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ABSTRACT.Purpose: To evaluate the EyeSi TM simulator in regard to assessing competence in cataract surgery. The primary objective was to explore all simulator metrics to establish a proficiency-based test with solid evidence. The secondary objective was to evaluate whether the skill assessment was specific to cataract surgery. Methods: We included 26 ophthalmic trainees (no cataract surgery experience), 11 experienced cataract surgeons (>4000 cataract procedures) and five vitreoretinal surgeons. All subjects completed 13 different modules twice. Simulator metrics were used for the assessments. Results: Total module score on seven of 13 modules showed significant discriminative ability between the novices and experienced cataract surgeons. The intermodule reliability coefficient was 0.76 (p < 0.001). A pass/fail level was defined from the total score on these seven modules using the contrasting-groups method. The test had an overall ability to discriminate between novices and experienced cataract surgeons, as 21 of 26 novices (81%) versus one of 11 experienced surgeons (9%) did not pass the test. The vitreoretinal surgeons scored significantly higher than the novices (p = 0.006), but not significantly lower than the experienced cataract surgeons (p = 0.32). Conclusion: We have established a performance test, consisting of seven modules on the EyeSi TM simulator, which possess evidence of validity. The test is a useful and reliable tool for assessment of both cataract surgical and general microsurgical skills in vitro.

ABSTRACT.Purpose: To investigate the amount of endothelial cell loss (ECL) and refractive predictability by femtosecond laser-assisted cataract surgery (FLACS) compared to conventional phacoemulsification cataract surgery (CPS). Methods: Forty-seven patients had one eye operated by FLACS and the contralateral eye operated by CPS (stop and chop technique). Both eyes had intraocular aspheric lenses implanted. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), central corneal endothelial cell count and hexagonality with a non-contact specular microscope were assessed preoperatively, 1-3 days postoperatively and 3 months postoperatively. Within both groups, 70% gained a CDVA of 6/6. Mean surgery time was 9.3 min (SD AE 1.9) by FLACS and 8.0 min (SD AE 1.9) by CPS, (p = 0.0018). Mean phaco energy was 3.78 U/S (SD AE 5.1) and 5.45 U/S (SD AE 4.6) (p < 0.0001) by FLACS and CPS, respectively. Conclusion: We found no significant difference in ECL and refractive predictability between FLACS and CPS 3 months postoperatively.

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Objective No method exists to measure aniseikonia tolerance in stereoacuity. The brain can compensate for 2%–3% aniseikonia (i.e. 2–3 dioptres of anisometropia) without impairing stereoacuity; however, a substantial proportion of anisometropic patients experience problems caused by disruptions of sensory fusion due to surgically induced aniseikonia. We hypothesized that individual differences in tolerance to aniseikonia exist and sought to develop a method to measure aniseikonia tolerance. Methods A total of 21 eye‐healthy phakic individuals older than 50 years of age and 11 patients awaiting clear lens extraction were included. Patients were tested with best corrected near and distance visual acuity, cover/uncover test, eye dominance test, stereoacuity threshold (TNO test), slit lamp examination and ocular coherence tomography. The stereoacuity threshold was determined with aniseikonia induced by different size lenses ranging from 1% to 9% magnification of both eyes in increments of 1%. The aniseikonia tolerance range (ATR) was defined as the percentage aniseikonia in which the stereoacuity threshold was maintained. Results We examined 32 patients with a median age of 65 (95% CI: 62–66 years), CDVA better than 6/7.5 (0.1 logMAR), and median near visual acuity better than 6/6 (0.0 logMAR). The median stereoacuity threshold was 60 arcsec (maximum 30, minimum 120). We observed large inter‐individual differences in ATR: 6/31 (19%) participants had an ATR of ≤1%, 1/31 (3%) had an ATR of 1‐5%, 7/31 (22%) had an ATR of 5‐10%, and 17/31 (54%) had an ATR of >10%. Conclusion We present a reliable method for measuring the amount of aniseikonia that a person can tolerate without impairing stereopsis. We report large inter‐individual differences in tolerance of aniseikonia.

To develop and investigate an Eyesi simulator-based test for the more experienced cataract surgeon for evidence of validity. Methods: The study was a prospective interventional cohort study and carried out at the Copenhagen Academy for Medical Education and Simulation. The Eyesi Simulator was used for the test which was developed by three expert cataract surgeons. Ten cataract surgeons (>250 surgeries performed) and ten ophthalmic residents performed two repetitions of the test. The test consisted of four modules: Iris Expansion Ring insertionlevel 1, Iris Expansion Ring extractionlevel 2, Capsulorhexislevel 3 and Anterior Vitrectomylevel 6. Results: Internal consistency reliability showed Cronbach's alpha of 0.63. Testretest reliabilities were significant for Iris Expansion Ring extractionlevel 2 (p = 0.012) and Capsulorhexislevel 3 (p = 0.018). Differences between the two groups were only significant in both repetitions for the Iris Expansion Ring extractionlevel 2 (p < 0.001 and p = 0.041, respectively). Furthermore, we found a statistically significant difference between the mean module scores for novices and the more experienced surgeons for Iris Expansion Ring insertionlevel 1 (p = 0.021) and Capsulorhexislevel 3 (p = 0.019) in the first repetition. Conclusion: The investigated modules show evidence of validity within several aspects of Messick's framework. However, the evidence is not strong enough to apply the test for certification purposes of cataract surgeons, but the modules may still be relevant in the training of advanced cataract surgical procedures.

C ataract surgery is a hugely important means of preventing poor-quality vision or vision loss, especially in the elderly and people with diabetes. Pseudophakic macular oedema (PMO) is a comparatively infrequent complication occurring in 0.2-2.35% of patients, but the increasing scale of cataract surgeries worldwide makes it a widespread and significant problem. PMO can affect vision and, if untreated, can damage the retina and, less commonly, cause pain. Effective and convenient treatment for PMO, therefore, is an important issue. The pathophysiology of PMO is not fully understood, but may result from multiple factors including traction, irritation and disturbance of the blood-retinal barrier, leading to secretion of inflammatory factors which affect the posterior segment. Among the non-steroidal anti-inflammatory drugs used in the management of PMO is nepafenac (NPF). NPF is a unique prodrug and use of the 0.1% formulation given three times daily is supported by several key phase II and III clinical trials, in which prophylactic use resulted in lower incidence of PMO, better visual outcomes and lower central subfield macular thickness than vehicle alone. Several studies have also shown that 0.1% NPF provided superior efficacy compared with bromfenac, fluorometholone or ketorolac in the treatment of PMO. More recently, a 0.3% NPF formulation has been developed to provide more convenient once daily dosing. A phase III trial (n=819) showed that 0.3% NPF was non-inferior to 0.1% NPF in terms of inflammation and proportion or patients who were pain-free with similar safety profiles for both doses. Other evidence from phase II and III vehicle-controlled, non-comparative trials also indicate the equivalence of frequent 0.1% NPF and the less frequent 0.3% NPF dosing. Greater use of the more convenient 0.3% NPF formulation may help improve patient adherence and consequently provide better outcomes in PMO.