Purpose Training within a proficiency-based virtual reality (VR) curriculum may reduce errors during real surgical procedures. This study used a scientific methodology to develop a VR training curriculum for phacoemulsification surgery (PS). Patients and methods Ten novice-(n) (performed o10 cataract operations), 10 intermediate-(i) (50-200), and 10 experienced-(e) (4500) surgeons were recruited. Construct validity was defined as the ability to differentiate between the three levels of experience, based on the simulator-derived metrics for two abstract modules (four tasks) and three procedural modules (five tasks) on a high-fidelity VR simulator. Proficiency measures were based on the performance of experienced surgeons. Results Abstract modules demonstrated a 'ceiling effect' with construct validity established between groups (n) and (i) but not between groups (i) and (e)-Forceps 1 (46, 87, and 95; Po0.001). Increasing difficulty of task showed significantly reduced performance in (n) but minimal difference for (i) and (e)-Anti-tremor 4 (0, 51, and 59; Po0.001), Forceps 4 (11, 73, and 94; Po0.001). Procedural modules were found to be construct valid between groups (n) and (i) and between groups (i) and (e)-Lenscracking (0, 22, and 51; Po0.05) and Phacoquadrants (16, 53, and 87; Po0.05). This was also the case with Capsulorhexis (0, 19, and 63; Po0.05) with the performance decreasing in the (n) and (i) group but improving in the (e) group (0, 55, and 73; Po0.05) and (0, 48, and 76; Po0.05) as task difficulty increased. Conclusion Experienced/intermediate benchmark skill levels are defined allowing the development of a proficiency-based VR training curriculum for PS for novices using a structured scientific methodology.
BACKGROUND The quality of ophthalmic surgical training is increasingly challenged by an untimely convergence of several factors. This article reviews the tools currently available for training and assessment in phacoemulsification surgery. METHODS Medline searches were performed to identify articles with combinations of the following words: phacoemulsification, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers. RESULTS Thus far phacoemulsification training outside the operating room include wet labs and micro-surgical skills courses. These methods have been criticised for being unrealistic, inaccurate and inconsistent. Virtual reality simulators have the ability to teach phacoemulsification psychomotor skills, as well as to carry out objective assessment. Other ophthalmic surgical skill assessment tools such as Objective Assessment of Skills in Intraocular Surgery (OASIS) and Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) are emerging. Assessor bias is minimised by using video-based assessments, which have been shown to reduce subjectivity. Dexterity analysis technology such as the Imperial College Surgical Assessment Device (ICSAD) and virtual reality simulators can be used as objective assessment devices. CONCLUSION Improvements in technology can be utilised in ophthalmology and will help to address the increasingly limited opportunities for training and assessment during training and throughout a subsequent career (re-training and re-validation). This will inevitably translate into enhanced patient care.
The authors present a case of secondary glaucoma associated with silicone oil in a patient with ocular cicatricial pemphigoid successfully managed with transscleral diode laser cyclophotocoagulation. Six months following treatment, the patient remained satisfied and free of pain, with an intraocular pressure of 24 mm Hg without topical drops or oral acetazolamide. There was no evidence of exacerbation of ocular cicatricial pemphigoid and no adjustment was required to the patient's immunosuppressive therapy. This case suggests that transscleral diode laser cyclophotocoagulation may be safely used to control raised intraocular pressure in patients with ocular cicatricial pemphigoid without causing an exacerbation of the condition.
We took great interest in the review by Spiteri et al 1 regarding the teaching and assessment of cataract surgery skills. We have recently employed the Kitaro wet and dry lab system at the University of Rochester and 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 outside the operating theatre. The authors mention virtual reality systems as an alternative to human and animal wet lab models, but we have found the cost of these systems restrictive. The major advantages of the virtual reality system are its instantaneous feedback, its objectivity and its standardisation, but a minority of training programmes in the USA are able to afford the expense.Regarding assessment of operative performance using video-based methods, we have found the major impediment is time. For an attending to review a single cataract surgery in detail and provide feedback on the case, it can consume more than 30 min. In addition to the time cost of video-based review, its objectivity can be questionable, especially when the input of only one attending is used. We have also had difficulty tracking resident performance over time using video-based assessments because of the time constraints involved and because of objectivity issues.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 training in the wet lab and in the operating theatre. We are not there yet. Author's response I would like to thank Khalifa et al. We too believe that simulation technology is here to stay and that it can only improve with its further development and more research in software validation, highlighting its strengths and weaknesses. To this aim, our group has completed one such validation trial which we hope to share with the published community shortly.Regarding the cost of these systems, we agree that these are currently restrictive (although we have already witnessed a substantial drop in price). We think that, for this reason, simulation based training works better on a regional training basis rather than individual hospitals investing heavily for a limited number of trainees. However, the increased demand caused by higher trainee to machine ratios will raise issues regarding how much minimum training will be required and for how long. Studies plotting learning curves required to reach standards set by validation trials are thus beckoning. These will produce more targeted training rather than simply 'the-more-the-better ' practising.Although we are not there yet, once these initial obstacles are overcome there are multiple advantages to look forward to. Running costs are minimal; reduced complication rates due to out-of-theatre training would provide financial benefits and the more obvious reduction in morbidity; inbuilt validat...
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