• Users Online: 1252
  • Print this page
  • Email this page

Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 2

Retrospective analysis of visual acuity and final refraction after phacoemulsification surgery with intra- or postoperative complications

Department of Ophthalmology, Pontifícia Universidade Católica De Campinas, São Paulo, Brazil

Date of Submission17-Nov-2021
Date of Decision26-Nov-2021
Date of Acceptance28-Nov-2021
Date of Web Publication13-Jan-2022

Correspondence Address:
Dr. Augusto Terra Baccega
Rua Dos Bandeirantes, 35, Ap31, Cambuí, Campinas, São Paulo 13024010
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_121_21

Rights and Permissions

Objective: The objective of this study was to assess the incidence of complications intra- and postoperative (until the 30th day) of phacoemulsification surgery performed by residents of the third year, and its implications on final refraction and best-corrected visual acuity (VA), compared to those who did not exhibit any complication.
Methods: This was a retrospective analysis of 300 medical records of patients who had their surgeries performed from January 2019 to February 2020 by the same three third-year residents. Fifty medical records were excluded. Initial VA logarithm of the minimum resolution angle and final VA with the best correction were analyzed, comparing whether there was a correlation with the presence of complications.
Results: Of the 250 medical records analyzed, 29 (11.6%) presented complications during the intraoperative period, been posterior capsule rupture the mean one. The mean VA of patients without complications was 0.13 ± 0.17 (0.00–1.00) compared to 0.29 ± 0.28 (0.00–1.00) for those who had complications. The spherical equivalent of those without complications was −0.87 ± 0.98 (−4.38–2.00) compared to −1.19 ± 1.14 (−3.75–0.50) of the that had.
Conclusion: As shown in this study, the percentage of complications is compatible with those found in the literature, also exhibits that surgeries with complications do imply in worst VA. However, when compared among themselves, before and after surgery, there was a significant improvement in the VA even in patients with complications.

Keywords: Best visual acuity, cataract, complications, final refraction, phacoemulsification, residents

How to cite this article:
Baccega AT, Patrus BP, Neves GL, Pedrosa Casagrande BA, De Andrade Sobrinho MV. Retrospective analysis of visual acuity and final refraction after phacoemulsification surgery with intra- or postoperative complications. Pan Am J Ophthalmol 2022;4:2

How to cite this URL:
Baccega AT, Patrus BP, Neves GL, Pedrosa Casagrande BA, De Andrade Sobrinho MV. Retrospective analysis of visual acuity and final refraction after phacoemulsification surgery with intra- or postoperative complications. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 Feb 6];4:2. Available from: https://www.thepajo.org/text.asp?2022/4/1/2/335854

  Introduction Top

Cataract is responsible for over 50% of the causes of blindness worldwide according to the World Health Organization.[1],[2] In Brazil, around 120,000 cases of blindness resulting from cataracts occur every year.[3],[4] With the advancement of surgical techniques, its correction is currently considered one of the safest and most effective outpatient procedures.[5]

Due to the quality of the operative result, the phacoemulsification technique (phaco) was included in ophthalmology residency programs.[6]

The rate of posterior capsule rupture (PCR) with vitreous loss in surgeries performed by residents varies in the literature from 2.0% to 14.7%,[7],[8] which can occur at various stages of the surgery. Complications in the learning process are a matter of great concern due to the importance of patient safety. The surgeons' learning curve shows a greater number of complications in the first steps, which decreases during training and the surgeon's progress.[9],[10],[11]

Phaco performed by surgeons in training under supervision has the same rate of complications as when performed by experienced surgeons.[12] Another factor that reduces the complication rate among residents is the early initiation of procedures. Ellis et al. divided the residents into two groups, one starting cataract surgery in the first year of residency and the other in the third year. The results pointed to a lower rate of complications in those who started surgical learning early,[13] also confirmed by Woodfield et al., who observed that the rate of surgical complications during the training of second- and third-year residents at phaco was similar, concluding that phaco could be safely taught from the second year of residency.[14]

Although complications are not something desired among surgeons, their real implication will be reflected in the patient's best-corrected visual acuity; thus, we will know if it was compromised. In the transition from extracapsular cataract extraction (ECCE) to phaco surgery, surgeons experienced in the current technique had similar difficulties in learning as of today's residents. Its complications and rates were similar to the ones presented today. Despite the present complications, 88–95% of their patients had a corrected VA of 0.30 or better (LogMAR).[15],[16] For residents who had less surgical experience, the complication rates and their results are similar to those mentioned above.[17],[18],[19]

  Methods Top

This is a descriptive retrospective study. The inclusion criteria were patients undergoing phaco surgery from January 2019 to February 2020, which corresponds to approximately 250 eyes (according to a previous survey carried out), in the ophthalmology service of one university in the São Paulo state country. The exclusion criteria for analyzing the incidence of complications were insufficient data in the medical records, surgeries performed by assistants or surgeries with the ECCE technique, leading to the exclusion of fifty medical records. For the analysis of data on best-corrected VA after surgery, another 62 medical records of patients who had any previous ocular pathology that could cause a decrease in the final VA were excluded.

The surgeries were performed with the INFINITI phacoemulsification device (Alcon Fort Worth, Texas). The intraocular lenses used were foldable hydrophilic acrylic 6 mm in diameter, and the viscoelastic used was 2% methylcellulose. In all surgeries, 0.1 mL of intracameral moxifloxacin 5.45 mg/mL was instilled. The surgical technique employed was the stop-and-chop with an ophthalmic block made by the anesthesiology team. All surgeries were performed by one of the three third-year residents, who had contact with microscopic surgery in the first year of residency, pterygium surgery, and in the second year, started cataract surgery with the ECCE technique. The residents were always accompanied by an assistant who orally guided them through the surgery and may have taken and performed some steps that the assistant was unable to perform or when there was some complication.

Patients are prescribed a combination of moxifloxacin 5 mg/ml and dexamethasone 1 mg/ml when they leave the hospital. They are evaluated 1 day after surgery, 7 days, and 30 days. For patients who had some intraoperative complication or in the 1st postoperative day, a fourth evaluation was made 15 days after surgery. All of their data were recorded in medical records.

We evaluated best-corrected VA (BCVA) LogMAR and the spherical equivalent before and after surgery, also the main complications until the 30th day after surgery. Best-corrected VA was compared from patients who had complications and those who did not; however, 61 eyes with ocular conditions before surgery were excluded from the sample.

  Results Top

A total of 250 eyes from 209 patients who underwent phacoemulsification surgery in the period from January 2019 to February 2020 were evaluated. The mean age was 70.6 ± 9.53 years (38–91 years), 142 eyes from female patients, and 107 eyes from male patients. Cataracts were classified as nuclear, anterior cortical, and posterior subcapsular, each one graded from 1 to 4+. The incidence of nuclear cataract was 234 (94%) of 250 eyes, of which 68 (29%) had 1+, 130 (55.6%) 2+, 33 (14.1%) 3+, and 3 (1.3%) 4+. Anterior cortical cataract was present in 80 (34.2%) of the patients, 34 (42.5%) 1+, 41 (52.5%) 2+, and 5 (6.3%) 3+. One hundred and thirty (52%) presented posterior subcapsular cataract, 30 (23%) 1+, 36 (27.7%) 2+, 47 (36.2%) 3+, and 17 (13%) 4+. Four (1.6%) had a total white cataract. Ninety (36%) had only one type of cataract, 120 (48%) had two simultaneously, and 40 (16%) had all three.

Of the 250 surgeries analyzed, 42 (16.8%) presented complications up to the 30th postoperative day. Twenty-nine (11.6%) were intraoperative complications, among them, 24 (9.6%) were PCR, 2 (0.8%) Argentine flag sign, 1 (0.4%) Descemet's membrane detachment, and 1 (0.4%) expulsive hemorrhage. Some of these had secondary complications, two with cortical remnants in the vitreous, one conversion to ECCE, and one with aphakia and secondary fixation posteriorly.

Thirteen (5.2%) were identified in the postoperative period up to the 30th day, 8 (3.2%) being posterior capsule opacification, 3 (1.2%) positive seidel, 1 (0.4%) cotton in the anterior chamber, 1 (0.4%) with cortical debris, and 1 (0.4%) hyphema. Only the hyphema was associated with a secondary complication of increased intraocular pressure.

The final VA of all patients who underwent surgery with the best possible correction on the 30th postoperative day was evaluated. It was compared between those who had no complications and those who had complications in the intraoperative and up to the 30th postoperative day. For this analysis, all patients who had any previous ocular pathology were excluded from both groups.

The mean VA (logMAR) with standard deviation of the 147 patients without complications was 0.13 ± 0.17 (0.00–1.00); of the 37 patients with complications, this average was 0.29 ± 0.28 (0.00–1.00). The unpaired t-test was performed and it was found that there is a statistical difference and that surgeries with complications compromise the patients' final VA (P < 0.05, IC95) [Graph 1].

The preoperative VA of the 37 patients who suffered complications was also compared with their postoperative VA. The mean preoperative VA of these patients was 0.62 ± 0.28 (0.18–1.00) and the mean postoperative VA was 0.28 ± 0.28 (0.00–1.00). The paired t-test was carried out, and a statistically significant difference was also found (P > 0.05, IC95) [Graph 2].

Furthermore, we compared the spherical equivalent of these patients pre- and postoperatively to analyze which reached the target range −1.00D to + 1.00D. Among patients who had no complications, only 47 (32%) patients were within this range. After surgery, there was an increase to 94 (64%) patients within the aforementioned range.

In patients who had complications, the percentage within the target was also evaluated. Preoperatively, 12 (32.4%) were within the range of −1.00D to + 1.00D, and after surgery, this number increased to 18 (48.6%).

  Discussion Top

To teach phaco surgery, a surgical center with the appropriate material and an experienced surgeon supervising the training are required. Since it is a more complex technique and involves new surgical steps and instruments in relation to ECCE, its initial learning process has been characterized by the so-called learning curve.[20],[21]

The incidence of surgical complications in the literature for residents varies from 2% to 14.7%,[7],[8],[22] and for experienced surgeons, it ranges from 1.11% to 2.66%,[23],[24],[25],[26] not being statistically significant.

To reduce the rate of complications, in addition to surgeries assisted by an experienced tutor, the total number of surgeries performed by the resident during his training is taken into account. In Brazil, the resident finishes his journey with approximately 130 phaco.[27] Taravella et al., in a prospective study with 324 cases operated on by residents, observed that the surgeon in training acquires competence to operate with a complication rate and with a surgery time comparable to experienced surgeons after having performed more than 75 phaco procedures, and when performing more than 100 procedures, acquires greater precision.[11] Early contact with microsurgery can be carried out through simulators and “wet laboratories”. This type of approach, in addition to starting the resident early, is safer for the patient since it reduces the number of complications in the first intraocular surgeries.[28]

Surgeries that present complications do not necessarily indicate a worse prognosis of corrected VA. We see in several studies that despite complications, VA is 0.3 or better in 80.5%–95% of cases.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31]

Our study showed a PCR rate of 9.6% of the 250 operated eyes, similar to several other studies previously published.[7],[8],[22],[31]

The improvement in VA of patients who underwent cataract surgery and that complications impair final vision were also proven (P < 0.05, IC95) [Graph 1], been the mean VA without complications of 0.13 ± 0. 17 (0.00–1.00) and that 93% of the patients achieved vision 0.3 or better, the same level as demonstrated in other studies.[7],[8],[17],[18],[32] From patients with complications, the mean VA was 0.29 ± 0.28 (0.00–1.00) and 72.7% of them achieved a VA equal to or better than 0.3.

Although complications make the final VA worse, we also proved that surgery is still worth it, as the VA of these patients has improved when compared before the surgery. The preoperative mean was 0.62 ± 0.28 (0.18–1.00) and the postoperative mean was 0.28 ± 0.28 (0.00–1.00) (P > 0.05, IC95) [Graph 2].

It is also possible to visualize through [Graph 3] and [Graph 4] that there was a concentration of spherical equivalents within the range between −1.00D and +1.00D. Of patients without complications, this target was reached by 64% of patients, compared to 48% of patients who suffered complications. However, both presented an increase when compared to the spherical equivalent before surgery, being 32% in both groups.

Comparing the final result of better VA of patients 30 days after surgery, patients with complications had a worse VA than patients without complications but still present an improvement in VA when compared to the vision before surgery. Therefore, cataract surgery performed using the phacoemulsification technique in resident training hospitals has a low complication rate with satisfactory visual results, provided they are accompanied by assistants with previous experience to guide and assist them in a few steps during learning curve.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Flaxman SR, Bourne RR, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV, et al. Global causes of blindness and distance vision impairment 1990-2020: A systematic review and meta-analysis. Lancet Glob Health 2017;5:e1221-34.  Back to cited text no. 1
Pararajasegaram R. The global initiative for the elimination of avoidable blindness. Community Eye Health J 1998;11:29.  Back to cited text no. 2
Ottaiano J, Ávila M, Umbelino C. and Taleb A, 2019. As Condições de Saúde Ocular no Brasil. p50. [online] Docplayer.com.br. Available at: <https://docplayer.com.br/148568790-As-condicoes-de-saudeocular- no-brasil-jose-augusto-alves-ottaiano-marcos-pereira-de-avilacristiano- caixet.  Back to cited text no. 3
Domingues V, Lawall A, Battestin B, Lima F, Lima P, Ferreira S,Moraes C. Senile cataract: a literature review. Revista de Medicina e Saúde de Brasília, 2016;5(1):135-44.  Back to cited text no. 4
Schwab L. Eye care delivery in developing nations: Paradigms, paradoxes, and progress. Ophthalmic Epidemiol 1994;1:149-54.  Back to cited text no. 5
Smith JH. Teaching phacoemulsification in US ophthalmology residencies: Can the quality be maintained? Curr Opin Ophthalmol 2005;16:27-32.  Back to cited text no. 6
Unal M, Yücel I, Sarici A, Artunay O, Devranoğlu K, Akar Y, et al. Phacoemulsification with topical anesthesia: Resident experience. J Cataract Refract Surg 2006;32:1361-5.  Back to cited text no. 7
Bhagat N, Nissirios N, Potdevin L, Chung J, Lama P, Zarbin MA, et al. Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School. Br J Ophthalmol 2007;91:1315-7.  Back to cited text no. 8
Stein JD. Serious adverse events after cataract surgery. Curr Opin Ophthalmol 2012;23:219-25.  Back to cited text no. 9
Fishkind William J. Complications in Phacoemulsification Avoidance, Recognition and Management. New York: Esther Gumpert; 2002.  Back to cited text no. 10
Taravella MJ, Davidson R, Erlanger M, Guiton G, Gregory D. Characterizing the learning curve in phacoemulsification. J Cataract Refract Surg 2011;37:1069-75.  Back to cited text no. 11
Barreto Junior J, Primiano Junior H, Espíndola R, Germano R, Kara-Junior N. Cirurgia de catarata realizada por residentes: avaliação dos riscos. Rev Bras Oftalmol, 2010;69(5), 301-5.  Back to cited text no. 12
Ellis EM, Lee JE, Saunders L, Haw WW, Granet DB, Heichel CW. Complication rates of resident-performed cataract surgery: Impact of early introduction of cataract surgery training. J Cataract Refract Surg 2018;44:1109-15.  Back to cited text no. 13
Woodfield AS, Gower EW, Cassard SD, Ramanthan S. Intraoperative phacoemulsification complication rates of second- and third-year ophthalmology residents a 5-year comparison. Ophthalmology 2011;118:954-8.  Back to cited text no. 14
Pedersen OO. Phacoemulsification and intraocular lens implantation in patients with cataract. Experiences of a beginning 'phacoemulsification surgeon'. Acta Ophthalmol (Copenh) 1990;68:59-64.  Back to cited text no. 15
Tabandeh H, Smeets B, Teimory M, Seward H. Learning phacoemulsification: The surgeon-in-training. Eye (Lond) 1994;8:475-7.  Back to cited text no. 16
Tarbet KJ, Mamalis N, Theurer J, Jones BD, Olson RJ. Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg 1995;21:661-5.  Back to cited text no. 17
Blomquist PH, Rugwani RM. Visual outcomes after vitreous loss during cataract surgery performed by residents. J Cataract Refract Surg 2002;28:847-52.  Back to cited text no. 18
Cruz OA, Wallace GW, Gay CA, Matoba AY, Koch DD. Visual results and complications of phacoemulsification with intraocular lens implantation performed by ophthalmology residents. Ophthalmology 1992;99:448-52.  Back to cited text no. 19
Olson RJ. Q when. Arch Ophthalmol 1991;109:1510.  Back to cited text no. 20
Dantas PEC, Nishiwaki-Dantas MC, Mandia Jr C, Waiswol M, Krasilchik G, Dias AKG. Conversion from extracapsular cataract surgery to phacoemulsification: Analysis of 50 consecutives cases.Arq Bras Oftalmol 1995;58)6):421-4. https://doi.org/10.5935/0004-2749.19950004.  Back to cited text no. 21
Domingues FG, P; Crema, AS Yamane, Y. Complicaçõ es intraoperatórias da facoemulsificaçã o durante a residência medica. Rev Bras Oftalmol. 2000;59:275-9.  Back to cited text no. 22
Haripriya A, Chang DF, Reena M, Shekhar M. Complication rates of phacoemulsification and manual small-incision cataract surgery at Aravind Eye Hospital. J Cataract Refract Surg 2012;38:1360-9.  Back to cited text no. 23
Ang GS, Whyte IF. Effect and outcomes of posterior capsule rupture in a district general hospital setting. J Cataract Refract Surg 2006;32:623-7.  Back to cited text no. 24
Mearza AA, Ramanathan S, Bidgood P, Horgan S. Visual outcome in cataract surgery complicated by vitreous loss in a district general hospital. Int Ophthalmol 2009;29:157-60.  Back to cited text no. 25
Narendran N, Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, et al. The Cataract National Dataset electronic multicentre audit of 55,567 operations: Risk stratification for posterior capsule rupture and vitreous loss. Eye (Lond) 2009;23:31-7.  Back to cited text no. 26
Junior NK. A situação do ensino da facoemulsificação no Brasil. Rev Bras Oftalmol 2011;70:275-7.  Back to cited text no. 27
Lucas L, Schellini SA, Lottelli AC. Complications in the first 10 phacoemulsification cataract surgeries with and without prior simulator training. Arq Bras Oftalmol 2019;82:289-94.  Back to cited text no. 28
Saad Filho R, Moreto R, Nakaghi RO, Haddad W, Coelho RP, Messias A. Costs and outcomes of phacoemulsification for cataracts performed by residents. Arq Bras Oftalmol 2020;83:209-14.  Back to cited text no. 29
Clarke C, Ali SF, Murri M, Patel SN, Wang L, Tuft M, et al. Outcomes and complication rates of primary resident-performed cataract surgeries at a large tertiary-care county hospital. J Cataract Refract Surg 2017;43:1563-70.  Back to cited text no. 30
Araujo MEXS, Chou AC, da Silva CR, Oliveira LB, Neustein I. Facoemulsificação: Resultados e complicações nos primeiros 100 olhos (Portuguese). Arq Bras Oftalmol 2000;65:29-31. https://doi.org/10.1590/S0004-27492000000100006.  Back to cited text no. 31
Randleman JB, Srivastava SK, Aaron MM. Phacoemulsification with topical anesthesia performed by resident surgeons. J Cataract Refract Surg 2004;30:149-54.  Back to cited text no. 32


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article

 Article Access Statistics
    PDF Downloaded130    
    Comments [Add]    

Recommend this journal