1563

ARTICLE

Outcomes and complication rates of

primary resident-performed cataract
surgeries at a large tertiary-care county hospital
Cameron Clarke, BS, Shazia F. Ali, MD, Michael Murri, BS, Saagar N. Patel, BA, BS, Li Wang, PhD, Marie Tuft, BS,
Mitchell P. Weikert, MD, Zaina Al-Mohtaseb, MD

Purpose: To identify the preoperative risk factors, intraoperative
events, and postoperative complications increasing the risk for
poor visual outcomes in resident-performed cataract surgeries at
a tertiary-care county hospital.
Setting: Ben Taub General Hospital, Houston, Texas, USA.
Design: Retrospective case series.
Methods: Resident-performed cataract surgeries were analyzed
for risk factors, comorbidities, and intraoperative and postoperative
complications. The main outcome measures were preoperative
and postoperative uncorrected distance visual acuity and cor-
rected distance visual acuity (CDVA), which were correlated with
preoperative demographics, intraoperative and postoperative
events, and resident training level. The data were subdivided into
cases without events and cases with events to determine which
complications led to poor visual outcomes.
Results: The study analyzed 1290 resident-performed cataract
surgeries. The mean visual acuity improved significantly after
surgery in all patients (P < .001), with 80.5% of patients without
complications and 70.7% with complications attaining a CDVA of
20/40 or better (P < .002). Poor visual outcomes were associated
with a-antagonist use (P Z .043) and pseudoexfoliation syndrome
(P Z .001). The most common intraoperative complications were
vitreous loss (6.7%) and posterior capsule tear (7.0%). The mean
postoperative visual acuity did not vary by trainee year, and the
rate of dropped nucleus during surgery declined as residents
progressed in training (P < .05). All other complication rates were
similar between levels of training.
Conclusion: Despite more complicated cataracts and advanced
comorbidities, primary resident-performed cataract surgery in a
tertiary-care county hospital system achieved visual outcomes and
complication rates similar to those found in other training hospitals.
J Cataract Refract Surg 2017; 43:1563–1570 Q 2017 ASCRS and ESCRS

T
he United States Accreditation Council of Graduate
Medical Education (ACGME) in 2016 recommend-
ed shifting resident education from a simple mini-
mum requirements program to an outcomes-based
approach to fulfill the escalating demand for efficient cata-
ract removal as the U.S. population ages.1 Although the
current literature contains numerous studies examining
the complications and outcomes of resident-performed
cataract surgery, applying the conclusions from other
studies to improve residency program outcomes can be
challenging because of the wide range of reported out-
comes, highly variable patient populations studied, and
the unique resident surgical curriculum in each program.2
For example, published rates for common intraoperative
events such as posterior capsule tear and vitreous loss
range widely from 0.6% to 18% and 1.8% to 19.7%, respec-
tively.3 Although novice surgeons have been associated
with higher levels of specific complications such as vitre-
ous loss, postoperative corrected distance visual acuity
(CDVA) has not been shown to differ based on year of
training.4 Identifying preoperative, intraoperative, and
postoperative events and stratifying them based on the
level of resident training might highlight areas for curric-
ulum revision to decrease complications and enhance
postoperative surgical outcomes.4,5
The majority of published literature on primary resident-
performed cataract surgeries has focused on Veteran Affairs
(VA) or university hospitals.2,3,6–19 A limited subset of the
literature examines data from county hospitals, which
have a diverse patient population with high rates of medical

Submitted: July 1, 2017 | Final revision submitted: August 21, 2017 | Accepted: September 4, 2017
From the School of Medicine (Clarke, Murri, Patel), Baylor College of Medicine, and the Cullen Eye Institute (Ali, Wang, Weikert, Al-Mohtaseb), Department of
Ophthalmology, Baylor College of Medicine, Houston, Texas, and the Department of Biostatistics (Tuft), Graduate School of Public Health, University of Pittsburgh,
Pittsburgh, Pennsylvania, USA.
Presented in part at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, California, USA, May 2017.
Corresponding author: Zaina Al-Mohtaseb, MD, 6565 Fannin, NC205, Houston, Texas 77030, USA. E-mail: zaina@bcm.edu.

Q 2017 ASCRS and ESCRS 0886-3350/$ - see frontmatter

Published by Elsevier Inc. https://doi.org/10.1016/j.jcrs.2017.09.025
1564 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY
comorbidities.3 Although previous publications have found
that visual outcomes are similar between county and VA
hospital patients after cataract surgery, these studies were
limited in size and most are over 20 years old.20–23 These
studies do not reflect current resident-performed cataract
surgery at county hospitals because they include a higher
rate of extracapsular cataract extraction (ECCE) as well as
older phacoemulsification technology and therefore are
not directly applicable.20–23
This study focused on primary resident-performed cata-
ract surgery outcomes at Ben Taub General Hospital
(BTGH), a large tertiary-care county hospital in Houston,
Texas. The hospital treats a patient base with a high rate
of complex medical problems and ocular comorbidities.
The hospital receives the majority of its funding to care
for indigent populations through county taxes, federal
Medicaid support, and private donations. As a result of
their limited healthcare access, these patients often have
advanced or end-stage comorbid diseases and present
more complex surgical cases to ophthalmology residents.
To our knowledge, this is one of the largest and most
comprehensive studies of resident-performed cataract sur-
gery in a county hospital setting. We hypothesize that this
complex and diverse patient population has more compli-
cations and poorer visual outcomes than populations found
in other training institutions. The main goal of this study
was to identify risk factors leading to poor visual outcomes
in these patients that can be used to improve future
outcomes-based residency training.
PATIENTS AND METHODS
A retrospective chart review of all primary resident-performed
cataract surgeries at BTGH from January 2012 to June 2015 was
performed with the approval of the institutional review board. Pri-
mary resident-performed surgeries were defined as those in which
the resident completed a majority of or an entire case in which key
portions were supervised by a faculty member. The surgeons were
first-, second-, and third-year ophthalmology residents (postgrad-
uate year [PGY]-2 through PGY-4); the data were further subdi-
vided based on the surgeon’s year of training.
The inclusion criteria included all cataract surgeries, both
phacoemulsification and ECCE. Cases performed by fellow-level
trainees, cases with inadequate preoperative or postoperative med-
ical documentation, patients lost to follow-up within the first post-
operative month, or cataract cases that were combined with a
glaucoma, corneal, or retinal procedure were excluded. All pa-
tients were seen in the clinic at least 1 month after the procedure
for follow-up and manifest refraction. All postoperative patient
charts were reviewed to evaluate for complications, such as poste-
rior capsule opacification (PCO), corneal edema, and macular
edema.
The hospital’s resident surgical training starts during the first
semester during which first-year residents accompany third-year
residents in the operating room to complete one step of the surgery
at a time under close faculty supervision. After completing all the
major steps of surgery, the first-year residents are assigned a few
primary cases without significant ocular or medical comorbidity
toward the end of their first year. Second-year residents are as-
signed more cases, which are typically uncomplicated cataracts
without significant ocular or medical comorbidity. The majority
of cataract training occurs during the third year, during which
the complexity of the cataracts and ocular comorbidities increases,
especially in the final semester of training. The patients in this
Volume 43 Issue 12 December 2017
study were aware they were being operated on by trainees with
attending staff physicians; however, they were not aware of the
year of training unless they specifically requested that information.
In general, the surgical technique was standard but might have
differed slightly based on surgeon preference because multiple fac-
ulty members supervised trainees. A clear corneal incision and
paracentesis were created, followed by a continuous curvilinear
capsulorhexis. Phacoemulsification was performed with the
Infiniti Vision System (Alcon Laboratories, Inc.) using the
divide-and-conquer or stop-and-chop technique. A foldable intra-
ocular lens (IOL) was then placed, and the wounds were closed
with stromal hydration or a nylon suture, if necessary.
Data collected included patient demographic information,
medical history, current medications, cataract type and density,
intraoperative and postoperative events, and preoperative and
postoperative visual acuities. Cataract density was determined
based on visual acuity, with a CDVA better than 20/50 classified
as mild, between 20/50 to 20/400 as moderate, and worse than
20/400 as dense.6 The primary outcomes measured were preoper-
ative risk factors and comorbidities, intraoperative complications,
and postoperative adverse events.
Statistical Analysis
Data were analyzed using Stata software (version 14.2, 2015, Sta-
tacorp LLC). Relationships between categorical variables were
analyzed using a Pearson chi-square or Fisher exact test, as appro-
priate. Continuous outcomes were compared between indepen-
dent groups using a Wilcoxon rank-sum test and between
paired groups using a Wilcoxon signed-rank test. Adjusted odds
ratios (ORs) were calculated using logistic regression. Multiple
comparisons were adjusted for using the Tukey method as appro-
priate. All tests were 2 sided, and a P value less than 0.05 was
considered statistically significant.
RESULTS
Of the 1514 patients with a cataract procedure during the
3-year study period, 224 patients were excluded and 1290
patients met the inclusion criteria. Of the patients, 1208
had phacoemulsification and 82 had ECCE. Approximately
53 of the 1290 patients were subsequently lost to follow-up
after the procedure, resulting in 1237 cases analyzed for
postoperative events.
Preoperative Characteristics
Table 1 shows the demographics and preoperative comor-
bidities of the patient population. The majority of patients
were Hispanic or African American. Almost 40% were clas-
sified as overweight or obese. The majority of patients had
diabetes, hypertension, or both.
Cataract Characteristics
Table 2 shows the types of cataracts and the intraoperative
devices used in their removal. Nuclear sclerotic cataracts
were the most prevalent type, with nearly two thirds graded
as moderate and a quarter as dense. At presentation, more
than a quarter of cataracts were classified as white and more
than 8% as brunescent, reflecting the complexity of these
cases. More than half the surgical cases required use of try-
pan blue staining and 5% had poor pupil dilation requiring
a pupillary expansion device. Approximately 92.4% (110 of
119) of complicated cases requiring intraoperative devices
were performed by PGY-4 residents, whereas PGY-2 resi-
dents did not use any devices intraoperatively.
 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY 1565

Table 1. Preoperative patient demographics in a large Table 2. Cataract types and intraoperative devices used.
county hospital cohort. Parameter Cases, n (%)
Parameter Cases, n (%)
Cataract type
Ethnicity/race Nuclear sclerotic 1042 (80.8)
Hispanic 754 (58.4) Mild 139 (13.3)
African American 269 (20.8) Moderate 660 (63.3)
Asian/Pacific Islander 138 (10.7) Dense 243 (23.3)
White 105 (8.1) Posterior subcapsular 633 (49.1)
Middle Eastern 21 (1.6) Mild 52 (8.2)
Other 3 (0.2) Moderate 395 (62.4)
Medical comorbidity Dense 186 (29.3)
Hypertension 756 (58.6) Cortical 294 (22.7)
Diabetes 711 (55.1) White 214 (16.6)
Obesity (BMI O30) 498 (38.6) Brunescent 109 (8.4)
Overweight (BMI 25–30) 491 (38.1) Intraoperative device
Anticoagulant use* 290 (22.5) Trypan blue 681 (52.8)
a-antagonist use† 65 (5.0) Iris hooks 36 (2.8)
Ocular comorbidity Malyugin ring 28 (2.2)
Glaucoma 193 (14.9) Capsular tension ring 27 (2.1)
History of retinal surgery 94 (7.3)
Diabetic macular edema/CME 58 (4.5)
History of glaucoma surgery 53 (4.1)
History of trauma 52 (4.0) Intraoperative and Postoperative Events
History of retinal detachment 18 (1.4) Of the 1290 eyes analyzed, 181 (14.0%) had an intraoper-
Uveitis 16 (1.2) ative or postoperative event (Table 3). Posterior capsule
History of corneal surgery 14 (1.1) tear was the most prevalent surgical complication fol-
Pseudoexfoliation syndrome 11 (0.9) lowed by vitreous loss and anterior capsule tear. The
History of refractive surgery 11 (0.9) most common postoperative complication was rebound
BMI Z body mass index; CME Z cystoid macular edema inflammation, defined as persistent anterior chamber
*Includes aspirin, clopidogrel, prasugrel, warfarin, heparin, enoxaparin, inflammation 1 month postoperatively after a standard
lepirudin, xaban, abciximab, argotroban, dabigatran, cilostazol
†
Includes tamsulosin, phenoxybenzamine, phentolamine, et al
steroid and nonsteroidal antiinflammatory drop taper.
At the 1-month postoperative visit, a small percentage
of patients developed PCO, cystoid macular edema
(CME), or corneal edema. There was a single case of en-
dophthalmitis (!0.1%) and few other serious complica-
tions. During the procedure, 415 patients (32.2%)
Table 3. Prevalence of intraoperative events and postop-
erative complications in a large county hospital cohort. received a retrobulbar block, 590 (45.7%) had topical
anesthesia only, and 267 (20.7%) received both. Eighteen
Complication Cases, n (%)
cases (1.4%) required general anesthesia based on patient
Intraoperative (n Z 1290)
comorbidities or for patient comfort.
Choroidal effusion 1 (!0.1)
Dropped nucleus 8 (0.6)
Iris prolapse 16 (1.2)
Corneal wound burn 24 (1.9) Training Level
Zonular dehiscence 37 (2.9) The majority of cases (670 [51.9%]) were performed by
Anterior capsule tear 51 (4.0) residents in their final semester of training (PGY-4 second
Vitreous loss 87 (6.7) semester) (Table 4). The mean surgical time decreased for
Posterior capsule tear 90 (7.0) each additional year of residency training (P ! .001).
Postoperative (n Z 1237) Residents in their first year of ophthalmology training
Endophthalmitis 1 (!0.1)
(PGY-2) performed 3.4% (44 of 1290) of the procedures
Hypotony 5 (0.4)
and were more likely to have a dropped nucleus than their
Hyphema 6 (0.5)
Wound leak 8 (0.6)
more experienced colleagues (P Z .006). The postopera-
Retinal detachment 9 (0.9) tive CDVA was only significantly different between
Vitreous hemorrhage 12 (1.0) PGY-4 residents in their final semester and PGY-3 resi-
Retained lens fragment 24 (1.9) dents (P Z .025), with worse visual outcomes in PGY-4
Intraocular pressure elevation 34 (2.7) group as a result of case complexity and the advanced
Corneal edema 41 (3.3) comorbidities of patients assigned to senior residents.
Cystoid macular edema 58 (4.7) Postoperatively, there were no statistically significant
Posterior capsule opacification 63 (5.1) differences in complication rates based on level of surgeon
Rebound inflammation 112 (9.1) experience.

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1566 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY

Table 4. Prevalence of intraoperative and postoperative events by year of residency training.

Event PGY-2, n (%) PGY-3, n (%) PGY-4a*, n (%) PGY 4b*, n (%)
†
Surgical time (min) 85 67 55 51
Mean CDVA (logMAR) G SD 0.10 G 0.12 0.14 G 0.25 0.19 G 0.36 0.24 G 0.55
Complication, n (%)
Dropped nucleusz 3 (7.1) d 1 (0.2) 4 (0.6)
Vitreous loss 6 (14.3) 10 (6.4) 26 (6.4) 45 (6.7)
Zonular dehiscence d 8 (5.1) 14 (3.4) 15 (2.2)
Anterior capsule tear 3 (7.1) 12 (7.6) 17 (4.1) 19 (2.8)
Posterior capsule tear 6 (14.3) 11 (7.0) 31 (7.6) 42 (6.2)
Anterior vitrectomy 6 (14.3) 9 (5.7) 20 (4.9) 35 (5.2)
Choroidal effusion d d d 1 (0.1)
Iris prolapse d 2 (1.3) 7 (1.7) 7 (1.0)
Wound burn 1 (2.4) 3 (1.9) 4 (1.0) 16 (2.4)
Iris hooks d 4 (2.5) 16 (3.9) 16 (2.4)
Malyugin ring d 1 (0.6) 14 (3.4) 13 (1.9)
Capsular tension ring d 4 (2.5) 7 (1.7) 16 (2.4)
Vein occlusion 1 (2.4) d d d
IOP elevation d 3 (1.9) 13 (3.2) 15 (2.6)
Hypotony d d 3 (0.7) 2 (0.3)
Wound leak d d 3 (0.7) 5 (0.7)
Endophthalmitis d 1 (0.6) d d
Rebound inflammation 2 (4.8) 12 (7.6) 31 (7.6) 67 (9.9)
Corneal edema 2 (4.8) 8 (5.1) 8 (2.0) 23 (3.4)
Retained lens fragment 3 (7.1) 3 (1.9) 7 (1.7) 11 (1.6)
Cystoid macular edema 1 (2.4) 8 (5.1) 15 (3.7) 34 (5.0)
Hyphema d d 2 (0.5) 4 (0.6)
Retinal detachment d d 3 (0.7) 6 (0.9)
Vitreous hemorrhage d d 5 (1.2) 7 (1.0)
Dislocated IOL d d 2 (0.5) 5 (0.7)

IOL Z intraocular lens; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution; PGY Z postgraduate year
*PGY-4 split into (a) first semester and (b) second semester
†
P ! .05 between all groups
z
P ! .05 between PGY-2 and all other groups

Postoperative Refractive Outcomes more likely to have a postoperative CDVA worse

Table 5 shows the logarithm of the minimum angle of reso-
lution (logMAR) and Snellen equivalent visual acuities at the
1-month postoperative visit. Comparing all cases, the mean
CDVA improved significantly in Group A (no complica-
tions) and in Group B (with complications) (P Z .001).
Eight hundred ninety-one (80.5%) of 1107 patients in Group
A and 128 (70.7%) of 181 patients in Group B achieved a
postoperative CDVA of 20/40 or better (P ! .001). Patients
with preexisting ocular comorbidities were significantly
than 20/200 than patients without comorbidities (P ! .05).
Few preoperative ocular comorbidities, such as a-antag-
onist use and pseudoexfoliation syndrome (PXF), were
associated with poor visual outcomes (Table 6). No other
ocular comorbidities were associated with an increased
risk for a visual outcome worse than 20/40. There was no
significantly increased risk for poor postoperative CDVA
(worse than 20/40) for any individual intraoperative or
postoperative event (P Z .99). As a group, those who had

Table 5. Refractive outcomes comparing preoperative and postoperative logMAR visual acuity further subdivided between
Group A (no complications) and Group B (with an intraoperative or postoperative complication).
Parameter Preop (All) Postop (All) P Value* Pre-Group A Pre-Group B Post-Group A Post-Group B
UDVA !.003
LogMAR 1.76 0.38 1.68 2.00 0.34 0.55
Snellen† 20/1150 20/48 20/957 20/2000 20/44 20/71
CDVA !.0001
LogMAR 1.26 0.20 1.19 1.42 0.18 0.36
Snellen† 20/364 20/32 20/310 20/526 20/30 20/46
Mean SE (D) 2.20 0.57 .0086 2.26 2.00 0.38 0.78

CDVA Z corrected distance visual acuity; LogMAR Z logarithm of the minimum angle of resolution; SE Z spherical equivalent; UDVA Z uncorrected distance
visual acuity
*Preop versus postop
†
Equivalent

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 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY
complications had worse outcomes overall; 11 (6.1%) of 181
patients in Group B patients and 11 (1.0%) of 1107 Group A
patients had CDVA worse than 20/200; the difference
between groups was statistically significant (P ! .0001).
Table 7 shows the preoperative and postoperative CDVA
values for each measured event; the majority of patients in
Group B had a statistically significant increase in their
visual acuity, even after experiencing a complication.
Less than 1.0% (11 of 1237) of all patients experienced
postoperative complications that prevented improvement
from preoperative vision; 1 patient developed endophthal-
mitis, 1 patient had a choroidal effusion, and 9 patients had
RDs.
DISCUSSION
As the tertiary referral center for the Harris Health
System, the BTGH serves a diverse population with
complicated cataracts as well as higher rates and more se-
vere presentations of common medical comorbidities. The
majority of our patients present with advanced disease
such as diabetes mellitus (DM) type II (55.1%), over-
weight/obesity (76.7%), and hypertension (58.6%), which
is higher than in other comparable published studies
(DM type II prevalence 47.0%).24–26 Furthermore, the ma-
jority of our patients are Hispanic, an ethnicity that is
associated with a greater risk for developing cataracts,
even after adjusting for the higher incidence of diabetes
in this subgroup.25 In addition, many patients face a
multiplex of social issues impeding proper care of these
problems. Because of prohibitive costs (real or expected),
employment issues, language barriers, and poor medical
literacy,22 many patients do not present to the clinic until
their disease has progressed. Our study aimed to deter-
mine the outcomes of resident-performed cataract surgery
in a tertiary-care county hospital setting.
In our study, approximately 80.0% of patients without in-
traoperative or postoperative events and 70.7% of patients
with an event attained a CDVA of 20/40 or better. Overall,
74.0% of patients achieved this visual outcome, which is
comparable to the rates of 74.0% to 97.8% found in the gen-
eral literature (Table 8).3,5–20,26 Although the overall rate of
a CDVA of 20/40 is on the lower end compared with out-
comes found in the literature, the majority of our patients
experienced significant visual improvement over their pre-
operative CDVA.
Optimal postoperative visual acuity outcomes might be
limited by a patient base with more advanced comorbid dis-
eases, such as high-risk diabetic retinopathy (DR) and end-
stage glaucoma. Diabetes mellitus not only increases the
probability of developing a cataract but also may increase
the risk for poor visual outcomes after surgery.27 Approxi-
mately 250 000 cataract surgeries per year are performed
in patients with DM; therefore, improving the postoperative
visual outcome in these patients would be highly advanta-
geous.27 An extensive study of VA hospitals28 estimated
the prevalence of diabetes in their population at less than
20.0%; in comparison, more than one half of our population
(55.1%) had diabetes. The presence of this comorbidity leads
1567
to more complicated cataract surgeries and can result in
postoperative diabetic macular edema or worsening of pre-
existing DR, increasing the risk for poor visual outcomes.29
The only measured comorbidities with a statistically sig-
nificant effect on visual acuity were a-antagonist use (OR,
1.933; P Z .043) and PXF (OR, 7.901; P Z .001). Alpha-
antagonist use, past or present, is highly associated with in-
traoperative floppy-iris syndrome, a well-known intraopera-
tive complication. Pseudoexfoliation syndrome is associated
with poor pupil dilation and loss of zonular integrity, leading
to increased difficulty in surgical cataract removal.
The intraoperative and postoperative complication rates
in our study are similar to those previously published in
the literature (Table 8). Rates of vitreous loss (6.7%), poste-
rior capsule tear (7.0%), CME (4.7%), corneal edema (3.3%),
and RD (0.9%) are comparable to those found in the litera-
ture at similar residency training programs. In other studies
of county hospital systems, the most common complication
is vitreous loss, with reported rates ranging from 3.8% to
11.2%,3 placing our vitreous loss rate in the middle of this
range. This comparison is limited, however, because the vit-
reous loss studies did not report their racial or ethnic demo-
graphics or cataract types and densities. Our patient base
had a higher rate of dense cataracts than those published
in other county hospital training programs; 23.3% of nuclear
sclerotic cataract cases had a preoperative CDVA worse
than 20/400 (versus 19.4%) and 29.3% of posterior subcap-
sular cataract cases had a preoperative CDVA worse than
20/400 (versus 14.4%).23 Our percentage of white cataracts
(16.6%) was also higher than that of Blomquist and Rugwani
(13.1%).16 Previous studies have shown that white, posterior
subcapsular, and brunescent cataracts lead to increased
complication rates.6 However, we found that only white
cataracts were associated with complications (P Z .046).
Our study also showed a high rate of intraoperative de-
vice use during cataract surgery, including trypan blue stain
(52.8%), pupil dilation devices (5.0%), and capsular tension
rings (2.1%), which is indicative of the advanced complexity
of cataracts. These more complicated cataracts were often
assigned to PGY-4 residents and despite the elevated case
complexity, their visual acuity outcomes were similar to
the patients operated on by junior residents (0.24 logMAR
versus 0.14 logMAR).
Although the majority of patients had a significant
improvement in their visual acuity, some patients did not
have any improvement after surgery. Intraoperatively,
only a dislocated IOL was associated with a lack of improve-
ment in visual acuity (P Z .0155). Postoperatively, there
was no significant increase in CDVA in patients with hy-
phema (P Z .67), RD (P Z .7556), vitreous hemorrhage
(P Z .1686), wound leak measured by Seidel positivity
without pressure (P Z .1798), or hypotony (P Z .668).
None of the other measured complications was associated
with an increased risk for a CDVA worse than 20/40. Other
severe complications in the postoperative period included a
vein occlusion, endophthalmitis, and choroidal effusion.
These cases could not be included in the analysis because
only 1 patient had each of these complications. Overall,
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1568 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY

Table 6. Association of preoperative ocular comorbidities with postoperative CDVA worse than 20/40 and adjusted odds ra-
tios (risk of CDVA worse than 20/40).
Ocular Comorbidity OR CI P Value
Diabetes mellitus 1.008 0.712, 1.427 .966
Hypertension 0.87 0.612, 1.234 .435
Rheumatoid arthritis 1.021 0.714, 1.46 .909
Body mass index O30 0.994 0.972, 1.016 .572
a-antagonist use 1.933 1.021, 3.659 .043*
Anticoagulant use 0.942 0.64, 1.386 .761
Steroid use 1.996 0.63, 6.321 .24
Immunosuppression 0 0 .999
AMD 1.047 0.21, 5.222 .956
Retinal detachment 2.358 0.713, 7.802 .16
Uveitis 0.86 0.183, 4.034 .848
Glaucoma 1.298 0.832, 2.026 .25
PXF 7.901 2.301, 27.121 .001*
Prior ocular trauma 0.906 0.397, 2.068 .815
Prior ocular surgery 0.769 0.429, 1.378 .337
Corneal opacity 0.721 0.088, 5.904 .76
Diabetic macular edema or CME 0.439 0.132, 1.459 .179
Pupil dilation 1.122 0.733, 1.718 .595

AMD Z age-related macular degeneration; CI Z confidence interval; CME Z cystoid macular edema; OR Z odds ratio; PXF Z pseudoexfoliation syndrome
*Statistically significant difference (P ! .05)

70.0% of patients had 20/40 or better CDVA postopera- study. We found a significant decrease in CDVA between
tively regardless of whether they had a complication. PGY-3 and PGY-4 residents, from 20/26 (0.14 logMAR)
There were few significant differences in the outcomes to 20/33 (0.23 logMAR). Although this finding was unlikely
between surgeons of varying training levels in the current clinically significant, it differs from previously published

Table 7. Comparison of preoperative versus postoperative mean logMAR visual acuity in patients with events (Group B).
Mean CDVA ± SD

Event Preoperative Postoperative P Value Improvement

Dropped nucleus 1.91 G 1.30 0.80 G 1.42 .0155* 1.11
Vitreous loss 1.38 G 1.15 0.41 G 0.78 !.0001* 0.97
Zonular dehiscence 1.46 G 1.16 0.32 G 0.69 !.0001* 1.14
Anterior capsule tear 1.72 G 1.24 0.37 G 0.77 !.0001* 1.35
Posterior capsule tear 1.50 G 1.26 0.42 G 0.82 !.0001* 1.08
Anterior vitrectomy 1.34 G 1.16 0.37 G 0.73 !.0001* 0.97
Choroidal effusion 2.00 3.00 NA C1.00
Iris prolapse 0.99 G 1.04 0.20 G 0.21 .0093* 0.79
Wound burn 2.08 G 1.27 0.46 G 0.80 !.0001* 1.62
Iris hooks 1.42 G 1.10 0.55 G 0.96 !.0001* 0.87
Malyugin ring 1.55 G 1.19 0.55 G 1.10 !.0001* 1.00
CTR 1.60 G 1.11 0.29 G 0.59 !.0001* 1.31
Vein occlusion 0.60 0.10 NA 0.50
IOP elevation 1.71 G 1.22 0.48 G 0.90 !.0001* 1.23
Hypotony 1.25 G 0.71 1.10 G 1.30 .6668 0.15
Wound leak 1.24 G 0.89 0.61 G 1.01 .1798 0.63
Endophthalmitis 0.70 0.20 NA 0.50
Rebound inflammation 1.29 G 1.14 0.23 G 0.44 !.0001* 1.06
Corneal edema 1.54 G 1.07 0.32 G 0.38 !.0001* 1.22
Retained lens fragment 1.68 G 1.20 0.45 G 0.77 .0009* 1.23
Cystoid macular edema 1.40 G 1.02 0.40 G 0.40 !.0001* 1.00
Hyphema 1.30 G 0.79 0.98 G 1.70 .6707 0.32
Retinal detachment 1.28 G 0.79 1.22 G 1.69 .7556 0.06
Vitreous hemorrhage 1.58 G 0.87 0.61 G 0.64 .1686 0.97
Dislocated IOL 0.83 G 0.39 0.34 G 0.24 .0457* 0.49

CDVA Z corrected distance visual acuity; CTR Z capsular tension ring; IOL Z intraocular lens; IOP Z intraocular pressure; NA Z not available, only 1 eye
*Statistically significant difference (P ! .05)

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 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY 1569

Table 8. Selected complication rates in Ben Taub Gen-

of training differed based on the rotation schedule of the
eral Hospital compared to published rates in the resident (ie, public hospital versus VA hospital versus pri-
literature. vate attending clinics). Although 1 resident might have
Percentage performed a few more cases than another resident in
the same month of training, in general, residents typically
BTGH Published complete a similar number of cases. Overall, by the end of
Complication Complication Rate Rates5–20,26
residency training, our residents perform an average of
CDVA 20/40 or better 74.0 to 97.8 250 primary cataract cases.
Overall 74.2 d In summary, we believe this is one of the largest studies
Group A 80.5 d
of resident-performed cataract surgeries in a county hos-
Group B 70.7 d
pital system with complex comorbidities and cataracts.
Vitreous loss 6.7 1.8 to 19.7
Previous studies of comparable county hospital patient
PC tear 7.0 0.6 to 18
PC tear with vitrectomy 5.1 0.8 to 8.2
populations are older (from 1984 to 1997), used older
Cystoid macular edema 4.7 0.6 to 4.6 phacoemulsification technology, and included a larger
Corneal edema 3.3 0.6 to 8.1 percentage of ECCE cases.15,21 In this complicated popu-
Endophthalmitis 0.1* 0.0 to 0.7 lation, special planning should be undertaken in patients
Retinal detachment 0.7 0.0 to 1.6 with comorbidities to limit poor visual outcomes, espe-
BTGH Z Ben Taub General Hospital; CDVA Z corrected distance visual
cially PXF, previous a-antagonist use, and white cataracts.
acuity; PC Z posterior capsule Following the results of our study, we recommend that pa-
*One case tients with these mentioned comorbidities should be as-
signed to more experienced residents to maintain
reports on resident outcomes.30 This might be because of optimum visual outcomes. Resident education should
the increasing complexity of cataracts assigned to senior focus on optimizing preoperative risk factors for patients
residents as well as the increased intraoperative autonomy with previously mentioned comorbidities and on the pre-
given to senior residents. vention of intraoperative and postoperative events. This
Previous studies have described significant decreases in attention should be applied specifically to dislocated
specific complications, such as vitreous loss or posterior lenses, hyphema, vitreous hemorrhage, wound leak, and
capsule tear, as residents improve their skills over time.30 hypotony because these were all associated with poor vi-
The only measured parameter that improved in our study sual outcomes. Although our cohort of tertiary-care
was the incidence of intraoperative dropped nucleus, county hospital patients carries a high incidence of medi-
decreasing from 7.1% in PGY-2 to 0.6% in PGY-4 cal disease and more complicated cataracts, we found vi-
(P Z .006). Overall surgical time also decreased by more sual outcomes and complication rates are comparable to
than 35 minutes as training progressed (P ! .001). These those found in the VA and other university hospital sys-
findings support the idea of providing novice residents tems. The results in this study can help guide residency
with less complicated cases and slowly increasing the diffi- training programs with county hospital systems as they
culty during training, thus allowing for excellent surgical adapt their curriculum to meet the new ACGME ophthal-
education without compromising patient care. mology training guidelines.
Our study is not without limitations. Our data analysis
was retrospective in nature and was hindered by resident
documentation and occasionally by limited follow-up in WHAT WAS KNOWN
our patient population possibly altering complication  Primary resident-performed cataract surgery by residents in
rates. For example, preoperative pupil size was not docu- VA hospitals achieve excellent visual acuity outcomes with
mented similarly in all preoperative documentation, which low complication rates.
precluded our ability to analyze the relationship between  Variable outcomes have been reported in county hospital
settings that do not necessarily reflect current resident
pupil dilation and postoperative outcomes. However, we
cataract surgery because they had a higher rate of ECCE as
did include the number of pupil dilation devices used well as used older phacoemulsification technology.
intraoperatively in an attempt to evaluate the number of
patients with poor dilation in our study. Inadequate WHAT THIS PAPER ADDS
follow-up could have been the result of low medical liter-  Despite high complexity of cataracts and percentage of
acy, unsatisfactory procedural outcomes, and/or prohibi- advanced comorbidities such as DM type II (55.1%), over-
weight/obesity (76.7%), and hypertension (58.6%), primary
tive travel, appointment, or medication costs. This might
resident-performed cataract surgeries in a tertiary-care
limit our rates of postoperative events such as PCO, which county hospital system achieved good visual and refractive
can develop months after phacoemulsification. Another outcomes with low complication rates.
limitation in our review is the comparison of our out-  In similar tertiary care hospital systems, patients with pre-
comes to the general population because there is a paucity operative a-antagonist use, PXF, and/or white cataracts
of information in the literature analyzing similar patient should have cataract surgery performed by more experi-
populations at other training sites across the nation. enced residents given the risk for poor visual outcomes.
Finally, the number of cataracts performed by each level

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1570 PRIMARY RESIDENT-PERFORMED CATARACT SURGERY
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Disclosure: None of the authors has a financial or proprietary in-
terest in any material or method mentioned.
First author:
Cameron Clarke, BS
School of Medicine, Baylor College of
Medicine, Houston, Texas, USA