From incision to implantation: holter-based stress profiling in ophthalmology residents during cataract surgery

To objectively evaluate intraoperative stress responses in ophthalmology residents by assessing heart rate (HR) and heart rate variability (HRV) during distinct steps of cataract surgery using Holter monitoring. In this prospective study, 26 ophthalmology residents performed standard, uncomplicated phacoemulsification surgery while continuously monitored with a 3-channel digital Holter device. Each surgery was divided into four steps: (1) incision and viscoelastic injection, (2) capsulorhexis, (3) nucleus removal, and (4) cortical aspiration with intraocular lens implantation. Time-domain HR parameters including maximum HR, minimum HR, and mean HR values were recorded and analyzed at baseline and during each surgical step. HRV metrics including mean NN intervals, SDNN, SDANN, SDNN index, and RMSSD were also analyzed. All surgical steps showed significantly elevated mean HR compared to baseline (p < 0.001). The highest mean HR was observed during the capsulorhexis step (108.9 ± 7.2 bpm), followed by nucleus removal (102.7 ± 14.0 bpm). HR remained elevated throughout the procedure without returning to baseline, suggesting sustained sympathetic activation. HRV indices revealed moderate autonomic variability, with SDNN (66.5 ± 24.2 ms) and RMSSD (34.9 ± 19.6 ms) indicating heightened arousal with preserved vagal tone. No significant correlation was found between HR/HRV parameters and residency duration or surgical time (p > 0.05 for all). Ophthalmology residents experience sustained autonomic stress throughout all steps of cataract surgery, with the highest sympathetic activation occurring during capsulorhexis step. These findings can underscore the utility of HRV monitoring in surgical training and support the integration of stress management and simulation strategies into ophthalmology residency curricula.