, cataract surgery has continued to evolve , with smaller incision procedures , development of premium intraocular lenses and laser - assisted surgery.13 in the field of retina , anti - vascular endothelial growth factor ( anti - vegf ) intravitreal injections have revolutionized treatment of macular edema and choroidal neovascularization.46 the field of glaucoma has experienced a new wave of therapeutic tools , with the development of microinvasive glaucoma surgery such as trabeculectomy ab interno and trabecular meshwork bypass shunts.7,8 in the cornea subspecialty , advances in partial thickness corneal transplant surgeries have transformed the field.9 all of these unique therapies continue to advance ophthalmology and offer hope for improved visual rehabilitation in various conditions . while expanding the array of therapeutic tools , these advances also challenge medical educators with the task of training residents with these new skills and in traditional management approaches .
given these recent advances , many studies have evaluated shifts in practice patterns among practicing ophthalmologists.1013 however , few studies have evaluated shifts in the experience of ophthalmology residents.14 the accreditation council for graduate medical education ( acgme ) is a nonprofit organization whose mission is to support high - quality resident and fellow education through accreditation of residency training programs .
it collects resident case logs annually as part of maintenance of accreditation . in this study
, we evaluate trends in resident surgical experience with core ophthalmic procedures from 2009 to 2015 by reviewing the acgme resident case logs .
acgme resident surgical case logs on cataract , cornea , retina , glaucoma , pediatrics , plastics , and trauma procedures published from 2009 to 2015 were analyzed for year - to - year trends in the average number of cases performed as primary surgeon.15 the yale university institutional review board ( irb)/ethics committee ruled that irb approval was not required for this study as it did not involve human subjects .
from 2009 to 2015 , the average number of residency programs per year was 166.3 , and the total number of residents was 2,797 for all 6 years . during this 6-year period ,
the average number of  phacoemulsification  cases performed by residents as primary surgeon steadily increased from 143.8 to 173.6 .
concurrently , the average number of  nonphacoemulsification / extracapsular cataract extraction  ( ecce ) cases decreased from 3.8 to 2.2 .
average number of primary anterior vitrectomy cases also declined from 3 to 1.8 over the same 6-year period ( table 1 ) . for cornea , the average number of  keratoplasty  and  other cornea  procedures remained relatively stable , ranging from 2.1 to 2.5 and 4 to 4.5 cases , respectively , over the 6-year period ( table 1 ) . for retinal procedures , average  vitreous
concurrently , average laser panretinal photocoagulation ( prp ) decreased from 59.6 to 45.5 cases and focal lasers decreased from 15.7 to 6.8 cases .
posterior vitrectomy cases remained stable , ranging from 4.8 to 5.4 from 2009 to 2015 ( table 1 ) . for glaucoma , from 2009 to 2015 , average  filtering procedures  decreased from 6 to 4.5 cases , while average  shunting procedures  with glaucoma drainage implants ( gdis ) increased from 4.5 to 6.7 cases ( table 1 ) .
pediatric , plastics , and trauma cases performed by residents as primary surgeon remained relatively stable from 2009 to 2015 .
average number of extraocular muscle surgery cases remained steady , ranging from 24.4 to 26.6 over the 6-year period .
ptosis repair and blepharoplasty / reconstruction cases slightly increased , ranging from 6.1 to 6.7 and 9.1 to 11.2 , respectively .
globe rupture repair ranged from 7.2 to 7.6 cases over this 6-year period ( table 1 ) .
a review of the acgme ophthalmology resident case logs from 2009 to 2015 revealed significant trends in the areas of cataract , retina , and glaucoma procedures , while cornea , pediatric , plastic , and trauma procedure experience remained relatively stable . in the category of cataract surgery , resident primary cases in phacoemulsification steadily increased while ecce cases declined .
since the advent of phacoemulsification , ecce has largely been reserved for mature or hypermature cataracts .
the trend in resident experience with ecce is likely a reflection of practicing ophthalmologists shift toward phacoemulsification for standard cataract surgery .
this trend suggests that over the next few years , residents may no longer have ecce experience during their training .
it raises the question of whether ecce case minimums should be established to equip residents with an alternate method of cataract extraction in cases not suitable for phacoemulsification .
this trend suggests that educators may need to provide more didactic education on this technique and highlight important steps during other procedures with related surgical maneuvers . additionally ,
since ecce is commonly practiced in other nations , where patients may present with more advanced cataracts , it may be advantageous for us residents to be familiar with this approach , which may prepare them better for experiences in international ophthalmology .
the field of retina has undergone tremendous advances over the past decade , with the development of intravitreal anti - vegf therapies .
most notably , primary resident vitreous tap / inject procedures almost tripled over this 6-year period , while laser prp and focal laser experience slowly declined .
although average prp experience demonstrated a declining trend , the average number of cases remained relatively high at 45.5 in the 20142015 academic year .
therefore , prp does not seem to be a skill at risk of becoming lost to future residents .
however , the number of focal laser cases was quite low and on a declining trend , which could make it absent from residency curricula in the future .
this shift in practice pattern has been demonstrated in american glaucoma society surveys of practicing glaucoma specialists as well as medicare claims data , and has likely influenced trainee surgical experience.1214 the decline in filtering surgery experience is concerning considering it is a core surgical management procedure in glaucoma .
glaucoma educators may need to find a way to maintain trabeculectomy training in the setting of decreasing surgical volume .
construction of partial thickness scleral flaps for gdi tube coverage may be a means of teaching flap creation for trabeculectomy .
while corneal surgery has experienced many advances in the area of partial thickness graft surgery , it does not seem to have impacted resident cornea surgery experience yet .
resident cornea procedure average values remained relatively stable . because cornea procedures were categorized broadly as 
keratoplasty  and  other cornea  procedures , it is difficult to analyze resident cornea experience in further detail .
botox injection for strabismus correction emerged as a new therapeutic option , but does not appear to have affected resident surgical experience with traditional muscle surgery and is not currently part of the case logs.16 likewise , in plastics , while many new technologies continue to emerge , resident case numbers with ptosis repair , blepharoplasty , and entropion / ectropion repair have remained stable .
lastly , resident trauma experience with globe rupture repair remained relatively stable from 2009 to 2015 .
in reviewing the acgme case logs of ophthalmology residents over the past 6 years , significant changes in surgical experience in the area of cataract , retina , and glaucoma were identified .
the trends in these subspecialty areas correspond to the development of new techniques or therapies in these fields .
these findings highlight a need for educators to be aware of how such shifts can influence ophthalmology residents experience and education .
they also suggest that required procedure minimums and resident achievement of these minimums should be periodically reevaluated as new technologies emerge , to help preserve training in core skills as well as remain current with new advances .
finally , educators may need to become innovative in teaching surgical technique of less common procedures .
 backgroundresident procedure minimums have been established in surgical training programs to ensure adequate training experience . 
 however , achievement of these minimums may fluctuate . 
 review of resident experience is essential for maintaining successful training curricula.objectiveto evaluate trends in ophthalmology resident surgical experience from 2009 to 2015.methodsthis was a database study reviewing accreditation council for graduate medical education ophthalmology resident surgical case logs . 
 case logs from 2,797 us ophthalmology residents were reviewed for trends in average surgical cases performed by residents as primary surgeon in the area of cataract , cornea , retina , glaucoma , pediatrics , plastics , and trauma from 2009 to 2015.resultssignificant trends in resident surgical experience were demonstrated in the areas of cataract , retina , and glaucoma , while experience in cornea , pediatrics , plastics , and trauma remained stable . 
 these trends included an increase in average cases of phacoemulsification cataract surgery from 143.8 to 173.6 , vitreous tap / inject procedures from 31.3 to 93.1 , and glaucoma shunt surgery from 4.5 to 6.7 , with a decline in average cases of nonphacoemulsification cataract surgery from 3.8 to 2.2 , retinal photocoagulation from 59.6 to 45.5 , and filtering surgery from 6 to 4.5.conclusiontrends in ophthalmology surgical experience in cataract , retina , and glaucoma paralleled new surgical or therapeutic developments as well as practice pattern shifts in these fields . 
 educators should be cognizant of the impact of such trends on resident experience and determine if curricular adjustments should be made to maintain comprehensive education of physicians - in - training . 