Intense Simulation-Based Surgical Education for Manual Small-Incision Cataract SurgeryThe Ophthalmic Learning and Improvement Initiative in Cataract Surgery Randomized Clinical Trial in Kenya, Tanzania, Uganda, and Zimbabwe


Key Points

Question  Does the addition of simulation-based surgical education to conventional training improve cataract surgical competence among trainees?

Findings  In this randomized clinical trial, a simulation-based training intervention resulted in an almost 3-fold increase in objectively assessed surgical competence of trainees.

Meaning  These results support pursuing simulation-based surgical training units, which may lead to safer, more effective, and more efficient surgical skills before trainees progress to conventional live surgical training.


The Trial was funded by the British Council for the Prevention of Blindness, Ulverscroft Foundation, Christian Blind Mission (CBM), L’Occitane Foundation, Orbis International, and Queen Elizabeth Diamond Jubilee Trust. Dr Burton is supported by grant 207472/Z/17/Z from the Wellcome Trust. The trial sponsor was the London School of Hygiene & Tropical Medicine.

Principle Instigator
William Dean, Gichuhi Stephen, John Buchan


Importance  Cataracts account for 40% of cases of blindness globally, with surgery the only treatment.

Objective  To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees.

Design, Setting, and Participants  A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis.

Interventions  The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period.

Main Outcomes and Measures  The primary outcome measure was overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period.

Results  Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95% CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95% CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8% (42 of 537) for the intervention group and 26.6% (54 of 203) for the control group (difference, 18.8%; 95% CI, 12.3%-25.3%; P < .001).

Conclusions and Relevance  This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety