Intraoperative Miosis Research Articles

Bimanual technique for placement of footplates of phakic intraocular lens in eyes with intraoperative miosis.

We describe and assess the efficiency of a novel technique of placing implantable collamer lens (ICL) footplates in the sulcus in poorly dilated pupils utilizing perioptic holes and two instruments simultaneously (Sinskey hook and ICL manipulator). Twelve eyes of 10 patients underwent ICL implantation through this technique. The technique employs a bimanual approach engaging perioptic holes in the eyes with intraoperative miosis. Perioptic holes were engaged with a Sinskey hook and pulled slightly back, while the footplates were tucked under the iris by using an ICL manipulator. All patients had uneventful surgery. At 1 week follow-up, uncorrected distance visual acuity (UCDVA) was -0.01 ± 0.04 logMAR with a mean vault of 606.17 ± 108.33 microns. No complications were noted. However, too small a pupil is a limiting factor; this technique can be of use in up to mid-dilated pupils. Bimanual placement of haptics of ICL may represent a safe and effective technique in insufficient mydriasis or intraoperative pupillary miosis.

Influence of Endogenous Substances on Site-II to Site-I Displacement of Diclofenac Bound to Albumin in the Aqueous Humor of Patients with Cataract.

Diclofenac instillation is useful in preventing intraoperative miosis and macular edema caused by postoperative inflammation in cataract surgery; however, optimum efficacy is not attained when the instilled diclofenac strongly binds to albumin in patients' aqueous humor. Therefore, a method that inhibits diclofenac binding and increases the concentration of its free fraction is needed. We conducted a basic study regarding the effects of inhibitors on the binding of instilled diclofenac to albumin and endogenous substances in aqueous humor. Aqueous humor samples from 16 patients were pooled together for analysis. The free fraction of diclofenac was measured using ultrafiltration methods in various experiments with pooled and mimic aqueous humor. Free fraction of diclofenac, a site II drug, in pooled aqueous humor was 0.363 ± 0.013. The binding of diclofenac in the presence of phenylbutazone (PB), a site I inhibitor, was significantly inhibited (free fraction = 0.496 ± 0.013); however, no significant inhibition by ibuprofen, a site II inhibitor, (free fraction = 0.379 ± 0.004), was observed. The unexpected result was due to free fatty acids (FFAs; palmitic acid (PA)) and L-tryptophan (Trp). The inhibition of diclofenac binding by PB in the mimic aqueous humor containing these endogenous substances revealed significant binding inhibition in the presence of PA and Trp. Diclofenac is strongly rebound from site II to site I in the presence of FFAs and Trp in the aqueous humor because FFAs and Trp induce a conformational change in albumin. Therefore, PB significantly inhibits the binding of diclofenac to albumin.

Cardiovascular effects of diluted intracameral combination of 0.02% tropicamide, 0.31% phenylephrine, and 1% lidocaine during phacoemulsification to manage intraoperative miosis.

Intracameral mydriatic agents (ICMAs) are replacing the conventional method of topical mydriasis for its fast action and no need for repeated instillation before cataract surgery. Its application for the management of intraoperative miosis needs to be studied with different doses of mydriatic agent. The objective of the study is to study cardiovascular effects of diluted intracameral combination of 0.02% tropicamide, 0.31% phenylephrine, and 1% lidocaine during phacoemulsification to manage intraoperative miosis. The study was conducted at Mojiram Lions Eye Hospital Akbarpur Majra village, Palla Bakhtawarpur Road, Delhi, during the year 2021-2022 after taking approval from the Ethical Committee of the hospital. Patients undergoing cataract surgery who were not dilated adequately during the preoperative period or developed intraoperative miosis were managed by injecting diluted intracameral combination of 0.02% tropicamide, 0.31% phenylephrine, and 1% lidocaine (phenocaine plus). 0.5 ml of phenocaine plus was diluted with 1.5 ml of ringer lactate solution and 0.50 ml of this solution was injected intracameral and its effect on pulse rate, blood pressure (BP), and oxygen saturation were monitored continuously on pulse oximeter. There was no statistically significant effect of diluted ICMA (Phenocaine Plus) on diastolic BP and oxygen saturation. However, systolic BP showed a little change from mean of 133.78 (standard deviation [SD] =16.04) mmHg to 133.92 (SD = 15.33) mmHg which was statistically significant but clinically not significant. Pulse rate increased slightly from mean 76.46 per minutes (SD = 15.14) to 79.40 (SD = 14.95) at 10 s and 76.49 (SD = 15.15) at 60 s. The difference was again statistically significant but clinically insignificant. Low concentration of intracameral combination of 0.02% tropicamide, 0.31% phenylephrine, and 1% lidocaine is a very safe and effective method for the management of intraoperative miosis.

Effect of Intracameral Lignocaine in Preventing Intraoperative Miosis in Patients Undergoing Small Incision Cataract Surgery

Effect of Intracameral Lignocaine in Preventing Intraoperative Miosis in Patients Undergoing Small Incision Cataract Surgery

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Four-Point Refixation for In-the-Bag Intraocular Lens Dislocation Into Vitreous Cavity With Implantable Capsular Hooks.

Pharmacological management of intra-operative miosis during cataract surgery.

Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.

Improved visibility of illuminated chopper-assisted cataract surgery involving iris challenges.

The aim of this study was to evaluate the efficacy of the illuminated chopper-assisted cataract surgery in terms of shortening the surgical time and reducing the use of pupil expansion devices in eyes with iris challenges. This was a retrospective case series of a university hospital. Four hundred forty-three eyes of 433 consecutive patients who underwent illuminated chopper-assisted cataract surgery were included in this study. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome were included in the iris challenge group. Use of tamsulosin, iris hooks, pupil size, surgical time, and improved visibility (100/surgical time × pupil size) were compared between eyes with and without iris challenges. Mann-Whitney U test, Pearson's Chi-square test, and Fisher's exact test were used for statistical analysis. Of 443 eyes, 66 were included in the iris challenge group (14.9%). Tamsulosin use was more common in patients with iris challenges and iris hooks were used more frequently (9.1% vs. 0%, P < 0.001) in patients with iris challenges than in those without iris challenges. Pupil size was smaller in patients with iris challenges (6.01 vs. 7.64 mm, P < 0.001). However, surgical time was not different (16.9 vs. 16.5 min, P = 0.064) between the two groups. As a result, improved visibility was calculated to be higher in patients with iris challenges (1.05 vs. 0.81, P < 0.001). In terms of surgical time and improved visibility, using the illuminated chopper simplified cataract surgery involving iris challenges. The use of an illuminated chopper is expected to be a good solution for challenging cataract surgeries.

A novel Y-shaper and chopper for small pupil management in cataract surgery: The initial experience.

Small pupil is a well-known risk factor for causing cataract surgery complications such as vitreous loss, anterior capsular tear, increased inflammation, and an irregular pupil shape. Because all currently available pharmacological approaches of dilating the pupil before or during cataract surgery cannot guarantee the result, the surgeon sometimes resorts to the use of mechanical pupil-expanding devices. However, these devices can increase the overall surgical cost and operative time. Very frequently, a combination of the two is needed; thus, we present the Y-shaped chopper designed by the authors, which serves the purpose of managing the intra-operative miosis and allows simultaneous nuclear emulsification.

Preservative Free Intracameral Pilocarpine for Intraoperative Miosis

We describe use of 0.5% intracameral preservative free pilocarpine during cataract and glaucoma surgery for pupillary miosis, as alternative to commonly used intraoperative intracameral miotic agents such as acetyl choline and carbachol. This agent is safe and effective in achieving intraoperative miosis and free of corneal toxicity and causing intraocular inflammation.

Formulation and Evaluation of Flurbiprofen Topical Emulgels

Topical drug delivery has been used for centuries for the treatment of local skin disorders. Emulgel have emerged as one of the most interesting topical delivery system as it has dual control release system i.e. gel and emulsion. One side the topical applications of the drug offers the potential advantages of delivering the drug directly to the site of action and secondly delivering the drug for extended period of time at the effected site. Topical non-steroidal anti-inflammatory drug (NSIAD) formulations are designed to deliver therapeutic levels of the active ingredients to the inflamed tissue without elevating serum levels after application on the skin. This route is an attractive alternative to the oral administration of NSAIDS which is associated with high incidence of gastrointestinal tract (GIT) complications and other systemic toxic effects. Flurbiprofen is a potent non-steroidal anti-inflammatory agent usually well tolerated as compared to other NSAIDS product. It has analgesic and antipyretic properties. It is used in the treatment of rheumatic disorders such as ankylosing spondilities, oesteoarthritis and intraoperative miosis. It suffers from major GIT disturbances. The aim of the present study was to develop an emulgel formulation of flurbiprofen using water soluble polymer of hydroxy propyl methyl cellulose (HPMC K100M), carbopol 940, carbopol 941 and xanthan gum. Oleic acid and propylene glycol were used as permeation enhancers. The influence of the type of the gelling agent on the drug release from the prepared emulgel was investigated. The prepared emulgels were evaluated for their physical appearance, pH determination, viscosity, spreadability, extrudability, in-vitro drug release, ex-vivo drug release and stability. All the prepared emulgels showed acceptable physical properties, homogeneity, consistency, spreadability, viscosity and pH value. The emulgels were found to be stable with respect to physical appearance, pH, and rheological properties and drug content at all temperature and conditions for one month. Keywords: Emulgel, Topical drug delivery, Flurbiprofen, Carbopol, Hydroxy propyl methyl cellulose

Delayed intracapsular hematoma after use of iris retractor hooks

Introduction: To the author's knowledge, this is the first reported case of a delayed intracapsular hematoma after complex femtosecond laser–assisted cataract surgery (FLACS) and the use of iris retractor hooks for intraoperative floppy-iris syndrome. It is important that cataract surgeons be aware of this association. Patient and Clinical Findings: An 83-year-old man underwent FLACS with astigmatic keratotomy and intraocular lens implantation. Iris retractor hooks were used to counter intraoperative miosis. Hyphema, corneal edema, and subconjunctival hemorrhage were observed on postoperative day (POD) 1. The patient returned on POD 3 with further decrease in vision due to Descemet folds, advanced corneal edema, layered hyphema, and a dense intracapsular hematoma. Diagnosis, Intervention, and Outcomes: Minimal improvement of the hematoma occurred through 4 weeks, at which time the hematoma was drained with Nd:YAG laser posterior capsulotomy. The hematoma reabsorbed within 1 month with full recovery of vision. Conclusions: The iris retractor hooks in the setting of complex FLACS likely caused postoperative bleeding with accumulation of blood within the capsule. Nd:YAG laser posterior capsulotomy is an effective treatment option for nonclearing intracapsular hematoma.

Comparative evaluation of once-daily and twice-daily dosing of topical bromfenac 0.09%: aqueous pharmacokinetics and clinical efficacy study.

To evaluate aqueous pharmacokinetics of topical bromfenac 0.09% and compare clinical outcomes of once- and twice-daily dosing in phacoemulsification. Dr. R.P. Center for Ophthalmic Sciences, AIIMS, New Delhi, India. Prospective interventional study. In phase I, single-drop aqueous pharmacokinetics of topical bromfenac was estimated at 15 minutes, 30 minutes, 1 hour, 2 hours, 4 hours, 12 hours, and 24 hours using liquid chromatography mass spectrometry in 60 eyes. In phase II, 45 eyes undergoing phacoemulsification were enrolled: group I (control, n = 15), group II (once-daily bromfenac, n = 14), and group III (twice-daily bromfenac, n = 16). Intraoperative pupillary miosis, postoperative anterior chamber (AC) flare, Summed Ocular Inflammation Score (SOIS), central macular thickness (CMT), and pain scores were assessed. Follow-up was performed at 1 day, 7 days, 28 days, and 90 days postoperatively. Half-life of topical bromfenac was 3.6 hours, mean residence time 5.5 hours, and peak concentration (63.73 ng/mL) achieved after 2 hours. Aqueous concentration was more than inhibitory concentration (IC50) at 12 hours but not at 24 hours. Cumulative effect was observed with repeated dosing with aqueous levels more than IC50 in once-daily and twice-daily groups at 5 days. Significant intraoperative miosis was observed in group I. Pain score, AC flare, and SOIS were significantly more in group I (P < .001) and comparable in groups II and III at all timepoints. CMT was comparable in all groups; no case developed cystoid macular edema. Single-dose topical bromfenac did not maintain therapeutic aqueous concentration over 24 hours; however, cumulative effect was observed with repeated dosing. Clinical efficacy of once-daily and twice-daily dosing was comparable.

A Descriptive Study of Intraoperative Complications in Manual Small Incision Cataract Surgery

Background: Senile cataract is the most common cause of reversible blindness in India and other developing countries. It is one of the significant social problem. Though phacoemulsification has become a routine procedure for cataract extraction in most parts of the developed world, it is not always appropriate either for its cost or the density of cataract involved in developing nations like India. Small incision cataract surgery is commonly performed surgery in developing countries. This procedure is safe, effective to increase the surgical outcome, reduces surgical time, easier to maintain instrumentation and at the same time affordable. The present study is undertaken to study the intraoperative complications and how best these complications can be minimized and managed. Methods: A total of 50 cases were studied from October 2020-January 2021. It is a hospital based, descriptive cross sectional study. Results: Intraoperative complications occurred in 10 cases (20%). It included iris prolapse in 3 cases (6%), tunnel related complications in 3 cases which included premature entry in 2 cases (4%) and button holing in 1 case (2%), Descemet membrane detachment in 1 case (2%), intraoperative miosis in 1 case (2%), intraoperative hyphema in 1 case (2%), capsule related complications in 1 case (2%) and PC rent in one case (2%). Conclusion: Over all the intraoperative complications of manual small incision cataract surgery are less and the procedure is well suited in our country, where there is a large number of backlog of cataract cases.

Comparison Between Topical Nepafenac and Flurbiprofen in Maintaining Intraoperative Mydriasis and Controlling Postoperative Inflammation in Cataract Surgery

Background: Preoperative dilation of pupil is one of the prerequisistes to perform an uncomplicated cataract surgery. Intraoperative miosis is one of the many challenges which a surgeon can encounter during cataract surgery. Preoperative use of NSAIDS like nepefenac, flurbiprofen, ketorolac have been used for maintaining intra operative mydriasis and controlling postoperative inflammation by blocking prostaglandin synthesis. Aims: To compare the efficacy of nepafenac and flurbiprofen in maintaining intraoperative mydriasis and controlling postoperative inflammation Settings and Design: This was an institutional prospective comparative study done in rural Karnataka. Methods and Material: This study was performed on 110 patients, 55 were allocated in each group and were given either of the topical NSAID’s Nepafenac or Flurbiprofen prior to cataract surgery. Pupillary diameter was measured at the beginning and at the end of the surgery and the values were compared between the groups. Postoperative inflammation was also compared between both the groups. Statistical analysis used: The difference in flare and cells grading across groups were tested using Chi-Square test. p value of < 0.05 was considered statistically significant Results: The mean pupillary diameter of the two groups were comparable at the beginning of surgery The mean change in the pupillary diameter was more in flurbiprofen group when compared to nepafenac group. There was statistically significant difference among both the groups in maintenance of intraoperative mydriasis .The comparison of postoperative inflammation was also statistically different between both the groups. Conclusions: Pre-operative Nepafenac was found to be better than flurbiprofen in maintaining intraoperative mydriasis and controlling postoperative inflammation. Keywords: Cataract surgery, Surgical miosis, NSAIDs, Nepafenac, Flurbiprofen

The application of the femtosecond laser in cataract surgery

Introduction: Since the introduction, femtosecond laser-assisted cataract surgery (FLACS) was believed to revolutionize cataract surgery. However, the judgment of clinical benefits was found to be far more complex than initially might have been thought. The aim of this review was to analyze the benefits and drawbacks of FLACS compared to traditional phacoemulsification cataract surgery.&#x0D; Results: The benefits of FLACS include lower cumulated phacoemulsification time and endothelial cell loss, perfect centration of the capsulotomy, and the possibility to perform precise femtosecond-assisted arcuate keratotomy incisions. The major disadvantages of FLACS are: high cost of the laser and the disposables for surgery, FLACS-specific intraoperative capsular complications, as well as the risk of intraoperative miosis and the learning curve.&#x0D; Conclusions: FLACS seems to be beneficial in some groups of patients i.e., with low baseline endothelial cell count, or those planning to receive multifocal intraocular lenses. Nevertheless, having considered that the advantages of FLACS might not be clear in every routine case, it cannot be considered as cost-effective.

Surgical outcomes with high and low pulse energy femtosecond laser systems for cataract surgery

Currently, there is no clear consensus in cataract surgery if low compared to high energy femto-lasers may enable better capsulotomy quality and induce lower inflammatory response. Therefore, the aim of this study was to compare the intra-operative outcomes achieved with high and low pulse energy femtosecond laser systems for cataract surgery. The charts of 200 eyes of 200 patients aged 68.3 ± 10.3 years who had undergone femtosecond laser-assisted cataract surgery using either group 1 high pulse energy: LenSx (Alcon Laboratories) (N = 100) or group 2 low pulse energy: FEMTO LDV Z8 (Ziemer) (N = 100) laser were reviewed retrospectively. Integrity of anterior capsulotomy, classified as (1) complete (free-floating or with minor microadhesions), (2) incomplete and (3) with capsular tears, intraoperative completeness of the clear corneal incisions (CCI, main incision and side port), incidences of intraoperative miosis and incidence of subconjunctival hemorrhage were evaluated and compared between the two groups. The proportion of complete capsulotomies was significantly higher in the group 2 than the group 1 (100% vs 94%; p = 0.03). The incidences of intraoperative miosis (0% vs 19%) and subconjunctival hemorrhage (1% vs 63%) were significantly lower in the group 2 than the group 1 (p < 0.001). Completeness of the main incision was comparable (97% vs 95%; p = 0.721) between the two groups. Although not statistically significant, the completeness of side-port incision was slightly better in the group 2 than the group 1 (91% vs 86%). Low energy laser system performed significantly better in terms of completeness of capsulotomy, intraoperative miosis and sub-conjunctival hemorrhage, compared with high energy laser; the CCI outcomes were comparable.

COMPARISON OF THE EFFECT OF TOPICAL BROMFENAC AND TOPICAL FLURBIPROFEN IN MAINTAINING MYDRIASIS DURING CATARACT SURGERY

At the time of cataract surgery, one of the challenges a surgeon encounters is intraoperative miosis. This might increase the chances of intraoperative and postoperative complications. Thus, maintainence of adequate pupillary dilatation is necessary during cataract surgery. Aim of the study was to compare the effectiveness of prophylactic administration of topical bromfenac (0.09 % w/V) and topical flurbiprofen (0.03 % w/V) in maintaining mydriasis during the cataract surgery. A total of 100 patients were randomly divided into two groups of 50 each. Group 1 received topical bromfenac (0.09 %) and Group 2 received topical flurbiprofen (0.03 %). The mean percentage loss of mydriasis from the baseline was lesser in bromfenac group compared to flurbiprofen group (p &lt; 0.001). Topical bromfenac was found to be more effective in maintaining mydriasis during the cataract surgery when compared to the topical flurbiprofen.

Role of Nepafenac 0.1% Ophthalmic Solution in Preventing Intraoperative Miosis during Phacoemulsification

Purpose: To compare 0.1% Nepafenac ophthalmic solution with placebo in terms of decreasing mean intraoperative miosis in patients undergoing cataract surgery.&#x0D; Study Design: Quasi experimental study.&#x0D; Place and Duration of Study: Department of Ophthalmology, Holy-Family Hospital Rawalpindi from September 2017 to March 2018.&#x0D; Methods: A total of 150 eyes with senile cataract of patients between 40-80 years of age and of both genders, undergoing uneventful cataract surgery and fulfilling the inclusion criteria were included. Patients were divided into 2 equal groups. Group A received Nepafenac eye drops and group B received placebo drops (Preservative free artificial tears). The diameter of pupil as viewed through the operating microscope was measured with Castroviejo Caliper at following steps; immediately before the start of surgery (baseline), after complete nucleus removal and at the end of surgery.&#x0D; Results: Mean decrease in pupil size from the start of surgery to the end of phacoemulsification in Group A (nepafenac group) was 0.48 ± 0.26 mm while in Group B (placebo group) it was 1.40 ± 0.49 mm (P = 0.0001). Mean decrease in pupil size from start to end in Group A (Nepafenac group) was 0.75 ± 0.32 mm while in Group B (placebo group) was 2.02 ± 0.62 mm (P = 0.0001).&#x0D; Conclusion: Intraoperative miosis in terms of mean decrease in pupils size (both from start of surgery till phacoemulsification and also from start of surgery till end of surgery) was lower in 0.1% Nepafenac group as compared to placebo group.&#x0D; Key Words: Phacoemulsification, Miosis, Nepafenac.

The benefits and drawbacks of femtosecond laser-assisted cataract surgery.

Since the introduction, femtosecond laser-assisted cataract surgery was believed to revolutionize cataract surgery. However, the judgment of clinical benefit was found to be far more complex than initially might have been thought. The aim of this review was to analyze the benefits and drawbacks of femtosecond laser-assisted cataract surgery compared with traditional phacoemulsification cataract surgery. PubMed and the Web of Science were used to search the medical literature. The following keywords were searched in various combinations: femtosecond laser, femtosecond laser-assisted cataract surgery, phacoemulsification cataract surgery, FLACS. The benefits of femtosecond laser-assisted cataract surgery include lower cumulated phacoemulsification time and endothelial cell loss, perfect centration of the capsulotomy, and opportunity to perform precise femtosecond-assisted arcuate keratotomy incisions. The major disadvantages of femtosecond laser-assisted cataract surgery are high cost of the laser and the disposables for surgery, femtosecond laser-assisted cataract surgery-specific intraoperative capsular complications, as well as the risk of intraoperative miosis and the learning curve. Femtosecond laser-assisted cataract surgery seems to be beneficial in some groups of patients, that is, with low baseline endothelial cell count, or those planning to receive multifocal intraocular lens. Nevertheless, having considered that the advantages of femtosecond laser-assisted cataract surgery might not be clear in every routine case, it cannot be considered as cost-effective.

Ophthalmology Residents' Experience with Complex Cataract Surgery at a VA Hospital over 10 Years

Abstract Objective The purpose of this study was to determine the proportion of complex cataract surgery performed by third-year ophthalmology residents at an academic Veterans Administration Medical Center. Methods A chart review was conducted of all resident cataract surgeries performed at the James J. Peters Veterans Administration Medical Center in The Bronx, NY between July 1, 2007, and June 30, 2017. Correct categorization was confirmed by review of operative report and reason for complex categorization was recorded, as well as the use and type of nonstandard device or technique. Results A total of 2,429 routine and 114 complex cataract surgeries were performed by 40 different residents over the 10-year period. In total, 4.5% of all cataract surgeries were categorized as complex. The most common reasons for complex categorization included intraoperative floppy iris syndrome (35.8%), miosis (38.4%), zonular instability (9.6%), mature cataract (7%), posterior synechiae (7.8%), and posterior capsular plaque (1.8%). Nonstandard techniques/devices included iris hooks (65.3%), pupil expansion device (8.5%), extracapsular cataract extraction (6.8%), synechiolysis (7.6%), mechanical iris dilation (0.8%), capsular tension ring (9.3%), and primary posterior continuous curvilinear capsulorhexis (1.7%). Conclusion A review of third-year resident cataract surgery experience at our institution's VA hospital where a significant amount of their surgical volume, approximately 50%, is obtained revealed that complex cataracts constituted a minimal portion of the cases. Education in cataract surgery should be competency based, extend beyond achieving minimums, and focus on variety and complexity of surgical experience. Formal tracking of routine versus complex cases should be considered to optimize training experience and assure patient safety.