EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/76185
July 2012 EW RESIDENTS 51 Virtual reality simulation for cataract surgery is still a relatively new tool, and we can likely expect iterative technologic improvements over time. The challenge for surgical educators is to determine how to best use simulation, when it should be used, and where this and other innovative tools fit into a modern surgical curriculum. References 1. Mahr MA, Hodge DO. Construct validity of anterior segment antitremor and forceps surgical simulator training modules; attending versus resident surgeon performance. J Cataract Refract Surg. 2008;34:980-985. 2. Feudner EM, Engel C, Neuhann IM, Petermeier K, Bartz-Schmidt K-U, Szurman P. Virtual reality training improves wet-lab performance of capsulorhexis: Results of a randomized, controlled study. Graefes Arch Clin Exp Ophthalmol. 2009;247:955-963. 3. Belyea DA, Brown SE, Rajjoub LZ. Influence of surgery simulator training on ophthalmol- ogy resident phacoemulsification perform- ance. J Cataract Refract Surg. 2011;37: 1756-1761. 4. Privett B, Greenlee E, Rogers G, Oetting TA. Construct validity of a surgical simulator as a valid model for capsulorhexis training. J Cataract Refract Surg. 2010;36:1835-1838. 5. Watts CE, Oetting TA. Surgical simulator improves early resident learning curve for cataract surgery. Association of University Professors of Ophthalmology, Annual Meeting, Jan 25, 2012, Miami, Fla. reading textbooks or videos alone. The resident must obtain hands-on surgical training in the operating room, wet laboratory, or with a simulator. In fact, the ACGME has mandated that residents must have access to either a wet lab or to simulators for skills development.1 Although commonly performed, cataract surgery is considered one of the most difficult surgeries to learn with nearly a 10-fold increase in complications during surgeries performed by residents compared to surgeries performed by experienced surgeons.3 Learning how to perform cataract surgery in a real operating room is preferred. However, with the rising costs of teaching, increased expectations in patient outcomes, and increased time constraints, educators are forced to seek out surrogates for operating room train- ing experience. Surgical simulators have recently become a viable option for some teaching programs. There are several advantages of simulator training. Similar to a wet laboratory, human cost in the form of adverse patient outcomes is mini- mized and residents can practice in a non-stressful learning environment at their own pace.3 Additionally, training on surgical simulators can be incorporated into a curriculum that can be available to residents at any time.4 Surgical preceptor pres- ence or absence need not be a limit- ing factor in the learning process. This is not to say that simulator training can serve as a substitute for individualized training with super- vising surgeons. Other surgical spe- cialties attempting to exclusively use a simulator have failed.5 Rather, it can serve as a complementary tool for resident education. Simulators are already being utilized in many different fields of surgical education, from neurosurgery6 to obstetrics and Bonnie An Henderson, M.D. Assistant clinical professor of ophthalmology, Harvard Medical School Partner, Ophthalmic Consultants of Boston Surgical competency is included by the American Board of Ophthalmol- ogy as an adjunctive core compe- tency to the six others that are required by the ACGME for resident training accreditation in ophthal- mology.1,2 Becoming a competent surgeon cannot be done passively by gynecology.7 The currently available surgical physical simulators (e.g., Eyesi Surgical Simulator) afford practice for microsurgery by familiarizing the resident with maneuvers performed under a microscope with both hands and both feet. However, training a successful cataract surgeon involves more than practicing the physical movements; it involves imparting cognitive knowledge, visual-spatial knowledge, and technical skill. Dividing the learning process into respective components can greatly benefit residents, enabling them to master one step at a time. A cognitive simulator, the Cataract Master computer program (Massachusetts Eye and Ear Infir- mary, Boston), has been developed to provide the intellectual training that is usually offered by a surgical mentor.8 A prospective multicenter masked trial of a prototype of this program was performed, and a statis- tically significant improvement in knowledge accumulation after use of this program compared to that with traditional teaching tools was found.9 The Cataract Master is cur- rently available and distributed on the ASCRS website, www.ascrs.org. The introduction of new tech- nology such as a surgical simulator can often be met with skepticism. Koch F. et al surveyed trainees and experienced surgeons participating in a dry lab with a simulator. The au- thors evaluated the participants' ac- ceptance of a simulator as a training method. The aspects scored included quality, complexity, clinical impact, learning effect, and overall impres- sion. The majority of both groups accepted and highly appreciated the simulator as a training tool.10 The development of physical and cognitive surgical simulators of- fers a different approach to learning than that of the traditional appren- ticeship model. Simulators cannot be substituted for experienced surgi- cal preceptors, but they are fast be- coming an attractive and acceptable adjunct in surgical curricula. As the technology improves, the simula- tions become more realistic and hence the experience will become more valuable. Simulation programs will continue to play a greater role in future surgical education. EW References 1. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education In Ophthalmology. July 1, 2007. 2. Mills R, Mannis M. Report of the American Board of Ophthalmology Task Force on the Competencies. Ophthalmology. 2004;111(7): 1267-1268. 3. Tarbet KJ, Mamalis N, Theurer J, et al. Complications and results of phacoemulsifica- tion performed by residents. J Cataract Refract Surg. 1995;21(6):661-5. 4. Sandrick K. Virtual reality surgery: Has the future arrived? Bull Am Coll Surg. 2001;86: 42-3, 63. 5. Gerson LB, Van Dam J. A prospective randomized trial comparing a virtual reality simulator to bedside teaching for training in sigmoidoscopy. Endoscopy. 2003;35:569-575. 6. Spicer MA, van Velsen M, Caffrey JP, Apuzzo ML. Virtual reality neurosurgery: A simulator blueprint. Neurosurgery. 2004;54:783-97; discussion 797-8. 7. Letterie GS. Medical education as a science: The quality of evidence for computer-assisted instruction. Am J Obstet Gynecol. 2003;188: 849-853. 8. Henderson BA, Neaman A, Kim BH, Loewenstein J. Virtual training tool. Ophthalmology. 2006;113:1058-1059. 9. Henderson BA, Kim JY, Golnik KC, Oetting TA, Lee AG, Volpe NJ et al. Evaluation of the Virtual Mentor Cataract Training Program. Ophthalmology. 2010;117(2):253-258. 10. Koch F, Koss MJ, Singh P, Naser H. Virtual reality in ophthalmology. Klin Monbl Augenheilkd. 2009 Aug;226(8):672-6. Editors' note: The doctors have no financial interests related to this article. Contact information Daly: mary.daly2@va.gov Henderson: bahenderson@eyeboston.com Naseri: ayman.naseri@va.gov