The Best Phaco Fellowship in India Part 2- When Fellowship “Levels” Don't Tell You the Whole Story

In an earlier post, I broke cataract fellowships into a framework of 5 training levels.

If you haven’t read that, start there first- The Best Phaco Fellowship in India

Quick recap:

Level 1 → SICS training

Level 2 → Phaco in basic cataracts

Level 3 → Phaco in advanced cataracts

Level 4 → Complication management

Level 5 → Topical phaco surgery

At a glance, this framework simplifies fellowship reviews.

You can quickly understand whether a program is producing

• an SICS surgeon

• a basic phaco surgeon

• or an independent surgeon who can handle most cataracts and manage complications

That’s useful.

But there are situations where this classification breaks down.

Example 1: When Progression ≠ Mastery

Take Agarwal Eye Hospital’s IOL Fellowship.

As a fellowship option, it looks attractive.

Just 1 year long and fellows are exposed to multiple levels within a year:

SICS → basic phaco → advanced phaco → anterior vitrectomy, glued IOLs

Or to put it another way,

SICS (level 1) → basic phaco (level 2) → advanced phaco (level 3) → anterior vitrectomy, glued IOLs (level 4)

Just this overview would cause us to think the program offers level 4 training.

But look at the numbers- you get a handful of SICS followed by ~80 phacos at most.

It takes way more than 80 phacos to cross level 2 in the first place. So there’s no way you are attaining even level 3 mastery with only these many cases by the end of fellowship.

What’s happening here is that you are progressing up the ladder (in terms of exposure to levels) but you are not mastering each level before moving to the next one. That’s a big disadvantage. You do not exit the program as an independent surgeon.

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Or, consider HV Desai Hospital’s Cataract & Refractive Surgery fellowship.

It's 18 months long, starts with SICS and introduces phaco after ~6 months. Looks like a great start.

But there’s a constraint. You get only one phaco per week, despite 3 OT days in a week.

So by the end, you've done around ~60–70 phacos total, get some exposure to managing complications in last 2 months (level 4), and also get a few token topical cases (level 5) toward the end as well.

Using the framework, it appears to reach Level 5.

But when you look at the numbers, they say a different story.

70 phacos including those training cases for complications and topical phacos. Nope, you do not exit as a level 4 or 5 surgeon with this one either.

Example 2 Where the Framework Breaks: Pure Phaco Fellowships

ASG Eye Hospital is a good example to use here.

Their phaco-focused fellowships often produce surgeons who are comfortable with topical phaco by the end.

That’s Level 5.

But there’s no SICS training.

So how do you classify such a program?

Effectively, it produces a Level 5 surgeon without Level 1 training.

This highlights a limitation of the framework (not the fellowship!)-

In phaco-dominant programs, Level 1 may be minimal or absent.

In such cases, the classification must be applied without level 1.

Which also tells you something else-

ASG-like programs are better suited for surgeons who are already comfortable with SICS (Level 1 proficient).

So Who Are These Fellowships Actually For?

Programs like Agarwal’s (with limited numbers and fast progression)- not suited for SICS beginners but also, not clear who their target base really is. Maybe basic phaco surgeons?

HV Desai- decent for SICS mastery, fair for phaco foundation, weak for phaco independence.

ASG-type programs- good fit for SICS surgeons who want to master phaco.

Once you look at both numbers + training levels of a fellowship, the ideal target audience becomes clearer.

Does Skipping Level 1 Really Matter?

It depends entirely on where you plan to work after fellowship.

If you’re entering a phaco-only setup, it may not matter.

But if you get into setups with heavy dense cataract volume, camp work, manual conversion scenarios or limited phaco access, then lack of SICS training absolutely matters.

Where Applicants Tend To Go Wrong

They will hear statements like

“You’ll be doing advanced cases”

“You’ll manage complications”

“You’ll get topical phacos”

And think it means higher-level training.

But without knowing numbers, these statements mean very little. 

What Actually Matters

A program claiming to produce a “Level 4 surgeon” means nothing if complication exposure is minimal or given towards the end of fellowship.

On the other hand, a “Level 2 program” may be far stronger if it builds phaco fundamentals and gives repetition in level 2 cases till the end.

So when assessing cataract fellowships, you have to evaluate three things together-

• Starting level of fellowship

• Case numbers

• End outcome level

Ignore any one of these and you're likely to misjudge the program.

So Why Use This Framework At All?

Because without it, discussing fellowships become vague.

“This program is good.”

“That one is better.”

“This one has good exposure.”

Good according to what? Exposure to what exactly?

The training levels framework gives you milestone markers to work with.

It's not perfect. It's not absolute, either.

But it's still better than judging fellowships based on stipend or brand name or random opinions.

Used correctly, along with factors like case numbers and duration, the Framework is an effective way to quickly understand what a fellowship actually offers. Those who go for long fellowships should ideally look for programs offering at least Level 3 proficiency. A program that makes you skilled in all 5 levels is the best (of course).