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Residents & Fellows Corner | Sept/Oct '19

Top Surgical Pearls for Trainees

A fellow’s take on eight key efforts to make in training.

The intricacy, precision, and dynamism of microsurgery draw many young individuals to the field of ophthalmology. However, in the midst of training, we quickly come to realize how challenging it is to master the complex surgical techniques performed effortlessly by our senior colleagues and mentors. Surgical education is an essential component of our training. This article details eight tips that I have found useful in expanding and refining my surgical skill set throughout my training as a resident and cornea fellow.

1. Practice in the Wet Lab

Before performing any intraocular or extraocular surgery, practice is crucial. Time spent in the wet lab practicing on model eyes and pig eyes or even with a surgical simulator serves us well during our actual cases. Before beginning my cataract and cornea rotations as a resident, I used the Eyesi Ophthalmic Surgical Simulator (VRMagic) and practiced corneal suturing on model corneas (Bioniko). I also ensured that I knew how to operate the microscope and the microscope pedals, and I reviewed all of the instruments that I would use with my senior residents so that I was comfortable on the day of surgery.

In my second and third years of residency, I benefitted greatly by attending didactic surgical courses, such as the Harvard Cataract Course and the Alcon and Johnson & Johnson resident surgical courses, and wet labs at the AAO and ASCRS annual meetings. These programs helped me gain a more thorough and hands-on understanding of advanced phaco techniques, complex IOL fixation and lamellar corneal transplantation techniques, and novel lens technologies. I seized every opportunity to practice my skills in the wet lab setting, which enabled me to be more confident and relaxed when performing cases live in the OR.

2. Prepare for Every Surgical Case

Before every OR day, I take the time to review all of the upcoming cases. I read my attending’s operative notes, review the steps of the case, and watch videos to ensure that I know how the case should flow. Excellent surgical video resources that I use include Eyetube.net, Cataractcoach.com, and YouTube. Many times, the steps of a procedure differ from one attending to another, so I review the notes I have jotted down detailing each attending’s preferences. I also ensure that I sleep well prior to an OR day and avoid caffeine on the morning of surgery. Incorporating these habits into my schedule ensures that I am able to achieve peak performance on surgery days.

3. Make Yourself Comfortable

As trainees, we often feel undue pressure to be efficient in the OR. We want to move swiftly and allow things to flow seamlessly to ensure that we are not a hindrance. However, preparation prior to any case will make a surgery day run much smoother.

Before starting a case, ensure that the bed height is appropriate for you, that your focus through the microscope is clear for you and your attending, and that you can comfortably reach the foot pedals. The extra minute it takes to make yourself comfortable will enhance your performance immensely and will enable you to be more efficient in your surgical technique. In the middle of a case, we may have to switch seats with our attendings to allow them to perform a step. Our attendings may be taller than us (as in my case) or have a different pupillary diameter. In these circumstances, upon switching, you should always take a few seconds to adjust the equipment before beginning to operate. You will never be faulted for taking an extra moment to prepare yourself and get comfortable.

4. Set a Personal Goal for Each Case

As a third-year resident, I worked with an attending who would ask me what my goal was before every cataract surgery I performed. This mental exercise forced me to be mindful of each step I completed, identify any errors I had made in past cases, and improve upon these errors at the next available opportunity. On days that I did not operate with this attending, I found myself subconsciously setting a personal goal before each case. I would set one objective per case, which ranged from improving my wound architecture, to creating a precise and centered 5.0-mm capsulorhexis, to successfully phaco-chopping the lens nucleus.

I have continued this practice in fellowship. I challenge myself to improve my stripping or tapping technique during Descemet membrane endothelial keratoplasty, become more finessed with the injection of air in Descemet stripping endothelial keratoplasty, or improve the radiality of my sutures while sowing a full-thickness corneal transplant. Importantly, I do not aim to be perfect at every step of a given case. I have found that several small victories over the course of multiple cases during an OR day ultimately help me refine my overall technique. With time, I know that these nuances that I focus on will become habitual and natural.

5. Record Your Cases

As a first-year resident, I often saw several of my senior residents sit down to watch their surgical videos at the end of a long OR day. They would share details of certain aspects of the case, point out any missteps, and ask one another for advice on how to improve.

As a senior resident and now as a fellow, I have found myself doing the same. I try to record nearly every case I perform and take the time, either on the same day or later in the week, to review my performance. If an unexpected event occurred during a case, such as a posterior capsular rupture or abnormal corneal graft behavior, I find it extremely educational to carefully review that specific clip of my surgical video. By doing so, I can typically identify why the error occurred (which is not always apparent during the case) and see which maneuvers were helpful or detrimental. In addition, by having recordings of various types of cases, I can review a range of approaches prior to an OR day and refresh my mind on the steps of a technique that I may not have recently performed.

6. Seek Feedback

We cannot learn in a bubble. The critical appraisal we receive from our more experienced colleagues is essential to our development and growth. At the end of a case, if I struggled with a particular step, I ask my attending to walk me through how to fix it the next time or even ask him or her to demonstrate it to me during the next case so that I can identify what I am doing incorrectly.

In residency, if I was discouraged by my performance after a surgery day, I would ask my senior residents or fellows to review my surgical videos with me. Their pep talks and the small tips and tricks they shared helped me to rectify my errors in subsequent cases. I also found it therapeutic to share my challenges and complications with others. Hearing the perspectives of those who had experienced similar difficulties helped me learn how to overcome certain hurdles and realize that I too would improve with additional practice.

7. Watch Your Attendings Operate

When I was a senior resident, I had the opportunity to be the primary surgeon for most of the surgical cases in which I participated. However, during this time, I came to realize that I rarely watched my attendings operate on their own. Toward the latter half of my third year of residency, I took time to scrub into cases with my attendings just to sit back and observe. I carefully watched the small steps they performed: how they held their forceps when completing a capsulorhexis; how they placed their chopper in relation to the phaco probe during a chopping maneuver; how they changed their phaco settings to account for zonular instability, a posterior capsular tear, or a dense nucleus; or how they artfully guided the suture needle through a corneal graft. I was amazed by how much I absorbed by watching them, and I found myself implementing many of their techniques into my own practice.

Further, it was eye opening for me to see how the same step could be performed so differently by various surgeons. By observing these technical variations, I was able to discern which approaches were most applicable to my surgical style and challenged myself to try them when I was the primary surgeon.

8. Challenge Yourself With Difficult Cases
and New Technologies

Our time in training affords us the unique opportunity to try many new and exciting technologies. This, in turn, allows us to offer new products and devices to our patients at no additional cost while we simultaneously gain expertise on the applications, strengths, and drawbacks of these tools.

As a resident, I seized the chance to implant a variety of premium IOLs, toric and multifocal, from multiple manufacturers in my patients undergoing cataract surgery. In the clinic, I practiced the art of patient selection, identifying which patients would benefit most from each IOL, and I tailored my conversations accordingly. In the OR, I sought the advice of my attendings in order to understand the nuances of implanting these IOLs, and I picked their brains on which lens platforms they preferred for their patients.

Additionally, I became certified in using intraoperative aberrometry. I also took the time to learn to use different femtosecond laser platforms (Alcon and Johnson & Johnson Vision) and was able to offer laser cataract surgery to a few of my patients. I requested that my attendings teach me to use the miLoop (Carl Zeiss Meditec) to fragment denser lenses and show me their techniques for small-incision cataract surgery. I also asked them to help me practice a variety of lens fragmentation techniques during my cases. With growing options for microinvasive glaucoma surgery, I was able to implant the iStent (Glaukos) and to use the Omni Surgical System (Sight Sciences) in patients with comorbid glaucoma.

My experiences as a resident thoroughly prepared me for fellowship training. I actively implement the skills I acquired in residency and simultaneously strive to try new techniques and refine my practices. As a cornea fellow, I operate on complex cataract and corneal transplant cases, and I continue to learn and seek active feedback from my mentors and colleagues to improve my surgical skills. I review my surgical videos, implement new technologies, and set small goals for myself every day in the OR, with the hopes of ultimately mastering these cases.


With any endeavor, dedicated practice helps us achieve mastery. Our attendings did not reach their level of expertise without years of experience. Surgery days are my favorite days of the week. I feel energized by the challenges that new procedures and techniques pose, and I perceive each surgery as a privilege and an opportunity to improve my abilities and help patients achieve better vision. It is important to take on challenging cases, even if they feel uncomfortable, as this helps us recognize our weaknesses and identify areas for improvement. In our field, we must commit to being lifelong learners, constantly embrace the continuous advances, and strive to improve our knowledge and skills to keep up with the changing times.

Nandini Venkateswaran, MD
  • Cornea, External Disease, and Refractive Surgery Fellow, Duke University, Durham, North Carolina
  • nandini.venkat89@gmail.com
  • Financial disclosure: None