Influence of surgeon learning on outcomes in new ophthalmic procedures: quantified nationwide evidence in endothelial corneal transplantation

Aims To investigate the impact of surgeon learning on endothelial keratoplasty (EK) procedure outcomes. Methods A prospective nationwide registry study of EK grafts in patients aged at least 21 years with Fuchs endothelial corneal dystrophy or pseudophakic bullous keratopathy undergoing a first EK procedure in that eye between 2005 and 2020. EK procedures were either Descemet Stripping Endothelial Keratoplasty (DSEK) or Descemet Membrane Endothelial Keratoplasty (DMEK). Primary outcome was transplant survival at 2 years. Secondary outcomes at 1-year post-transplant were (1) best-corrected visual acuity, (2) requirement for repeat air injection procedures to treat graft detachment and (3) iatrogenic primary graft failure. Results Following analysis of 11516 EK transplants, significant impact of surgeon learning was indicated by (1) the influence of surgeon prior experience in that EK technique, (2) the influence of surgeon prior experience in postoperative management and (3) the time interval from introduction of that EK technique in the United Kingdom to time of surgery. EK grafts reported to have failed within the first 6months were a significant proportion of all transplant failures. Conclusions Influence of surgeon learning and inexperience in EK of clinical and statistical significance can be quantified and diminishes over time. Equivalent analyses may be feasible for novel procedures in other ophthalmology specialties and surgical training. Training programmes and nationwide advisory networks may be helpful in reducing the duration and impact of surgeon learning curves.