Shunmugaranjan et al report that surgical experience is strongly associated with better outcomes after endothelial transplantation.1 The authors used prospective national registry data from over 11 000 endothelial keratoplasties, including Descemet stripping (automated) endothelial keratoplasty (DSEK/DSAEK) or Descemet membrane endothelial keratoplasty (DMEK) to evaluate the impact of surgeon experience. The authors provide compelling evidence that surgical expertise is strongly associated graft survival at 2 years, primary graft failure and need for additional interventions for both DSAEK and DMEK. Visual acuity was better among experienced surgeons post DSEK/DSAEK.

In medicine, learning curves were used in the 1980s to describe the uptake of new surgical skills for minimally invasive surgery.2 The ‘learning curve’ describes the fact that a learner’s performance and skills improve over time when the task is repeated. This improvement is quicker in the initial stages and then flattens with subsequent small improvements. In the context of surgical practice, the learning curve is associated with increased risk to patients during the study period when a surgeon is gaining …