi et al[19] in Germany (3.8%), Differences may be explained by the different numbers of
Fong et al[4] in Australia (6.1%), Oliveira-Ferreira et al[6] phaco surgeries performed by residents during the residency
in Portugal (6.3%), and Ellis et al[20] in the USA (7.8%). program in different countries, because increased resident
Further, complication rates during phaco surgeries performed experience seems to decrease the incidence of intraoperative
by specialists alone in Hungary (4.8%) were slightly higher complications.
compared to that reported in Australia (2.7%)[4] and Portugal Phaco surgery is a cornerstone of the residency training
(3.3%)[6]. Comparisons of intraoperative complication rates worldwide[21]. While only 7.3% of all phaco surgeries involved
between residents and specialists showed different results in residents in Hungary, studies from other industrialized
different countries. While Low et al[5] and Fong et al[4] did not countries reported much higher resident involvement rates
find a significant difference between the two groups, our study (21%-64%)[1,4-5,22]. Our institution is the biggest and leading
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Tel: 8629-82245172 8629-82210956 Email: [email protected]

ophthalmic center in Hungary, and about 4 new residents residents found phaco, capsulorhexis, and irrigation/aspiration
begin their residency training every year in the clinic. The to be the most challenging parts of the surgery[9-10]. Based
ophthalmology residency lasts for 5y and phaco surgery on the subjective and objective assessment of phaco surgery
training begins in the second year. During the entire residency difficulties and the incidence of different complication rates
training, every resident performs 50 to 150 phaco surgeries among residents, phaco and capsulorhexis may be considered
at our institution, and this number may be associated with the the most challenging steps in phaco surgery for residents.
lesser surgical experience compared to that in Canada, United In our curriculum, the number of phaco surgeries performed
Kingdom and Portugal where every resident performs 320 to by residents during the 5y of residency is lower compared to
400 phaco surgeries on average during the same period[5-6,23]. published data from other developed countries. This is because
To ensure patient safety, specialists are allowed to swap the our department places emphasis on theoretical knowledge
operating position with the resident during the surgery, in prior to surgical skill in the first part of the training, after which
case of intraoperative complication or before predictable the resident begins to perform a higher number of surgeries.
complication(s). This difference in the curriculum explains the disparity in the
In the present study, the order and incidence of the most number of surgeries performed by specialists and residents.
notable intraoperative complications were similar to findings The limitations of our study include its retrospective design, its
from other studies as follows: PCT (2.6%), ACT (1.53%), involvement of only a single center, and the non-randomization
zonular fiber loss (1.38%), and dropped nucleus (0.4%)[4-6]. The of patients.
incidence of PCT (2.3%) and that of dropped nucleus among In conclusion, intraoperative complication rates were higher in
specialists (0.3%) were also similar to data from Canada and residents than in specialists. Resident involvement into phaco
Portugal[5-6]. The incidence of ACT (5.81%) and PCT (6.22%) surgery should be increased in our department in Hungary, in
in residents was higher in our sample compared to that reported order to improve surgical confidence and acquire safe phaco
by Oliveira-Ferreira et al[6] from Portugal (ACT: 1.0%; PCT: techniques until the end of the residency. Objective assessment
3.4%), Corey and Olson[24] and Bhagat et al[25] from the USA of difficulty stages in phaco surgery was in line with the
(PCT: 2.0% and 6.7%), and Low et al[5] from Canada (PCT: subjective measurement of difficulty levels reported by other
0.8%). Dropped nucleus occurred also more frequently among surveys, with the most challenging parts of phaco surgery
residents in Hungary (2.0%) than in Germany (1.2%)[19], Portugal being phaco and capsulorhexis.
(0.6%)[6], and in the USA (0.6%)[26]. PCT and vitrectomy due to ACKNOWLEDGEMENTS
dropped nucleus are considered as a benchmark intraoperative Authors’ contributions: Magyar M conducted the survey,
complication[27-28], because they are associated with a higher analyzed the data, and wrote the article. Sándor GL and
incidence of postoperative endophthalmitis (8×) and retinal Ujváry L conducted the survey and analyzed the data. Nagy
detachment (42×)[29]. ZZ planned the survey and reviewed the manuscript. Tóth G
The intraoperative complication rate also depends on case designed the survey, and edited and reviewed the manuscript.
complexity[18]. Al-Jindan et al[30] reported that the complication Conflicts of Interest: Magyar M, None; Sándor GL, None;
rate may be twofold in complex cases, compared to that in simplex Ujváry L, None; Nagy ZZ, None; Tóth G, None.
cases. To reduce the effect of complex cases on complication REFERENCES
rates, we also analyzed the intraoperative complication rates in 1 Pingree MF, Crandall AS, Olson RJ. Cataract surgery complications
simple cases. The incidence rates showed similar values across in 1 year at an academic institution. J Cataract Refract Surg
the entire sample and compared to other studies with one 1999;25(5):705-708.
exception, where the incidence of PCT among residents also 2 Randleman JB, Srivastava SK, Aaron MM. Phacoemulsification with
showed a higher value (6.9%) as in the whole sample. topical anesthesia performed by resident surgeons. J Cataract Refract
The most difficult steps of the phaco surgery, where the Surg 2004;30(1):149-154.
specialist took over the operation from the resident, were phaco 3 Ünal M, Yücel I, Sarıcı A, Artunay Ö, Devranoglu K, Akar Y, Altın M.
(60.0%), capsulorhexis (19.1%), irrigation/aspiration (11.8%), Phacoemulsification with topical anesthesia: Resident experience. J
and hydrodissection (8.2%). The difficulty of each stage of Cataract Refract Surg 2006;32(8):1361-1365.
phaco surgery is of great interest. Knowing which part of the 4 Fong CSU, Mitchell P, de Loryn T, Rochtchina E, Hong T, Cugati S,
surgery poses the greatest complexity for residents would be Wang JJ. Long-term outcomes of phacoemulsification cataract surgery
useful to design training methods alongside to enhance the performed by trainees and consultants in an Australian cohort. Clin Exp
practice of those critical steps. Several authors subjectively Ophthalmol 2012;40(6):597-603.
evaluated the difficulty of each stage of phaco surgery among 5 Low SAW, Braga-Mele R, Yan DB, El-Defrawy S. Intraoperative
residents. Based on their results and similar to our results, complication rates in cataract surgery performed by ophthalmology

589
IntraOP complications in phaco surgery in Hungary

resident trainees compared to staff surgeons in a Canadian academic 22:bjophtha2020-318645.

center. J Cataract Refract Surg 2018;44(11):1344-1349. 19 Briszi A, Prahs P, Hillenkamp J, Helbig H, Herrmann W. Complication
6 Oliveira-Ferreira C, Leuzinger-Dias M, Tavares Ferreira J, Macedo JP, rate and risk factors for intraoperative complications in resident-
Falcão-Reis F. Cataract phacoemulsification performed by resident performed phacoemulsification surgery. Graefes Arch Clin Exp
trainees and staff surgeons: intraoperative complications and early Ophthalmol 2012;250(9):1315-1320.
postoperative intraocular pressure elevation. J Cataract Refract Surg 20 Ellis EM, Lee JE, Saunders L, Haw WW, Granet DB, Heichel CW.
2020;46(4):555-561. Complication rates of resident-performed cataract surgery: impact of
7 Gan KD, Rudnisky CJ, Weis E. Discussing resident participation in early introduction of cataract surgery training. J Cataract Refract Surg
cataract surgery. Can J Ophthalmol 2009;44(6):651-654. 2018;44(9):1109-1115.
8 Nguyen TN, Silver D, Arthurs B. Consent to cataract surgery performed 21 Rutar T, Porco TC, Naseri A. Risk factors for intraoperative
by residents. Can J Ophthalmol 2005;40(1):34-37. complications in resident-performed phacoemulsification surgery.
9 Sen S, Patil M, Saxena R, Kumar A, Amar SP, Das D, Brar AS, Ophthalmology 2009;116(3):431-436.
Saini P. Perceived difficulties and complications in learners of 22 Muhtaseb M, Kalhoro A, Ionides A. A system for preoperative
phacoemulsification: a principal component analysis model. Indian J stratification of cataract patients according to risk of intraoperative
Ophthalmol 2019;67(2):213-216. complications: a prospective analysis of 1441 cases. Br J Ophthalmol
10 Dooley IJ, O'Brien PD. Subjective difficulty of each stage of 2004;88(10):1242-1246.
phacoemulsification cataract surgery performed by basic surgical 23 Dean WH, Grant S, McHugh J, Bowes O, Spencer F. Ophthalmology
trainees. J Cataract Refract Surg 2006;32(4):604-608. specialist trainee survey in the United Kingdom. Eye (Lond)
11 Sándor GL, Tóth G, Szabó D, Szalai I, Lukács R, Pék A, Tóth GZ, 2019;33(6):917-924.
Papp A, Nagy ZZ, Limburg H, Németh J. Cataract blindness in 24 Corey RP, Olson RJ. Surgical outcomes of cataract extractions
Hungary. Int J Ophthalmol 2020;13(3):438-444. performed by residents using phacoemulsification. J Cataract Refract
12 Pék A, Szabó D, Sándor GL, Tóth G, Papp A, Nagy ZZ, Limburg Surg 1998;24(1):66-72.
H, Németh J. Relationship between diabetes mellitus and cataract in 25 Bhagat N, Nissirios N, Potdevin L, Chung J, Lama P, Zarbin MA,
Hungary. Int J Ophthalmol 2020;13(5):788-793. Fechtner R, Guo S, Chu D, Langer P. Complications in resident-
13 Zetterberg M, Kugelberg M, Nilsson I, Lundström M, Behndig A, performed phacoemulsification cataract surgery at New Jersey Medical
Montan P. A composite risk score for capsule complications based on School. Br J Ophthalmol 2007;91(10):1315-1317.
data from the Swedish national cataract register: relation to surgery 26 Clarke C, Ali SF, Murri M, Patel SN, Wang L, Tuft M, Weikert MP,
volumes. Ophthalmology 2021;128(3):364-371. Al-Mohtaseb Z. Outcomes and complication rates of primary resident-
14 Hashemi H, Pakzad R, Yekta A, Aghamirsalim M, Pakbin M, Ramin performed cataract surgeries at a large tertiary-care County hospital. J
S, Khabazkhoob M. Global and regional prevalence of age-related Cataract Refract Surg 2017;43(12):1563-1570.
cataract: a comprehensive systematic review and meta-analysis. Eye 27 Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM,
(Lond) 2020;34(8):1357-1370. Asaria RH, Galloway P, Sparrow JM. The Cataract National Dataset
15 Swampillai AJ, Nowak VA, Maubon L, Neffendorf JE, Sahota D, electronic multicentre audit of 55, 567 operations: risk stratification for
Williams O, Lakhani B, Soare C, Sychev I, Ridyard E, Patel PJ, Park posterior capsule rupture and vitreous loss. Eye (Lond) 2009;23(1):31-37.
JC; Ophthalmology Trainee Clinical Research Network. Confidence 28 Lundström M, Dickman M, Henry Y, Manning S, Rosen P, Tassignon
of UK Ophthalmology Registrars in Managing Posterior Capsular MJ, Young D, Stenevi U. Risk factors for dropped nucleus in cataract
Rupture: Results from a National Trainee Survey. Ophthalmol Ther surgery as reflected by the European Registry of Quality Outcomes
2022;11(1):225-237. for Cataract and Refractive Surgery. J Cataract Refract Surg
16 Szabó D, Sándor GL, Tóth G, Pék A, Lukács R, Szalai I, Tóth GZ, 2020;46(2):287-292.
Papp A, Nagy ZZ, Limburg H, Németh J. Visual impairment and 29 Ferris JD, Donachie PH, Johnston RL, Barnes B, Olaitan M, Sparrow
blindness in Hungary. Acta Ophthalmol 2018;96(2):168-173. JM. Royal College of Ophthalmologists’ National Ophthalmology
17 Jakobsson G, Montan P, Zetterberg M, Stenevi U, Behndig A, Database study of cataract surgery: report 6. The impact of EyeSi
Lundström M. Capsule complication during cataract surgery: Retinal virtual reality training on complications rates of cataract surgery
detachment after cataract surgery with capsule complication: Swedish performed by first and second year trainees. Br J Ophthalmol
Capsule Rupture Study Group report 4. J Cataract Refract Surg 2020;104(3):324-329.
2009;35(10):1699-1705. 30 Al-Jindan M, Almarshood A, Yassin SA, Alarfaj K, Al Mahmood A,
18 Hård Af Segerstad P. Risk model for intraoperative complication Sulaimani NM. Assessment of learning curve in phacoemulsification
during cataract surgery based on data from 900 000 eyes: previous surgery among the eastern Province ophthalmology program residents.
intravitreal injection is a risk factor. Br J Ophthalmol 2021:2021 Clin Ophthalmol 2020;14:113-118.

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