Dr Gunjand: residents finish without phaco; 99.99% standard

Dr Gunjand said on May 21 that many ophthalmology residents complete training without performing phacoemulsification, even though the technique is widely treated as the default modern cataract operation in routine practice. The post, published on X, framed the issue as a training mismatch rather than a dispute about cataract surgery’s importance. It also gave the debate a stark number, saying phaco is the standard in “99.99%” of cataract cases. The claim circulated among ophthalmology trainees and educators as a shorthand for a broader complaint: residents may log cataract experience, but not necessarily the same kind of cataract surgery they will be expected to perform after graduation. ### What exactly is the gap Dr Gunjand is pointing to? Phacoemulsification is the small-incision cataract technique in which ultrasound energy is used to break up the lens before removal and replacement with an intraocular lens. In many higher-resource settings, it is the routine approach for cataract surgery, and the International Council of Ophthalmology has a dedicated phaco surgeon training curriculum built around teaching objectives, methods and evaluation. (acgme.org) Dr Gunjand’s point was narrower than a general complaint about cataract training. The complaint was that residents may finish ophthalmology training having assisted with cataract cases, or having performed other cataract techniques, without independently performing phaco cases themselves. That matters because phaco is often the procedure new consultants or attendings are expected to do in day-to-day cataract practice. (icoph.org) ### Don’t residency programs already require cataract surgery experience? The Accreditation Council for Graduate Medical Education requires U.S. ophthalmology residents to log at least 86 cataract cases as surgeon, with “surgeon” defined as performing at least 50% of the critical portions under faculty supervision. The ACGME document tracks cataract surgery as a category, but the publicly available case-log information does not break that minimum out by phaco versus other cataract techniques. (icoph.org) That distinction is central to the debate. A resident can meet a cataract minimum while training in a program, region or service where manual small-incision cataract surgery or other techniques remain a substantial part of the teaching mix. A 2023 report from the University of Colorado described adding a formal manual small-incision cataract surgery curriculum to a U.S. residency program, showing that programs may deliberately train residents in techniques beyond phaco for global ophthalmology and low-resource care. (acgme.org) ### Why would residents finish without phaco if phaco is so common? India-based training literature offers one explanation: phaco often requires structured supervision, wet-lab work, machines, faculty time and careful case selection. A nine-year multicenter Indian training program published in the Indian Journal of Ophthalmology said 989 ophthalmologists were trained in an intensive two-week phaco program across seven institutes, then went on to perform more than 1 million phaco surgeries after training. (pmc.ncbi.nlm.nih.gov) The existence of separate short-term phaco programs suggests that many surgeons still need focused training beyond standard residency exposure. Phaco also has a steep learning curve. A BMJ Open Ophthalmology paper describing a “reverse order” resident teaching method said cataract surgery presents learning challenges and reported posterior capsule rupture rates of 8.42% and 7.9% in the first two years after the method was introduced. The authors said standardized teaching checkpoints and logbooks helped replicate the approach across instructors and trainees. (pmc.ncbi.nlm.nih.gov) ### Is this only a problem in one country or one training model? The published literature suggests the issue is broader than one system. U.S. regulators specify cataract case minimums, international educators publish dedicated phaco curricula, and multiple centers advertise post-residency or short-term phaco courses for practicing ophthalmologists. Those facts do not prove how many residents finish without phaco, but they do show that cataract volume and phaco-specific competence are not identical measures. (bmjophth.bmj.com) The next step for trainees and program directors is likely to be more specific than social-media debate. The ACGME case-log framework, ICO phaco curriculum and program-level surgical logbooks already provide the tools to ask a narrower question: not whether residents performed cataract surgery, but how many completed supervised phaco cases before graduation. (acgme.org)