SEP 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/82503

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Page 83 of 103

84 EW RESIDENTS September 2012 There's nothing like the real thing, baby—or is there? Sherleen Chen, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary improves the porcine model, but the difficulty of obtaining fresh tissue, the risk of infection, and the hassle of storage and disposal remain drawbacks. We continue to use porcine eyes Yousuf M. Khalifa Assistant professor, Department of Ophthalmology University of Rochester Medical Center School of Medicine and Dentistry Rochester, N.Y. Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary T echnology is advancing at a lightning pace, and with it is the learning process. We email, text, and tweet our colleagues, fellows, and residents, and this has quickly replaced the concept of being "on call." Surgical training is similarly progressing as we increasingly use simula- tors to assess performance instead of animal models. This shift toward artificial environments has spurred the use not only of simulators but of synthetic eyes in the acquisition of surgical skills to more readily emulate the "real McCoy" in learning oph- thalmic surgery. In this column, our cataract teachers will review their experience with these devices and express their likes and dislikes with the new technology in helping our junior colleagues gain valuable surgical experience. Sherleen Chen, M.D., and Roberto Pineda, M.D. Dr. Khalifa: Resident surgical train- ing can be approached from a variety of ways. Traditionally, the resident gained experience in a step- wise fashion with graduated respon- sibilities. As oversight of residency training has expanded and compe- tencies introduced, a trainee's surgi- cal skills are no longer judged by length of training or number of cases. The onus is now to establish surgical competency—a difficult task. How do we prepare our resi- dents for the responsibilities of primary surgeons? Once they have started operating, how do we help them improve and grow? How do we verify after 3 years of residency that they have gained sufficient knowledge? Simulation in ophthalmology surgical training usually involves porcine eyes. Fresh tissue is excellent for practicing incisions and scleral and corneal suturing. Cataract surgery training using animal eyes falls short when it comes to capsu- lorhexis and phacoemulsification. The capsule of the porcine eye is rubbery and the lens quite soft, and the resident practicing on this type of model fails to develop techniques that are transferrable to the operat- ing room and, even worse, may develop techniques that are counter- productive for successful cataract surgery. Using a microwave to in- duce nuclear sclerosis and combin- ing this with formaldehyde fixation for wound construction and wound closure instruction, but intraocular simulation of capsulorhexis, phaco grooving, nucleus disassembly, quadrant removal, I/A, and IOL placement is now done on the Kitaro WetLab system (FCI Oph- thalmics, Marshfield Hills, Mass.). We have found the accuracy of the simulation to be excellent. We believe the fidelity of this system will fundamentally change the role of phacoemulsification training out- side the operating theater. The feel of the capsulorhexis is quite real, and many advanced techniques can be taught such as saving a rhexis that is running out or can opener capsulotomy. Phaco grooving using the Kitaro WetLab system provides the resident with an opportunity to appreciate depth of field and learn the three foot pedal positions. Nucleus disassembly is a complex bimanual maneuver that can be difficult to master in the operating room, but with the Kitaro magnetic mounting system, the effect of sur- geon force on the globe is simulated, and the resident learns to control centration during this step. The weakest part of the Kitaro simulation has been the irrigation/aspiration step because the remaining "cortex" actually behaves like epinucleus and comes out like a shell. We have adapted the Subjective Phacoemulsification Skills Assess- ment for our wet lab curriculum and call it the Subjective Phacoemulsifi- cation Wet Lab Skills Assessment. Residents are assigned a task in the wet lab and asked to digitally record multiple examples of their tech- nique. Each assignment is preceded by a didactic lecture and live demonstration in the wet lab. The residents have a week to complete the assignment and submit it for grading. The simple addition of a video recording requirement makes the wet lab much more effective be- cause the resident is working toward a final product of which he or she wants to be proud. With the growing number of factors that often limit opportunities for resident surgical education, it is of great importance that effective methods of phacoemulsification training be developed. Objective, valid, and reliable tools that provide rapid feedback are essential for train- ing in the wet lab and in the operat- ing theater. We are not there yet. Lisa Park, M.D. Clinical associate professor Associate residency program director Department of Ophthalmology NYU School of Medicine, New York Dr. Park: An important aspect of learning phacoemulsification is the use of practice systems prior to oper- ating on patients. The traditional wet lab has utilized animal or cadav- eric eyes, requiring a dedicated facil- ity where human surgery does not take place. Obstacles to having a successful wet lab include set-up costs, maintenance, and disposal of bio-hazardous materials, as well as provision for off-hours access. The use of synthetic eye systems attempts to address some of these issues. I recently had the opportu- nity to use the Kitaro WetLab and DryLab kits, which were developed by Junsuke Akura, M.D. The kits consist of a plastic base with two "orbits" in which magnets hold a scleral base in place. A cornea/iris piece snaps onto this shell, and a rubber facemask is placed on top. What differentiate the dry kit from the wet kit are es- sentially the pieces that snap onto the scleral base. The dry kit utilizes an "open sky" plastic cornea with sideport openings for the cystotome and capsulorhexis forceps. The cellophane capsular material is easily

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