EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/76185
50 EW RESIDENTS July 2012 Cataract tips from the teachers Of synthetics and simulators: Part 1 Sherleen Chen, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Mary K. Daly, M.D. Chief of ophthalmology, Veterans Affairs Boston Healthcare System Associate professor of ophthalmology, Boston University School of Medicine Lecturer, Harvard Medical School Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary he rehearsal, solidification, and polishing of surgical techniques before entering the operating room is crucial to performing efficient and elegant surgery. While practice on tissues as close to the real thing is ideal, this is not always possible. Human cadaver eyes are a pre- cious gift not readily or widely available. As such, many models have been developed to simulate the human eye and the experience of performing surgery. This two-part series will focus on the use of surgical simulators and synthetic eye models in training for cataract surgery. In this column, we invite three experts to discuss the benefits and use of surgical simulators in developing the manual, as well as cognitive, skills required to successfully prepare for cataract surgery. T Sherleen Chen, M.D., and Roberto Pineda, M.D. The word "surgeon" comes from the Greek "cheir," which means hand, and "ergon," which means work. Ability in surgery, "chiurgery," or handwork, depends on many fac- tors. Few would argue that one key ingredient to prime performance is practice. Dr. Shin'ichi Suzuki (1898- 1998) said, "You don't have to prac- tice every day, only on the days you eat." His point is well taken and can be easily transferred from his specialty of music to our field of surgery. Practice and commitment to our trade should be as integral to our daily experience as activities we cannot live without. Ophthalmol- ogy programs have a duty to provide adequate skills training and acquisi- tion for residents and fellows in an environment that is safe for pa- tients. Simulators, which have been available in general surgery for some time, have shown faster adaptation to psychomotor and perceptual skills, improved learning curves, and better OR performance. VRmagic (Mannheim, Germany) has now made simulation in ophthalmology available through its Eyesi Surgical Simulator. This ophthalmic simula- tor offers amazingly life-like surgical experience in a risk-free environ- ment. Formal evaluations are provided after each task, a feature critical to the user's learning process. VRmagic has designed a set of consecutive courses for beginner and advanced surgeons that we have incorporated into our rotation at VA Boston. The program begins with modules introducing residents to the handling of instruments and se- quentially leads to ones for perform- ing surgical procedures. Junior and intermediate residents must pass the beginner cataract course before they are allowed to perform intraocular surgery at our institution, and senior residents are expected to complete the advanced program during their third year. The feedback from trainees has been overwhelmingly positive. They report the simulator not only to be a great learning tool, but fun to use. They appreciate its accessibility, as they can use it at their discretion, with or without at- tending mentorship, receiving im- mediate feedback after every task. They rejoice when they achieve high scores and try harder when they don't, motivated and energized by this high technology teaching tool. The Eyesi provides a safe, accessible, and engaging environment for skills acquisition and repetition of tasks, with quantifiable evaluation data that can be reviewed by the trainee and supervisor alike. It is a wonder- ful addition to traditional training (wet lab, hands-on) and when united, increases the comprehen- siveness of teaching programs to ensure our trainees develop the skills they need to become quality ophthalmic surgeons. range of difficulty in a controlled environment. For this reason, many ophthalmology programs have acquired virtual reality simulation in order to assist in the training of residents who are learning cataract surgery. One of the virtual reality simulation devices, the Eyesi Surgical Simulator, has already been acquired at almost 60 sites in North America and over 160 locations worldwide. Despite the increasing popular- ity of simulation in ophthalmology, the evidence demonstrating the effectiveness of this technology at improving patient outcomes is limited. Two recent retrospective studies found no statistical differ- ence in the cataract surgery compli- cation rate of ophthalmology residents who trained on a simulator versus those who did not. But these studies did demonstrate one other potential benefit of simulator train- ing: In both studies, residents who trained on a simulator performed cataract surgery more efficiently than those who did not use a simu- lator. The study from George Washington University revealed a statistically significant difference in the phaco time and power used by simulator-exposed residents, while the study from the University of Iowa revealed a shorter total opera- tive time. To be fair, studies demonstrating Ayman Naseri, M.D. Associate professor, vice chair, University of California, San Francisco (UCSF) Residency program director, UCSF Chief of ophthalmology, San Francisco VA Medical Center Virtual reality simulation has the potential to offer numerous benefits to surgical educators. In an effort to try to traverse the surgical learning curve without putting patients at risk, a validated simulation device can offer trainees the opportunity to improve surgical skills with deliber- ate and repetitive practice over a the effect of simulator training on patient outcomes are difficult to conduct due to challenges of sample size, randomization, and control of the many potential variables that can affect resident performance. But the benefits of simulator training may lie in other qualitative arenas such as improved trainee confi- dence, decreased teacher/learner stress, or the opportunity for struc- tured remediation and evaluation. One of the greatest challenges for surgical educators is the resident who struggles in the operating room. This situation creates signifi- cant anxiety for the trainee and for the instructors responsible for his/ her surgical education. In an era of minimum surgical case numbers mandated by the Accreditation Council for Graduate Medical Edu- cation (ACGME), simulators may prove to be a welcome asset for this uncommon yet difficult scenario.