Virtuelle Realitäten für die augenchirurgische Ausbildung

Update on simulation-based surgical training and assessment in ophthalmology: a systematic review

TOPIC

This study reviews the evidence behind simulation-based surgical training of ophthalmologists to determine (1) the validity of the reported models and (2) the ability to transfer skills to the operating room.

CLINICAL RELEVANCE

Simulation-based training is established widely within ophthalmology, although it often lacks a scientific basis for implementation.

METHODS

We conducted a systematic review of trials involving simulation-based training or assessment of ophthalmic surgical skills among health professionals. The search included 5 databases (PubMed, EMBASE, PsycINFO, Cochrane Library, and Web of Science) and was completed on March 1, 2014. Overall, the included trials were divided into animal, cadaver, inanimate, and virtual-reality models. Risk of bias was assessed using the Cochrane Collaboration's tool. Validity evidence was evaluated using a modern validity framework (Messick's).

RESULTS

We screened 1368 reports for eligibility and included 118 trials. The most common surgery simulated was cataract surgery. Most validity trials investigated only 1 or 2 of 5 sources of validity (87%). Only 2 trials (48 participants) investigated transfer of skills to the operating room; 4 trials (65 participants) evaluated the effect of simulation-based training on patient-related outcomes. Because of heterogeneity of the studies, it was not possible to conduct a quantitative analysis.

CONCLUSIONS

The methodologic rigor of trials investigating simulation-based surgical training in ophthalmology is inadequate. To ensure effective implementation of training models, evidence-based knowledge of validity and efficacy is needed. We provide a useful tool for implementation and evaluation of research in simulation-based training.

Virtual reality simulator for vitreoretinal surgery using integrated OCT data

Operative practice using surgical simulators has become a part of training in many surgical specialties, including ophthalmology. We introduce a virtual reality retina surgery simulator capable of integrating optical coherence tomography (OCT) scans from real patients for practicing vitreoretinal surgery using different pathologic scenarios.

Simulateur pédagogique médical : la phacoémulsification en réalité virtuelle

INTRODUCTION

Improvements in computer technology have made it possible to design a cataract surgery teaching simulator in real time.

MATERIAL AND METHODS

A computed representation of the lens was made with a mechanical model simulating the behavior of the lens, to which we added texture. The different models use mesh to make a section, which allowed us to make a section in real time using element removal or separation. Different models were used: a mass-spring mesh, a rigid model and a deformable model created using the finite element method. The contact with the lens is simulated by a collision sphere, which provides the interaction between the surgical instruments and the virtual environment. The surgical instruments viewed on the screen are controlled by a stylus with 6 degrees of freedom.

DISCUSSION

We obtained the first step of phacoemulsification in real time with a good visual aspect. The surgeon views the procedure and can modify his movements instantaneously. This simulator provides the opportunity for students to safely learn phacoemulsification and improve their technique with an infinite number of procedures.

CONCLUSION

The realism offered by this tool provides a rigorous teaching tool that might reduce the learning curve for phacoemulsification.

Lifelong Learning

Early American physician education lacked quality and consistency. Poorly funded institutions with weak curricula and little patient contact before graduation trained our earliest doctors. With the advent of the twentieth century, a reformation of medical education took place that created the foundation of our modern American medical education system. The importance of physician education increased, leading to the production of specialty boards and requirements for continuing medical education and culminating in a continuous certification process now required of all specialties including the American Board of Emergency Medicine. While the utility of continuing medical education has been questioned, technological advances, the Internet, and improved education techniques are helping physicians practice modern medicine in a time of rapidly expanding science.

VIRTUAL VITREORETINAL SURGICAL SIMULATOR AS A TRAINING TOOL

OBJECTIVE

To demonstrate the feasibility and potential applicability of a virtual reality simulator for vitreoretinal surgery as a training and/or assessment tool.

METHODS

The subjects of this study included medical students, ophthalmologic residents, and trained vitreoretinal surgeons. There were three study groups. Group I comprised 22 subjects who performed a navigation task. The time to complete the task was recorded. The relationship between the completion time, experience, and stereopsis was evaluated. Group II included 6 subjects who consecutively performed the navigation task to evaluate their learning curve. Group III included 16 subjects who performed the membrane peeling task. The number of retinal contacts and the completion time were recorded. The relationship between experience and stereopsis with the number of contacts and the completion time were evaluated.

RESULTS

The average completion time in Group I for students, residents, and trained surgeons was 121.6, 92.5, and 70.6 seconds. There was a significant difference between students and trained surgeons (P = 0.004). In Group II, there was a significant decrease in the completion time with training (P = 0.001). In Group III, the average completion time for students, residents, and trained surgeons was 197, 144, and 118.2 seconds; the respective number of retinal contacts was 14, 8, and 3. There was a significant difference between students and residents (P = 0.05) and between residents and trained surgeons (P = 0.003) for the average completion time in Group III. There was a significant difference between students and trained surgeons (P = 0.003) for the number of contacts per average time and between students and residents (P = 0.05). There was a significant inverse correlation between stereopsis vision score and completion time in Group I and number of contacts per average time (P = 0.0004 and P = 0.01, respectively).

CONCLUSIONS

This study demonstrates potential applications of a vitreoretinal surgical simulator as a training and skills assessment tool for novice, inexperienced, and trained surgeons. A simulator can be used to teach specific techniques and train surgeons.

Illuminated artificial orbit for the training of vitreoretinal surgery in vitro

PURPOSE

Demonstrations and practical experiments are important constituents of the teaching of surgical principles and techniques to residents in ophthalmology. The objective was to develop an eye-support device for experimental and didactic use during vitreoretinal microsurgery in vitro.

METHODS

Various eye-support devices with different light sources and illumination intensities were designed and tested. The main components of the final prototype are a high-intensity halogen lamp, a flexible light guide, a cylinder with a mirror inside, and a replaceable, transparent eye support with a ring-adapter. Light from the point source is reflected via the light guide into the cylinder and through the eye support transsclerally into the eye.

RESULTS

The device illuminates the retina and the vitreous body sufficiently. It accentuates the transparent appearance of the retina and makes the three-dimensional structure more visible, for example, in case of retinal detachment. Subretinal tissue can be visualized and differentiated more precisely.

CONCLUSIONS

The device is useful, in the teaching of residents and in experimental vitreoretinal surgery.

Computer-assisted training system for pars plana vitrectomy

PURPOSE

To evaluate whether microsurgical steps in vitreoretinal surgery can be taught by a computer-assisted training system.

METHODS

This prospective, randomized experimental study included 14 ophthalmic residents and medical students who were completely inexperienced in microsurgery. They were randomized into two groups. The study group underwent training programmes in a computer-assisted training system for simulation of pars plana vitrectomy. The control group did not participate in any in vitro training. In the second phase of the study, participants of both groups performed a pars plana vitrectomy in three pig eyes, which included picking a metallic foreign body from the retinal surface.

RESULTS

The amount of retinal detachment and the number of retinal defects at the end of the vitrectomies were smaller, the time needed to remove the foreign body was shorter, the number of retinal lesions associated with the foreign body removal was lower, and the mark given was better in the trained study group than in the untrained group. The relatively small number of study participants did not allow the differences between the study and control groups to reach the 5% level of error probability.

CONCLUSIONS

In an animal model, training by a computer-based medical work station for simulation of pars plana vitrectomy showed better outcome measures for trained study participants compared with untrained study participants. Future studies may show whether further refinements of such training programmes will result in statistically significantly better results in surgical outcome parameters.