Cataract extraction is one of the most elegant and rewarding surgeries in all of medicine, but it is also one of the most difficult to learn. We surgeons work in a very tight space that allows little room for error, and we are always aware that our efforts will affect how patients see the world for the rest of their lives. Although we spend years as residents learning the basics of cataract surgery, we master the techniques only through a lifetime of practice.¹ The pearls presented in this article are intended to reduce the rate of complications encountered by beginning cataract surgeons and to help them to build a foundation for their future careers.

UNDERSTANDING BASIC CONCEPTS
Just as beginning drivers need to complete a class before they get behind the wheel of a car, ophthalmic residents need to learn the basics of cataract surgery before they pick up surgical instruments in the OR. A comprehensive educational curriculum should address everything from selecting patients and calculating the power of IOLs to creating incisions and utilizing phaco fluidics. Of particular importance, surgeons should acquire a thorough understanding of how a phaco machine works and the rationale underlying the choice of fluidic and power settings. Simply copying a senior surgeon's settings is not an ideal way to learn how to perform phacoemulsification.

Several excellent books provide beginning cataract surgeons with a step-by-step approach to learning phacoemulsification. One example is Achieving Excellence in Cataract Surgery: A Step-By-Step Approach by D. Michael Colvard, MD (video supplement available at http://eyetube.net/?v=fakiru).

In addition, surgical videos hosted by Eyetube.net and Youtube.com are valuable means of observing how experienced surgeons transform theory into practice, particularly during challenging cases.

Individual interaction is also important for preparing ophthalmologists to perform cataract surgery. For the past 10 years, Dr. Devgan has tested the knowledge of ophthalmic residents at the UCLA Jules Stein Eye Institute in Los Angeles by asking them a series of questions before he clears them to perform cataract surgery (see Dr. Devgan's Questions for Assessing Surgeons' Readiness). The questionnaire encourages beginning surgeons to think about the various aspects of surgery and gives them an incentive to prepare before they enter the OR.

SPENDING TIME IN THE WET LAB
The next step in learning how to perform cataract surgery is transforming basic knowledge into practical skills. We recommend that beginning surgeons spend a considerable amount of time (approximately 2 to 4 hours per week) in the surgical wet lab. Acquiring the skills needed to operate under a microscope and to use small-gauge instrumentation requires practice. We recommend that residents concentrate on closing incisions with 10–0 nylon, improving the dexterity of their nondominant hand, and pivoting or floating within the incisions. We have found that beginning surgeons need to tie hundreds of knots with 10–0 nylon before they achieve sufficient proficiency and finesse to place the suture with the right spacing and depth. They also must learn to create a square knot that has the correct amount of tension to ensure the apposition of the wound's edges without inducing astigmatism.

To develop a consistent surgical technique, residents should use the same phaco machines, viscoelastics, and instruments in the wet lab that they would use in the OR. Trainees should always keep in mind, however, that the young porcine eyes used in wet labs are significantly different from the eyes they will treat in senescent humans. We therefore urge residents to proceed with caution in the OR, even after they have become proficient in the wet lab.

USING SURGICAL SIMULATORS
Beginning surgeons can now supplement their experience in the wet lab with devices that simulate the conditions of cataract surgery. Recent evidence suggests that working with a surgical simulator can help surgeons acquire basic skills and improve their ability to execute the different maneuvers used during cataract extraction.^2-4 Educators are still determining the utility of surgical simulators in ophthalmic training, but further study may show that this exciting new technology is an important adjunctive tool for teaching young surgeons how to perform cataract surgery.

SEEKING INTRAOPERATIVE SUPERVISION
Once beginning surgeons are ready to enter the OR, they should choose an appropriate mentor to attend at least their first 100 procedures (Figure 1). This practice continues for the entire 3 years of residents' training in our respective programs. Because every step of cataract surgery depends on the previous ones, it often makes sense for residents to perform the last part of their mentors' surgeries. A poor incision can cause leakage and a radialized capsulorhexis, which can lead to a broken posterior capsule, vitreous loss, and a poor visual outcome. To avoid setting off this cascade of complications, beginning surgeons can start their practical education by closing the incision at the end of the case. Thereafter, they can work their way back through inserting the IOL, aspirating viscoelastic, and the incision's closure. Residents who are ready to perform an entire case by themselves should choose an appropriate patient and reserve enough time in the OR for an unhurried case. Most beginning surgeons find it easiest to begin with phaco techniques such as divide-and-conquer followed by stop-and-chop and finally phaco chop. They should also record and review all of their cases to learn from their mistakes.

We suggest that beginning surgeons watch recordings of every case they perform in real time and critique themselves. This exercise will allow them to identify the best parts of the surgery and to note areas where they need to improve. Since the goal of surgery is to improve patients' vision, postoperative monitoring is as important as the actual procedure. In addition, tracking patients' outcomes allows surgeons-in-training to hone their lens calculations, measure the incision's effect on astigmatism, and examine the level of trauma induced by the surgery.

CONCLUSION
Our advice to beginning surgeons is to stay focused and to be prepared to spend years sharpening their cataract surgical skills. In our experience, performing 100 to 200 cataract surgeries during residency is a good start, but ophthalmic surgeons truly become competent only after they complete an additional 500 to 1,000 cases. Surgical skill, judgment, and confidence should then consistently improve year after year over the course of a long career.

Richard E. Braunstein, MD, is an associate professor of clinical ophthalmology with the Edward S. Harkness Eye Institute at Columbia University Medical Center in New York. He acknowledged no financial interest in the products or companies mentioned herein Dr. Braunstein may be reached at reb10@columbia.edu; (212) 326-3320.

Uday Devgan, MD, is in private practice in Los Angeles, chief of ophthalmology at the Olive View UCLA Medical Center, and an associate clinical professor at the UCLA School of Medicine. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Devgan may be reached at (310) 208-3937; devgan@ucla.edu.

Laurence Sperber, MD, is director of the residency program, chief of the Cornea Service, and clinical professor of ophthalmology at the New York University School of Medicine and Manhattan Eye, Ear & Throat Hospital. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Sperber may be reached at (212) 263-6434; lsperbermd@post.harvard.edu.

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4. Mahr MA, Hodge DO. Construct validity of anterior segment anti-tremor and forceps surgical simulator training modules. Attending versus resident surgeon performance. J Cataract Refract Surg. 2008;34:980-985.