The research team, led by Franziska Eckardt, Maximilian-Joachim Gerhardt and Siegfried Priglinger, enrolled 32 participants with no prior microsurgical experience: 16 medical students who had some exposure to ophthalmology and 16 residents. Each participant completed standardized cataract and vitrectomy training modules on the EyeSi surgical simulator, manufactured by Haag-Streit in Köniz, Switzerland, once under the conventional microscope and once with a 3D display. Because every trainee used both systems, the crossover design allowed direct within-participant comparison. The investigators recorded objective performance parameters scored by the simulator and collected subjective evaluations through questionnaires covering safety, handling, comfort, learning progress and interaction with instructors.

The objective results were mixed but largely reassuring for advocates of heads-up technology. In the vitrectomy simulation, scores did not differ significantly between the two visualization systems, with a p-value of 0.126. In the cataract simulation, however, the conventional microscope achieved significantly higher scores, with a p-value of 0.023. Across both modules combined, the overall task scores showed no significant difference between the systems, at p = 0.376.

Where the 3D heads-up system clearly stood out was in subjective ratings. Participants rated it significantly superior in terms of control, with p = 0.013; instrument handling, with p = 0.033; and movement precision, with p < 0.001. It was also rated better for comfort and for interaction with the instructor, both reaching p < 0.001.

Preferences for one system over the other diverged by level of training. Students tended to prefer the 3D system, whereas residents more often preferred the conventional microscope, although this difference in preference was not statistically significant, with p = 0.183. The authors interpret this pattern as a possible habituation effect: residents, having spent more time at the slit lamp and with conventional visualization techniques, may simply be more familiar with the traditional arrangement, while students arrive without those learned habits and adapt readily to the digital display.

Notably, every participant in the study reported that skills acquired while training with the 3D system could be transferred to the conventional microscope. This perceived transferability matters for training programs, because it suggests that introducing trainees to microsurgery through a heads-up display is unlikely to lock them out of conventional operating environments, even if it does not yet match the conventional microscope for objective cataract simulator performance.

The findings arrive as 3D digital visualization systems are becoming increasingly integrated into contemporary ophthalmic surgery. The authors argue that early exposure to heads-up technology during simulator-based training may help familiarize trainees with these modern visualization techniques before they encounter them in the operating room.

The study’s conclusions are bounded by its design and scale. It was a single-center trial with 32 participants, all novices to microsurgical simulation, and its outcome measures were simulator scores and subjective questionnaires rather than performance in real operations. The authors explicitly state that future clinical studies are required to determine whether these simulator-based findings translate into improved operative performance in actual surgery. The published version is an open-access article released early as a citable accepted manuscript, subject to further editorial processing before the final Version of Record appears.

For surgical educators, the study offers a pragmatic message. The 3D heads-up display achieved comparable simulator performance in vitrectomy training and somewhat lower performance in cataract training compared with the conventional microscope, while trainees consistently rated it better for comfort, precision, control and interaction with instructors. Given the varying preferences between students and residents and the possible role of habituation, the results do not declare one technology superior overall, and the authors note only that early simulator exposure to heads-up systems may familiarize trainees with visualization techniques that are increasingly common in contemporary ophthalmic surgery.

Subject of Research: Comparison of conventional operating microscopy and 3D heads-up visualization for teaching ophthalmic microsurgical skills on a virtual reality simulator

Article Title: Teaching ophthalmic microsurgical skills: conventional microscopy versus heads-up visualization

Article References: Eckardt, F., Gerhardt, M. J., & Priglinger, S. (2026). Teaching ophthalmic microsurgical skills: conventional microscopy versus heads-up visualization. BMC Medical Education, 26(1), Article 1403. https://doi.org/10.1186/s12909-026-10269-9

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10269-9

Keywords: ophthalmology, microsurgery, surgical training, 3D heads-up visualization, virtual reality simulator, cataract surgery, vitrectomy, medical education, EyeSi simulator, ergonomics, Teaching, ophthalmic

The descriptive, correlational study was conducted at a university hospital’s eye clinic between April and August 2025. Before surgery, researchers collected data through face-to-face interviews using a personal information form and scales measuring surgical fear, health perception and health literacy. The reported mean scores were 6.38 ± 10.98 for surgical fear, 51.35 ± 4.98 for health perception and 95.44 ± 19.08 for health literacy.

No significant correlation was observed between surgical fear and either health perception or health literacy. Health perception and health literacy, however, had a strong positive correlation. A moderation analysis showed that health literacy significantly modified the relationship between health perception and surgical fear. Simple slope analysis indicated that lower health perception was associated with higher surgical fear among patients with low health literacy, whereas the association was not significant among those with high health literacy.

The results are limited by the descriptive, correlational design, the sample of 225 patients recruited from one university hospital’s eye clinic and the preoperative timing of data collection. The abstract does not provide details about participant characteristics, scale interpretation, model specifications, potential confounding factors or clinical outcomes. It also does not report whether surgical fear or health literacy affected compliance, recovery or other postoperative results. The authors suggest that health literacy levels may be relevant to tailored preoperative communication and counselling for cataract surgery, but the study did not test such strategies or their effects.

Subject of Research: Moderation of the association between health perception and surgical fear by health literacy in preoperative cataract patients

Article Title: Examining the moderating role of health literacy in the relationship between surgical fear and health perception in cataract surgery

Article References: Gülşen, M., Ünal, Z., Binokay, H., & Arslan, S. (2026). Examining the moderating role of health literacy in the relationship between surgical fear and health perception in cataract surgery. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15716-3

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15716-3

Keywords: cataract surgery, health literacy, surgical fear, health perception, preoperative care, moderation analysis, observational study, university hospital, Examining, moderating, role, health

The study, published in Frontiers in Ophthalmology by Koen Willekens of Visionair oogzorg in Geel, Antwerp, enrolled ten eyes of ten patients with glaucoma scheduled for cataract surgery between October 2024 and June 2025. All procedures were performed with the Zeiss Quatera 700 system, with the intraocular pressure target set to its minimum of 30 mmHg for every step of the operation. The cohort included eight eyes with primary open-angle glaucoma and two with primary angle-closure glaucoma, with patients averaging 71.5 years of age and most taking two or more pressure-lowering medications daily.

The primary outcome was deliberately simple: the occurrence of any intraoperative surgical complication. All ten procedures were completed without a single observed complication, an event rate of 0.0 percent. The exact 95 percent Clopper–Pearson confidence interval, however, stretched from 0.0 to 30.8 percent—a statistical reminder that ten eyes cannot rule out rare events like posterior capsule rupture, which typically occurs in 0.6 to 2.1 percent of modern cataract surgeries. The study was explicitly framed as a feasibility pilot, not powered to establish comparative safety.

What makes the Quatera 700 technically distinctive is its QUATTRO Pump, a synchronized dual-pump system that balances infusion and aspiration in real time. Conventional peristaltic or Venturi machines rely on gravity-fed bottles and must compensate for post-occlusion surge—the sudden collapse of the anterior chamber when an occlusion breaks—by raising infusion pressures well above physiologic levels. The QUATTRO Pump instead continuously calculates and adjusts fluid flow based on incision leakage, predicted occlusion breaks, and sudden changes in aspiration demand. Bench-testing data cited in the study show that the platform maintains effective intraocular pressure within roughly 2 mmHg of its programmed target, even at aspiration flow rates up to 90 cc/min, and bounds post-occlusion surge durations to a brief 282 to 408 milliseconds.

The distinction between target pressure and measured pressure is crucial. Target intraocular pressure is the digital parameter programmed into the console; measured pressure is the true dynamic hydrostatic pressure inside the patient’s anterior chamber during active surgery. In standard platforms, high fluidic demand or an occlusion break creates a large discrepancy between these two metrics, frequently producing unmeasured hypotony or surges that collapse the chamber. The Quatera’s sensor-driven pump minimizes this fidelity gap, which is why the anterior chamber remained stable even during critical moments such as phaco tip occlusion and sudden surge, with no recorded instances of shallow anterior chamber, iris prolapse, or capsular protrusion.

Beyond safety, the study tracked efficiency metrics. Mean effective phaco time—the cumulative ultrasound energy delivered—was 3.24 seconds with a standard deviation of 2.01 seconds, aided by a pre-chopping technique that obviated the need for sculpting. Mean surgical duration was 443 seconds, or roughly seven and a half minutes. Lower ultrasound energy reduces thermal injury risk, corneal endothelial cell loss, and postoperative inflammation, and prior work by Rauen and colleagues in 2024 demonstrated that maintaining pressures at or below 30 mmHg with active fluidics significantly reduced corneal trauma and endothelial cell loss compared to conventional high-pressure techniques.

Visual outcomes were encouraging. Best-corrected visual acuity improved in nine of ten eyes, with a median paired logMAR change of −0.10 from baseline to one month postoperatively, a statistically significant improvement with a p-value of 0.0137. Visual field mean deviation, a functional measure of glaucomatous damage, remained stable at one month with a mean paired shift of +0.58 dB. Mean intraocular pressure actually decreased from 18.65 to 14.79 mmHg at one month, consistent with prior reports showing modest pressure reduction following phacoemulsification, though this change did not reach statistical significance in this small sample.

Two patients experienced postoperative pressure spikes above 30 mmHg—one delayed spike of 33.4 mmHg at week one and one acute spike of 35.0 mmHg on day one—yielding a 20 percent event rate. Both resolved within 48 hours following short-term systemic acetazolamide. The study notes that transient pressure elevation on the first postoperative day is common in glaucoma patients, likely due to retained viscoelastic, inflammation, or trabecular meshwork debris, and was within a manageable range in this cohort.

Structural monitoring revealed an increase in average retinal nerve fiber layer thickness of +4.02 micrometers at one month, alongside a marked improvement in OCT signal strength from a baseline mean of 6.50 to a postoperative mean of 8.80. The study cautions that this RNFL increase likely reflects improved image acquisition after cataract removal rather than true neural tissue change, a phenomenon previously reported by Mwanza and colleagues in 2011. Cataract removal clears the optical media, allowing OCT scanners to capture cleaner images of the same tissue.

The study’s limitations are substantial and acknowledged by the author. Ten patients, a single surgeon, a single center, no masking, no control group, and a one-month follow-up window collectively restrict statistical power and generalizability. The cohort was highly selected, excluding patients with endothelial dystrophy, active uveitis, known corticosteroid responders, or functionally monophthalmic eyes. Larger randomized comparative trials are required to confirm these preliminary safety profiles and determine long-term clinical benefits in a broader glaucoma population. Still, as a proof of concept, the study demonstrates that operating at a target of 30 mmHg—the lowest setting currently available in the Quatera 700 software—is clinically feasible, and the author suggests that efficient cataract extraction at truly physiologic pressures near 15 mmHg might be possible in the future as the technology matures.

Subject of Research: A pilot feasibility case series of low-pressure cataract surgery at 30 mmHg using the Zeiss Quatera 700 in ten glaucoma patients reported no intraoperative complications and improved visual acuity.

Article Title: Prospective descriptive pilot feasibility case series of low-pressure cataract surgery with the Zeiss Quatera 700 in glaucoma patients

Article References: Willekens, K. (2026). Prospective descriptive pilot feasibility case series of low-pressure cataract surgery with the Zeiss Quatera 700 in glaucoma patients. Frontiers in Ophthalmology, 6, Article 1824059. https://doi.org/10.3389/fopht.2026.1824059

Image Credits: AI Generated

DOI: 10.3389/fopht.2026.1824059

Keywords: cataract surgery, glaucoma, intraocular pressure, Zeiss Quatera 700, QUATTRO Pump, phacoemulsification, ocular perfusion, pilot study, anterior chamber stability, effective phaco time, logMAR, optical coherence tomography

The retrospective study, conducted at Alexandrovska University Hospital in Sofia, evaluated 56 patients representing 67 eyes who underwent uncomplicated phacoemulsification cataract surgery with implantation of the lens into the capsular bag. All operations were performed by a single experienced surgeon, and patients were divided into three groups according to the lens they chose after preoperative counseling. Twenty-five patients received a standard monofocal lens drawn from several commercially available models, 17 patients received the Evolux™ enhanced monofocal lens, and 14 patients received an extended depth of focus, or EDOF, lens. Patients with corneal astigmatism of 0.50 diopters or more and those with toric lenses were excluded, keeping the comparison as clean as the retrospective design allowed.

The Evolux™ lens, developed by AffaMed Therapeutics and SIFI S.p.A., is made from a hydrophobic material and carries a non-diffractive optical profile. Unlike multifocal lenses, which split incoming light between multiple focal points, and unlike diffractive EDOF designs, which redistribute light to stretch the focal range, the enhanced monofocal profile is engineered to sharpen intermediate vision while preserving distance clarity equivalent to a traditional monofocal lens. Its optical technology is reported to show very low dependence on pupil diameter at far and intermediate distances, similar image contrast across different pupil sizes, and good tolerance to residual refractive errors, with a low reported incidence of tilt, decentration, and photic phenomena.

Visual acuity was measured before surgery and again on the seventh and thirtieth postoperative days, using a Snellen chart calibrated at six meters for distance vision and an intermediate chart calibrated at 66 centimeters. Before surgery, the three groups were closely matched: mean best-corrected distance acuity ranged from 0.18 in the monofocal group to 0.21 in the EDOF group, and mean intermediate acuity ranged from 0.25 to 0.30. On the thirtieth postoperative day, distance acuity had converged across all groups, with mean uncorrected values of 0.80 for the monofocal group, 0.83 for the Evolux™ group, and 0.84 for the EDOF group. The researchers emphasize that this convergence is clinically relevant, because any gain in intermediate vision should ideally not come at the expense of distance clarity.

The real separation appeared at 66 centimeters. The monofocal group averaged 0.54 uncorrected intermediate acuity, meaning most patients still needed glasses for computer-distance tasks, and the best individual result in that group was 0.8. The Evolux™ group averaged 0.79, with six eyes reaching 1.0, or 20/20, at the intermediate distance. The EDOF group led with a mean of 0.93, and post hoc analysis confirmed that its intermediate acuity was significantly better than both the Evolux™ lens and the monofocal lenses. Expressed relative to preoperative values, intermediate acuity improved by 116 percent in the monofocal group, 182 percent in the Evolux™ group, and 210 percent in the EDOF group, a hierarchy the authors note is consistent with the intended optical characteristics of each lens category.

Acuity alone, however, does not capture the full quality of vision. Optical strategies that extend the depth of focus necessarily alter how light is distributed across the retina, which can reduce the ability to distinguish objects of similar luminance, particularly under dim or unfavorable conditions. To probe this, the team measured contrast sensitivity on the thirtieth postoperative day using the Pelli-Robson chart at one meter, a logarithmic test on which scores near 2.00 indicate normal contrast sensitivity. The results were striking. In the monofocal group, 79.31 percent of eyes recorded 2.00 log units, and in the Evolux™ group 68.18 percent did so. In the EDOF group, only 25 percent of eyes reached 2.00, while 56.25 percent recorded 1.85 log units. Although the sample size limits definitive conclusions, the distribution suggests that the broader visual range of EDOF optics is accompanied by a measurable reduction in contrast sensitivity, a finding consistent with earlier work by Kohnen and colleagues.

Patient-reported outcomes added a subjective dimension to the objective measurements. On a satisfaction scale from 0 to 10, nearly all patients in every group reported their distance vision as excellent, with only isolated scores of 9 or lower. The differences emerged in the frequency of photic phenomena: one patient in the monofocal group reported halos with nighttime driving difficulties, one reported diplopia, and another reported glare. In the Evolux™ group, only a single patient reported glare, and no one reported halos. In the EDOF group, three patients, or 18.75 percent, reported photic phenomena such as glare or halos around light sources. The authors attribute the low frequency of complaints in the Evolux™ group to its non-diffractive design, which avoids the light splitting that generates halos and glare in diffractive optics.

The pattern that emerges across the three groups is essentially a trade-off between range and quality. Conventional monofocal lenses delivered good distance vision and preserved contrast sensitivity but left patients dependent on spectacles for anything closer than arm’s length. EDOF lenses delivered the highest intermediate acuity and the greatest spectacle independence but showed reduced contrast sensitivity and the most frequent photic symptoms. The Evolux™ enhanced monofocal occupied the middle ground, delivering a substantial gain in intermediate vision over conventional monofocal lenses, comparable distance acuity, preserved contrast sensitivity, and a low incidence of halos and glare. The authors also point to an economic dimension, noting that enhanced monofocal lenses may be an attractive option for patients for whom the premium price of EDOF or multifocal lenses is a limiting factor.

For clinical counseling, the findings suggest that not every patient requires maximal spectacle independence at all distances. Some prioritize excellent distance vision, good intermediate vision for screens, and minimal photic phenomena over the highest possible near acuity, and for these patients an enhanced monofocal lens may represent an appealing alternative. The study’s strengths include its direct three-group comparison in a single clinical setting, the combination of objective acuity and contrast sensitivity with patient-reported satisfaction, and the standardization offered by a single surgeon and uniform postoperative treatment. The authors caution that the retrospective design and modest sample size are real limitations, and they call for larger prospective studies with standardized patient-reported outcome measures and longer follow-up to confirm the position of enhanced monofocal lenses in the cataract surgery landscape.

Subject of Research: Ophthalmology

Article Title: A comparative study of visual outcomes and patient satisfaction with Evolux™, monofocal, and extended depth of focus intraocular lenses

Article References: Zdravkov, Y., Dzhambazov, R., Veleva, N., Haykin, V., & Oscar, A. (2026). A comparative study of visual outcomes and patient satisfaction with Evolux™, monofocal, and extended depth of focus intraocular lenses. Pharmacia, 73, Article e200063. https://doi.org/10.3897/pharmacia.73.e200063

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e200063

Keywords: cataract surgery, intraocular lenses, enhanced monofocal IOL, Evolux, EDOF lens, contrast sensitivity, patient satisfaction, intermediate vision, ophthalmology, vision correction, comparative, visual

Researchers at Ziv Medical Center in Safed, a tertiary hospital serving a region where Jewish and Arab communities live in close geographic proximity, reviewed the records of 251 patients aged 60 and older who underwent cataract surgery during 2023. Of these, 153 were Jewish and 98 were Arab. Every operation was performed using the same standardized phacoemulsification technique on the same Centurion Vision System, carried out by senior attending surgeons or supervised senior residents. On paper, the two groups were remarkably similar: the median age was 73 years in both, and the sex split was nearly identical, with roughly half of each cohort being male.

The team extracted demographic details, comorbidities, cataract types, complications, and best-corrected visual acuity from electronic medical records, comparing outcomes at baseline and again at 30 days after surgery. Statistical analysis was performed with IBM SPSS Statistics version 31, using non-parametric Mann-Whitney tests for continuous variables and chi-square or Fisher’s exact tests for categorical ones. Crucially, the two groups started from the same place: preoperative visual acuity was statistically indistinguishable, with both cohorts showing a median LogMAR of 0.7, corresponding to moderately impaired vision before the operation.

But by 30 days after surgery, the trajectories had separated. Jewish patients achieved a median LogMAR of 0.5, while Arab patients remained at 0.7 — a statistically significant difference that reflects meaningfully better visual recovery in the Jewish cohort. In Snellen terms, the Jewish group’s median acuity improved to roughly 20/40 territory while the Arab group lagged behind. Because both groups began with equivalent vision and were operated on under identical conditions, the divergence points to factors beyond the operating room itself.

The complication data were even more striking. Sixty-six percent of Jewish patients experienced no postoperative complications at all, compared with just 28.6 percent of Arab patients. Corneal edema — swelling of the transparent front window of the eye, the most common early complication of phacoemulsification — affected 43.9 percent of Arab patients versus 15.7 percent of Jewish patients, a difference with a p-value below 0.001. Posterior capsule rupture, a more serious intraoperative complication in which the thin membrane holding the lens in place tears, occurred in 11.2 percent of Arab patients versus 3.3 percent of Jewish patients. Rates of retained lens fragments, posterior capsular opacification, intraocular lens dislocation, and elevated intraocular pressure, by contrast, were statistically similar between the groups.

To test whether these gaps could be explained by measured baseline differences, the researchers ran a multivariable logistic regression adjusting for age, sex, hypertension, and diabetes. Even after this adjustment, Arab ethnicity remained independently associated with postoperative complications, with an adjusted odds ratio of 4.74 — meaning Arab patients were nearly five times more likely to experience at least one complication. Male sex carried a borderline association with complications, and diabetes showed a borderline-significant trend, but neither age nor hypertension reached statistical significance. The persistence of the ethnic signal after adjustment suggests that unmeasured factors — not the variables captured in the chart — are doing much of the work.

One obvious candidate is the comorbidity burden itself. Arab patients in the cohort had significantly higher rates of diabetes, 54.1 percent versus 35.9 percent, and hypertension, 70.4 percent versus 58.2 percent. Diabetes is a well-recognized risk factor for more complex cataract surgery and slower postoperative recovery, and regional epidemiological studies have consistently documented higher diabetes prevalence among Arab populations in Israel. The study authors are careful to note, however, that these lifestyle and dietary patterns were not directly assessed in this study, and no causal inferences can be drawn from the observed associations.

Perhaps the most important conceptual contribution of the paper is how the authors frame ethnicity itself. They emphasize that ethnicity in this context should be understood as a social and structural variable — a marker for differences in comorbidity burden, socioeconomic status, health literacy, healthcare access, and utilization patterns — rather than as an indicator of any biological or genetic difference between groups. This framing aligns with a substantial body of literature on ethnic health disparities in Israel, which attributes such gaps primarily to structural and socioeconomic determinants. In other words, the disparity is real, but it is not about ethnicity per se; it is about everything that travels with it.

The authors also acknowledge significant limitations that temper the findings. The study was retrospective and single-center, restricting generalizability and introducing potential selection bias. Follow-up was limited to 30 days, which may underestimate long-term recovery — corneal edema, the most common early complication, often resolves over weeks to months, potentially narrowing the observed gap over time. Critically, the study lacked standardized preoperative lens grading using the Lens Opacities Classification System III, meaning that denser or more advanced cataracts in the Arab cohort — which require longer phacoemulsification time and greater ultrasound energy — cannot be excluded as a contributor to the higher rates of posterior capsule rupture and corneal edema. Inter-surgeon variation in technique and experience was also not captured, and socioeconomic status, health literacy, and adherence to postoperative eye drops were not directly measured.

Those unmeasured factors may prove decisive. Prior research has linked poor compliance with anti-inflammatory and antibiotic eye drops to higher complication rates, including persistent corneal edema and cystoid macular edema, and differences in health literacy, language proficiency, understanding of postoperative instructions, and cultural patterns of healthcare utilization could all plausibly shape recovery. Delayed presentation and barriers to accessing ophthalmic care before surgery may also play a role, though referral patterns were not assessed. The authors call for multicenter, prospective studies with longer follow-up, surgeon-level data, and objective adherence measures such as medication possession ratios or electronic drop monitors to disentangle these threads. In the meantime, the study delivers a clear message for clinicians and policymakers: achieving equity in cataract care requires more than equal access to the same operating room — it demands attention to the comorbidities, education, adherence, and social circumstances that patients carry with them through the hospital doors.

Subject of Research: Ethnic disparities in short-term visual outcomes and complications after cataract surgery among elderly Jewish and Arab patients in Northern Israel

Article Title: Comparative analysis of cataract surgery outcomes in elderly Jewish and Arab patients from Northern Israel, a retrospective cohort study

Article References: Boqaaiya, S., Nujedat, D., Cohen, Y., Ward, S., Ghnem, E., Sharabi Nov, A., Beiruti Wiegler, K., & Chassid, O. (2026). Comparative analysis of cataract surgery outcomes in elderly Jewish and Arab patients from Northern Israel, a retrospective cohort study. Frontiers in Ophthalmology, 6, Article 1942047. https://doi.org/10.3389/fopht.2026.1942047

Image Credits: AI Generated

DOI: 10.3389/fopht.2026.1942047

Keywords: cataract surgery, ethnic disparities, health equity, corneal edema, posterior capsule rupture, phacoemulsification, visual acuity, diabetes, elderly patients, Israel, ophthalmology, health literacy

The reasoning behind the project is straightforward yet profound. A transit to Mars can require almost a year, and returning to Earth for a vision-limiting cataract, an injury, or another surgical eye problem may simply not be realistic. Dr Micheletti told the congress that he believes someone will need cataract surgery on Mars within his lifetime, and that treatment will ultimately need to happen where the patient is. Astronaut candidates, he noted, do not need perfect uncorrected vision, and refractive correction or certain prior refractive surgeries are compatible with selection. More importantly, good vision at launch does not prevent aging, radiation exposure, injury or disease later in the mission. As human spaceflight expands beyond career astronauts, the travelling population will become more diverse, and the medical systems that support it must be designed and validated long before the first patient needs them. In his words, we cannot wait until someone is on Mars to ask whether the lens, equipment and sterile supplies survived the trip.

To begin answering that question, Dr Micheletti launched the Joint Assessment Of Material Exposure In Space, or JAMES, project. The experiment flew 135 unpackaged intraocular lenses to the International Space Station, where they were mounted in special carriers positioned at three different exterior locations. The carriers, named CLAIRE, short for Carrier for Lens Analysis in Interstellar Research Expeditions, held lenses at three distinct test sites: Ram, where the lenses were exposed to high levels of atomic oxygen; Zenith, where they received substantial ultraviolet radiation from the Sun; and Underdeck, where they were partially shielded from direct atomic oxygen and solar ultraviolet by being mounted beneath the exposure platform. This placement strategy allowed the researchers to observe how different combinations of space-environment stressors affect lens materials.

Dr Micheletti was careful to explain that the study was not intended to recreate how a packaged intraocular lens would normally be shipped to Mars. Instead, the purpose was to identify potential failure modes under harsh exposure so that better packaging, shielding, storage and material selection strategies can be designed. Testing the lenses inside the station would not answer the same question, because the interior is controlled and pressurised. The team wanted to minimise packaging and, ideally, determine whether these products can be shipped without climate-controlled crew-cabin storage, because mass and volume carry significant costs in spaceflight. Every kilogram launched toward deep space demands fuel, money and payload capacity, so medical supplies that can survive the journey without elaborate protective enclosures would represent a meaningful engineering advantage.

On Earth, 45 intraocular lenses were removed from their original packaging and placed in a control carrier called WILLIAM, the Worldly Interface for Lens Logistics and Integrated Astronomical Monitoring. These control lenses remained at room temperature and atmospheric pressure for the duration of the experiment. After approximately six months in orbit, the 135 flight lenses returned to Earth for laboratory analysis. The current analysis included 61 of the space-flown lenses and 20 of the 45 terrestrial controls, a total of 81 lenses. Dr Liliana Werner and her team at the Intermountain Ocular Research Center at the University of Utah examined each lens for overall clarity, how well the lens materials remained intact, and whether any deposits or surface changes had developed during the mission.

The results revealed a spectrum of responses to the space environment. Most of the lenses, 42 of the 61 analysed, showed no notable exposure-associated findings when examined. The remaining 19 lenses displayed three principal patterns of change. In the most directly exposed Ram tray, eight of the nine lenses showed cracks and localised surface roughening consistent with early atomic oxygen erosion. All eight were acrylic lenses, including five hydrophobic and three hydrophilic designs, while the ninth lens, made of silicone, showed yellow discoloration instead. Atomic oxygen, the highly reactive form of oxygen that predominates in low-Earth orbit, is a well-known hazard for spacecraft surfaces, and these findings suggest it can degrade certain ophthalmic materials even over a relatively short orbital stay.

The second pattern involved yellow discoloration in five space-exposed lenses, including two hydrophobic acrylic and three silicone lenses. Four of these were located in the Zenith tray and one in the Ram tray. Spectrophotometry measurements showed lower light transmission in the affected lenses, particularly between 400 and 500 nanometres, the blue region of the visible spectrum that is essential for colour perception and contrast. This finding is especially relevant for a device whose entire purpose is to transmit light clearly to the retina. A yellowed lens inside an eye would act somewhat like a permanent filter, subtly altering the colour and quality of the vision it delivers, which could matter for pilots, scientists or anyone performing precision tasks in space.

The third and perhaps most puzzling pattern emerged among the light-adjustable lenses. All six of these space-exposed lenses, located across all three positions on the station’s exterior, developed a similar cobblestone or bubble-wrap appearance on both surfaces and along the optic edge. Neither of the two corresponding terrestrial controls showed this appearance. The mechanism behind the change remains unknown, and the researchers note that an explanation unrelated to direct space exposure cannot yet be excluded. Light-adjustable lenses are a sophisticated class of intraocular lenses whose optical power can be fine-tuned after implantation using ultraviolet light, making any unexplained surface alteration on their polymers particularly worthy of investigation before such devices are trusted on a mission where no replacement is available.

Dr Micheletti stressed that this was an exploratory, descriptive study, not designed to compare different makes or types of lenses or to test a formal hypothesis. The analysis covered a selected subset of the payload, sample sizes were small and uneven, and in some carrier positions there was only one lens of a given model. The lenses were deliberately unpackaged, so handling or environmental contamination could not be fully excluded, and the control lenses did not undergo launch, return or flight handling, which limits attribution of the observed changes specifically to external exposure. Beyond transmission spectrophotometry, image-quality, mechanical and clinical-performance testing has not yet been completed. The findings, he cautioned, should not be used to rank manufacturers or lens models and do not imply any safety concern for routine cataract surgery on Earth. What they do suggest is that lens material and exposure location may influence the changes observed, and that packaging, shielding and storage are the next protective strategies to test. The engineering challenge, he said, will be providing enough protection without adding unnecessary mass, because every kilogram sent into space carries a cost.

The significance of the work was underlined by Dr Joaquín Fernández, ESCRS Secretary, CEO of Qvision and Medical Director of the Andalusian Ophthalmology Institute at Vithas Hospitals in Almería, Spain, who was not involved in the research. He observed that as more people travel into space and for longer periods, eye surgery will likely be required at some point, making it imperative to understand how lenses and other surgical materials behave beyond Earth’s atmosphere, and he described the research as forward-thinking and certain to play an important role in preparations for deep space exploration. The JAMES study is, to the investigators’ knowledge, the first controlled experiment to expose multiple modern intraocular lens materials directly to the external low-Earth-orbit environment and return them for laboratory analysis. While published clinical reports have described astronauts who flew with implanted lens devices, those devices were protected inside the eye and body, so preimplantation exposure had never been studied. Dr Micheletti now hopes to investigate how a phacoemulsification system, the ultrasound and fluidics platform at the heart of modern cataract surgery, performs during the brief microgravity of parabolic flights, with the longer-term path leading to sustained microgravity testing and eventually an in-orbit surgical experiment. His guiding philosophy is deliberate: first the materials, then the equipment, then the procedure, and ultimately the surgery, in the hope of helping make the first eye operation beyond Earth a reality.

Subject of Research: Exposure of intraocular lenses to the low-Earth-orbit environment outside the International Space Station to assess their suitability for space-based cataract surgery.

Article Title: ‘Space: The final frontier’ for cataract surgery!

Article References: ‘Space: The final frontier’ for cataract surgery!. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: intraocular lenses, cataract surgery, International Space Station, space medicine, atomic oxygen, ultraviolet radiation, light-adjustable lenses, Mars missions, ophthalmology, JAMES project, low-Earth orbit, ESCRS

The research team followed the PRISMA 2020 reporting guidelines, the international standard for conducting and reporting systematic reviews in health care. They searched four major electronic databases, PubMed, Scopus, the Cochrane Library, and ERIC, in December 2025, casting a wide net across the medical education literature. From an initial pool of 4,233 records, only twelve studies published between 2007 and 2022 ultimately met the strict inclusion criteria. To qualify, studies had to evaluate surgical training outcomes among ophthalmology residents, covering measures such as intraoperative or postoperative complications, surgical efficiency, case-volume and learning-curve effects, surgical success, trainee competency, or the impact of simulation-based training. Research on non-residency populations or on educational interventions unrelated to surgery was excluded.

That attrition rate, from more than four thousand records to just twelve included studies, tells its own story. Despite decades of concern about how surgeons learn their craft, the evidence base for one of medicine’s most technically demanding specialties remains remarkably thin and fragmented. The twelve studies that survived screening came from the United States, the United Kingdom, India, Australia, and sub-Saharan Africa, a geographic spread that the authors note is heavily skewed toward high-income countries. Because the included studies varied so widely in their populations, interventions, and outcome measures, the team chose a narrative synthesis rather than a meta-analysis, meaning they could map the direction and consistency of reported effects but not pool them into a single summary statistic.

One of the clearest signals to emerge concerns case volume. Across the reviewed literature, higher cumulative surgical volume was consistently associated with lower complication rates, reinforcing the long-standing intuition that practice makes safer surgeons. Yet the picture is not purely mechanical. The review found that case-specific risk factors, such as the complexity of an individual patient’s pathology, independently predicted complications even after accounting for trainee experience. In other words, a resident’s hundredth cataract operation on a routine patient may be safer than a supervised first operation on an eye with a traumatized cornea or a weak lens support. This finding carries practical weight: it suggests that training programs should think not only about how many operations a resident performs, but about which operations, matched to the resident’s current level of skill and the level of supervision available.

The review also confronted a question that every surgical patient implicitly asks: is it safe to let a trainee operate? The evidence indicates that surgery performed by residents is associated with higher short-term complication rates compared with surgery performed by experienced surgeons, a result that will surprise no one. More encouraging, however, is the finding that long-term outcomes were often comparable between trainee-performed and consultant-performed procedures. This distinction between immediate and delayed results matters enormously for how training programs and patients think about the learning process. It suggests that the short-term bump in complications associated with supervised trainee surgery may not translate into lasting harm, provided that cases are appropriately selected and supervised and that patients receive adequate follow-up to catch and manage early problems.

Perhaps the most consistent and practically important finding of the entire review involves simulation. Across four studies, including two randomized controlled trials, simulation-based and virtual-reality training was consistently associated with lower complication rates and higher competence scores among trainees. Randomized controlled trials sit at the top of the evidence hierarchy, so their presence in this small literature is notable, and the fact that both pointed in the same direction strengthens confidence in the conclusion. Virtual reality cataract surgery simulators, which allow residents to practice capsule tearing, phacoemulsification, and instrument handling on a computer-generated eye with real-time feedback on tremor and tissue damage, have become increasingly sophisticated over the past two decades. The review’s findings suggest that this technology is not merely a convenient substitute for the operating room but an active driver of safer surgical performance once residents reach real patients.

The authors assessed the methodological quality of the included studies using design-specific tools. Observational studies were appraised with the Joanna Briggs Institute critical appraisal checklists, randomized controlled trials with the Cochrane Risk of Bias 2 tool, and the single instrument validation study with the COSMIN Risk of Bias checklist. Two reviewers independently screened titles, abstracts, and full texts, with disagreements resolved by consensus. This multi-tool approach reflects the heterogeneity of the underlying literature, but it also exposed a deeper problem: most of the evidence rests on observational designs, which are vulnerable to confounding and selection bias. Programs that give residents more cases may also differ in countless other ways from programs that give fewer, making it difficult to isolate the true causal effect of volume alone.

If simulation emerged as the strongest positive finding, the assessment of competency emerged as the weakest link. The review found that validated competency assessment instruments remain strikingly limited, with only one study in the entire evidence base addressing instrument validity in depth. This is a critical gap for a specialty built on microsurgical precision. Without validated tools to measure surgical competence, program directors are left to judge readiness using subjective supervisor impressions, logged case counts, or ad hoc rating scales whose psychometric properties are largely unknown. The authors highlight cataract surgery, the most common operation most ophthalmology residents will perform and the procedure on which much of the global burden of avoidable blindness depends, as an area particularly in need of validated assessment instruments.

The geographic concentration of the evidence adds a further layer of concern. With studies drawn predominantly from the United States, the United Kingdom, India, Australia, and parts of sub-Saharan Africa, the review notes that the evidence base is concentrated in high-income settings, leaving vast regions of the world where cataract surgical backlogs are greatest essentially unstudied in the medical education literature. Training conditions, case mix, supervision ratios, and available technology differ enormously between a well-funded academic center in North America and a district hospital in a low-resource setting. Findings about learning curves and complication thresholds generated in one context may simply not transfer to another, which is why the authors call for more geographically diverse, prospective research.

The overall message of the review is one of cautious optimism paired with a demanding agenda. Simulation-based training and structured, experience-matched case selection are associated with improved surgical outcomes and surgical competence among ophthalmology residents, giving training programs concrete, evidence-supported levers to pull today. At the same time, the field needs prospective studies that follow residents over time, validated assessment tools that can objectively certify competence, and research that extends beyond wealthy countries to the settings where surgical training capacity is most constrained. As virtual reality simulators become cheaper and more widespread, and as regulators and patients increasingly demand objective proof of surgical readiness, the pressure to build a rigorous educational evidence base for eye surgery will only grow. This review provides both a map of what is known and a clear picture of how much work remains.

Subject of Research: Surgical training and competency assessment in ophthalmology residency programs

Article Title: Ophthalmology residency surgical training and competency assessment: a systematic review of medical education evidence

Article References: Krungkraipetch, L., Leelawongs, S., & Krungkraipetch, K. (2026). Ophthalmology residency surgical training and competency assessment: a systematic review of medical education evidence. BMC Medical Education. https://doi.org/10.1186/s12909-026-10546-7

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10546-7

Keywords: ophthalmology residency, surgical education, competency assessment, simulation training, virtual reality, cataract surgery, case volume, learning curve, systematic review, medical education, surgical complications, BMC Medical Education