Improving surgical outcomes

of cataract surgery are worse than we would like them to be. Community-based studies show that up to 40% of eyes have a postoperative presenting vision of <6/60. 1 Eyes with intraocular lenses (IOLs) do better; however, it has been shown that even in prosperous middle-income countries, such as Venezuela, in 20% of pseudophakic eyes presenting vision was <6/60 and in 15% best corrected vision was worse than 6/60. Poor outcomes matter. Patients deserve improved vision whenever possible and poor outcomes deter prospective patients from coming for surgery and probably reduce their willingness to pay for their treatment – particularly if they have to pay in advance! In this article, we offer some suggestions for improving the quality of cataract surgery. We admit that there is little evidence base for most of these suggestions and that some of them are controversial. However, we hope to stimulate debate. 1 selection and training of ophthalmologists Selection processes usually emphasise academic credentials rather than clinical or surgical skills. It is difficult to test surgical aptitude during a selection process; however, generic tests of hand-eye coordination do exist and are used routinely in the selection and training of pilots. Should we consider using similar tools to select ophthalmologists? At the very least, we should ensure that trainees have stereoscopic vision. Selection is not always based on quality. Some postgraduate programmes do not even identify candidates who are interested in ophthalmology, because the country desperately needs ophthalmologists. The training of ophthalmic assistants in many countries in Africa offers another example. Originally, this training consisted of one year of clinical ophthalmology for everyone, after which suitable candidates were selected for another year of training in cataract surgery. However, to answer needs in personnel, training programmes now last eighteen months to two years and all students on the course are trained in cataract surgery, regardless of inclination or aptitude. The trainees' cataract surgical skills vary greatly and it is unlikely that this change has improved cataract outcomes. Postgraduate training of eye surgeons should also have explicit targets for trainees, such as: number of operations that must be • performed before trainees can qualify as ophthalmologists (e.g. in the UK, this number is 300, but most trainees perform more than 500 in practice) level of supervision: initially the trainee will • be closely supervised by the trainer, but, by the conclusion of training, trainees should be able to …