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Survey of Scottish ophthalmic trainees' experiences using 3-piece IOLs in cataract surgery

Guthrie, Stuart MB ChB(Hons); Goudie, Colin FRCOphth; Lockington, David FRCOphth

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Journal of Cataract & Refractive Surgery: March 2018 - Volume 44 - Issue 3 - p 409
doi: 10.1016/j.jcrs.2018.01.016
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Recent publications have highlighted the need for real-life training in the context of uncommon, yet predictable, surgical complications associated with cataract surgery. These include conducting low-cost surveys of surgical experience, real-time “fire drills” for vitreous loss, and expensive computer surgical simulation.1–4 Total completed cataract cases have a poor correlation with exposure to the management of surgical complications (possibly because of risk stratification and case selection), and this has been shown to have an impact on trainees’ surgical confidence to manage such scenarios independently, even if the prerequisite 350 completed cataract cases have been achieved.5 The Royal College of Ophthalmologists has recognized the need for formal structured teaching regarding such perioperative scenarios through the recent advent of a simulation lead position, improved access to surgical simulators through the deaneries, and competency-based assessments.


This study assessed the surgical training experience of ophthalmology trainees in Scotland and, in particular, their exposure to using 3-piece intraocular lenses (IOLs). Previously, such IOLs were commonly used as the primary IOL choice for in-the-bag implantation; however, the advent of preloaded injectable IOLs means that 3-piece IOLs are now rarely used in routine cataract surgery. However, they still fulfill a valuable role in the setting of a surgical complication that affect the integrity of the posterior capsule. In this setting, the surgeon might choose to use the residual anterior capsule and place a 3-piece IOL in the sulcus as a primary or secondary procedure. To evaluate exposure to this surgical scenario, an online questionnaire was sent to ophthalmic trainees across Scotland in November 2017 using, an online survey website.A


The response rate was 58% (40/69) in 1 week (24/36 West Regional Deanery, 7/15 South East, 5/9 North, 4/9 East). Eight trainees reported working in departments that used 3-piece IOLs as their standard practice instead of preloaded injectable IOLs and so were discounted from the remainder of the report. Evaluating the remaining 32 trainees, there was a good breadth of surgical experience, with 6 (18.8%) in locum appointment for training posts, 11 (34.4%) in specialty registrar years 1 to 3 (junior trainee) posts, and 13 (40.6%) in specialty registrar years 4 to 7 (senior trainee) posts.

Only 2 trainees (6.5%) had had wet lab training for this scenario. Eight trainees had inserted fewer than 10 3-piece IOLs to date, and 15 trainees (47.0%) had never used them. Only 6 trainees (18.8%) had inserted more than 30 3-piece IOLs throughout the course of their training.

Regarding the most recent 3-piece IOL insertion by trainees, 8 (25.0%) were as a planned secondary procedure and 9 (28.1%) were unplanned use in the setting of a complication (15 [46.9%] had never used one). Twenty-seven of 32 (84.4%) had not inserted a 3-piece IOL in the most recent 2 months, with 19 (59.4%) responding “not in the past year.” Twenty-one (65.6%) had not observed their supervisor insert a 3-piece IOL in the previous 2 months, and 14 (43.8%) had not observed this in more than 6 months.


These results suggest that a lack of experience and exposure in using 3-piece IOLs exists within ophthalmic surgical trainees in Scotland. After the results of this survey were analyzed, a wet lab session was organized for all trainees in the West of Scotland Deanery to address this gap in surgical experience. Providing the opportunity to practice such skills in the controlled wet lab environment should permit surgeons to be better equipped to manage future surgical complications because they will be familiar with the necessary techniques and not have the additional intraoperative stress of inserting an unfamiliar IOL.1–5

We would also advocate the use of a simple online survey as a low-cost, simple, and confidential method to evaluate trainees’ experiences and exposure to the management of surgical complications. Using such tools on a yearly basis would allow any training deficiency to be identified early and addressed promptly to ensure familiarity with the appropriate technique and/or maintenance of skills, resulting in better surgical outcomes for both surgeon and patient.


1.Lockington D, Belin M, McGhee CNJ. The need for all cataract surgeons to run a regular vitreous loss fire drill [comment]. Eye. 2017;31:1120-1121.
2.Lockington D, Flowers H, Young D, Yorston D. Ensuring accuracy of intra-vitreal antibiotics and the need for training [letter]. Br J Ophthalmol. 2009;93:1126.
3.McCannel CA, Reed DC, Goldman DR. Ophthalmic surgery simulator training improves resident performance of capsulorhexis in the operating room. Ophthalmology. 2013;120:2456-2461.
4.Yen AJ, Ramanathan S. Advanced cataract learning experience in United States ophthalmology residency programs. J Cataract Refract Surg. 2017;43:1350-1355.
5.Turnbull AMJ, Lash SC. (2016). Confidence of ophthalmology specialist trainees in the management of posterior capsule rupture and vitreous loss. Eye, 30, 943-948, Available at:


A.SurveyMonkey. Available at: Accessed January 25, 2018
© 2018 by Lippincott Williams & Wilkins, Inc.