Early Performance on an Eye Surgery Simulator Predicts Subsequent Resident Surgical Performance

Immersive teaching using virtual reality technology to improve ophthalmic surgical skills for medical postgraduate students

Medical education is primarily based on practical schooling and the accumulation of experience and skills, which is important for the growth and development of young ophthalmic surgeons. However, present learning and refresher methods are constrained by several factors. Nevertheless, virtual reality (VR) technology has considerably contributed to medical training worldwide, providing convenient and practical auxiliary value for the selection of students' sub-majors. Moreover, it offers previously inaccessible surgical step training, scenario simulations, and immersive evaluation exams. This paper outlines the current applications of VR immersive teaching methods for ophthalmic surgery interns.

Preclinical training of future ocular surgeons: a French opinion-based study

PURPOSE

To assess ophthalmology residents satisfaction regarding surgical training during residency in France.

METHODS

A questionnaire consisting of 28 questions was designed and sent to residents of ophthalmology across the 27 French regions.

RESULTS

A total of 30.3% ophthalmology residents in France completed our questionnaire. All French regions participated. They rated 5,27 ± 2.42/10 the global surgical training during residency. They had performed at least one step of any type of ocular surgery for 93.4% of them, while 80.7% had completed at least one full cataract surgery, by the beginning of their second year of residency on average (Paris: 2.59 ± 1.36 semesters; regions: 4.05 ± 1.96 semesters, p < 0.0001). Only 48.9% identified a surgical mentor during their residency, but 82.2% did not clearly identify surgical goals & objectives during their training. Simulation was available for any type of ocular surgery to all residents in the Paris (Île-de-France) region and to 78.1% in other regions (p < 0.005). Residents who accessed drylabs and wetlabs gave a satisfaction score of 7.31 ± 1.89/10 and 6.39 ± 2.15/10 to it respectively. Simulation was a mandatory part of the curriculum for 35.2% of the resident. They commented on on reduced access to subspecialized surgery. They were willing for more access to simulation and surgery on real patients, as well for closer mentoring and clearly defined surgical goals within the curriculum.

CONCLUSION

Ophthalmology residents seemed globally satisfied with their surgical training nationwide, although we observed disparities across region. They largely acknowledged a lack of standard procedures nationwide. They acclaimed simulation during the initial phase of residency, progressively switching towards surgery on real patients. An "operating license" during residency could be a viable way for the resident to demonstrate that they have acquired enough surgical abilities to perform surgery on real patients.

Resident performance in simulation module is associated with operating room performance for laparoscopic cholecystectomy

BACKGROUND

Simulation is an important tool in surgical training. However, the transferability of skills obtained in the simulation setting to the operating room (OR) is uncertain. This study explores the association between resident simulation performance and OR performance in a laparoscopic cholecystectomy (LC) simulation module.

METHODS

A simulation module focused on LC utilizing a virtual reality simulator was completed by general surgery residents. Simulation performance was evaluated using the validated Global Operative Assessment of Laparoscopic Skills (GOALS) and Objective Structured Assessment of Technical Skills (OSATS), as well as a LC-specific simulation assessment form (LC-SIM). Resident subsequent OR performances of LC were measured by the Surgical Training and Assessment Tool (STAT), an online mobile-based evaluation completed by attending surgeons.

RESULTS

Twenty-one residents who completed the simulation module and also with STAT data on LC from 2016 to 2020 were included. Higher scores on incision/port placement on LC-SIM is associated with better tissue handling (coefficient 0.20, p = 0.048) and better time & economy of motion on STAT (coefficient 0.22, p = 0.037). However, higher scores on time and motion on OSATS are associated with worse tissue handling (- 0.28, p = 0.046), worse time & economy of motion (- 0.37, p = 0.009), and worse overall grade (- 0.21, p = 0.044). Higher scores on overall performance on OSATS is associated with worse time & economy of motion (- 0.80, p = 0.008). Higher scores on depth perception on GOALS are associated with worse tissue handling (- 0.28, p = 0.044).

CONCLUSION

We found significant positive and negative associations between resident simulation performance and OR performance, particularly in tissue handling and economy of motion. This could suggest that simulation performance does not reliably predict OR performance. However, this could highlight the concept of excessive caution in the real OR environment and longer operative time which could be interpreted as worse time and economy of motion by the attending surgeons.

Modern Educational Simulation-Based Tools Among Residents of Ophthalmology: A Narrative Review

INTRODUCTION

With no specific overview on simulation-based training for educational purposes among residents in ophthalmology, this narrative review attempts to highlight the current literature on modern educational simulation-based tools used to educate residents in ophthalmology.

METHODS

We searched databases Web of Science and PubMed between March 15 and July 21, 2022. Relevant and accessible articles and abstracts published after 2006 and in English only were included.

RESULTS

Simulation-based cataract surgery is associated with better outcomes in the operating room and faster surgeries. Construct validity has been established across different procedures and levels in simulation-based cataract surgery and simulation-based vitreoretinal surgery. Other simulation-based procedures indicate promising results but in general lack evidence-based validity.

DISCUSSION

This narrative review highlights and evaluates the current and relevant literature of modern educational simulation-based tools to train ophthalmology residents in different fundamental skills like simulation-based ophthalmoscopy and complex surgical procedures like simulation-based cataract surgery and vitreoretinal surgery. Some studies attempt to develop simulators for the use in education of ophthalmology residents. Other studies strive to establish validity of the respective procedures or modern education tools and some studies investigate the effect of simulation-based training. The most validated modern educational simulation-based tool is the Eyesi Surgical Simulator (VRmagic, Germany). However, other modern educational simulation-based tools have also been evaluated, including the HelpMeSee Eye Surgery Simulator (HelpMeSee Inc., New York, USA) and the MicroVisTouch Surgical Simulator (ImmersiveTouch, USA).

CONCLUSION

Simulation-based training has already been established for residents in ophthalmology to benefit the most from skill-demanding procedures resulting in better learning and better patient handling. Future studies should aim to validate more simulation-based procedures for the teaching of ophthalmology residents so that the evidence is kept at a high standard.

Augmented Reality, Virtual Reality, and Game Technologies in Ophthalmology Training

Ophthalmology is a medical profession with a tradition in teaching that has developed throughout history. Although ophthalmologists are generally considered to only prescribe contact lenses, and they handle more than half of eye-related enhancements, diagnoses, and treatments. The training of qualified ophthalmologists is generally carried out under the traditional settings, where there is a supervisor and a student, and training is based on the use of animal eyes or artificial eye models. These models have significant disadvantages, as they are not immersive and are extremely expensive and difficult to acquire. Therefore, technologies related to Augmented Reality (AR) and Virtual Reality (VR) are rapidly and prominently positioning themselves in the medical sector, and the field of ophthalmology is growing exponentially both in terms of the training of professionals and in the assistance and recovery of patients. At the same time, it is necessary to highlight and analyze the developments that have made use of game technologies for the teaching of ophthalmology and the results that have been obtained. This systematic review aims to investigate software and hardware applications developed exclusively for educational environments related to ophthalmology and provide an analysis of other related tools. In addition, the advantages and disadvantages, limitations, and challenges involved in the use of virtual reality, augmented reality, and game technologies in this field are also presented.

A portable, low-cost practice model for microsurgical skills training

PURPOSE

We describe a portable practice model for acquisition of microsurgical skills using widely available inexpensive tools and materials as a model in learning ophthalmic corneal suturing skills.

METHODS

Interested participants without prior microsurgery experience affiliated with the Jacobs School of Medicine and Biomedical Sciences with no prior microsurgical experience qualified to participate. Each participant completed written informed consent. We developed a 3-dimensional micro-stellated icosahedron model using microtubules, monofilament fishing line, jewelers' forceps, and a basic laboratory dissection microscope. We tested this model in improving microsurgical skills in a randomized, controlled intervention trial. Following a pre-assessment task of passing a microsurgical needle and performing a tie, participants were randomized to a control or an intervention (building the micro-stellated icosahedrons) group. The assessment task was repeated after two weeks. Videos of pre- and post-assessments were rated by two masked ophthalmologists. Technique scores and time to complete microsurgical tasks were analyzed to determine improvement in skills.

RESULTS

A total of 27 microsurgically naïve participants were recruited and randomized (14 Intervention / 13 Control). Comparing pre- and post-assessments, the intervention group showed significant decrease in time required to pass the needle (P = 0.018) and significant improvement in technical scores. (P = 0.001). In the control group, there was no significant decrease in time or improvement in technical scores.

CONCLUSIONS

The portable inexpensive micro-stellated icosahedron skills acquisition model is an effective practice model to acquire skills necessary to perform a microsurgical tie. The similarity in dimensions between the model and the eye suggests translatability to ophthalmic surgery.

Impact of Video Describing Cataract Surgical Simulator Training on Patients' Perceptions of Resident Involvement in Cataract Surgery

Purpose The aim of this article is to investigate the impact of a 1-minute video describing resident training with a cataract surgical simulator on patients' perceptions regarding resident involvement in cataract surgery and to identify factors associated with patient willingness to have cataract surgery performed by a resident.

Design Cross-sectional survey.

Methods An anonymous Likert-style survey was conducted among 430 consecutive adult patients who presented for eye examination at the Penn State Health Eye Center. The survey included questions regarding demographics, understanding of the medical training hierarchy, and patient willingness to have a resident perform their cataract surgery. There were six questions regarding patient willingness to have residents perform their cataract surgery and the second question in this set informs the patient that residents are supervised by an experienced cataract surgeon. Patients were randomly assigned to one of two groups: patients in Group 1 completed the survey only, while patients in Group 2 watched a 1-minute video describing resident training with a cataract surgical simulator prior to completing the survey.

Results Four hundred fourteen of the 430 patients (96.3%) completed the survey. Overall, 24.7% (n = 102) of respondents expressed willingness to allow an ophthalmology resident to perform their cataract surgery, and that proportion increased to 54.0% (n = 223) if the patient was informed that the resident would be supervised by an experienced cataract surgeon. Patients in Group 2 were twice as likely compared with patients in Group 1 to express willingness to allow an ophthalmology resident to perform their cataract surgery (odds ratio 1.92 [1.18–3.11], p = 0.009).

Conclusions A thorough informed consent process including information regarding attending supervision and a brief video detailing resident training with a cataract surgery simulator may increase patient willingness to allow resident participation in cataract surgery.

Applications of Extended Reality in Ophthalmology: Systematic Review

BACKGROUND

Virtual reality, augmented reality, and mixed reality make use of a variety of different software and hardware, but they share three main characteristics: immersion, presence, and interaction. The umbrella term for technologies with these characteristics is extended reality. The ability of extended reality to create environments that are otherwise impossible in the real world has practical implications in the medical discipline. In ophthalmology, virtual reality simulators have become increasingly popular as tools for surgical education. Recent developments have also explored diagnostic and therapeutic uses in ophthalmology.

OBJECTIVE

This systematic review aims to identify and investigate the utility of extended reality in ophthalmic education, diagnostics, and therapeutics.

METHODS

A literature search was conducted using PubMed, Embase, and Cochrane Register of Controlled Trials. Publications from January 1, 1956 to April 15, 2020 were included. Inclusion criteria were studies evaluating the use of extended reality in ophthalmic education, diagnostics, and therapeutics. Eligible studies were evaluated using the Oxford Centre for Evidence-Based Medicine levels of evidence. Relevant studies were also evaluated using a validity framework. Findings and relevant data from the studies were extracted, evaluated, and compared to determine the utility of extended reality in ophthalmology.

RESULTS

We identified 12,490 unique records in our literature search; 87 met final eligibility criteria, comprising studies that evaluated the use of extended reality in education (n=54), diagnostics (n=5), and therapeutics (n=28). Of these, 79 studies (91%) achieved evidence levels in the range 2b to 4, indicating poor quality. Only 2 (9%) out of 22 relevant studies addressed all 5 sources of validity evidence. In education, we found that ophthalmic surgical simulators demonstrated efficacy and validity in improving surgical performance and reducing complication rates. Ophthalmoscopy simulators demonstrated efficacy and validity evidence in improving ophthalmoscopy skills in the clinical setting. In diagnostics, studies demonstrated proof-of-concept in presenting ocular imaging data on extended reality platforms and validity in assessing the function of patients with ophthalmic diseases. In therapeutics, heads-up surgical systems had similar complication rates, procedural success rates, and outcomes in comparison with conventional ophthalmic surgery.

CONCLUSIONS

Extended reality has promising areas of application in ophthalmology, but additional high-quality comparative studies are needed to assess their roles among incumbent methods of ophthalmic education, diagnostics, and therapeutics.

EyeSi Surgical Simulator: validation of a proficiency-based test for assessment of vitreoretinal surgical skills

PURPOSE

To develop and investigate an evidence-based performance test for assessment of vitreoretinal surgical skills on the EyeSi Surgical Simulator.

METHODS

Ten junior residents without any surgical experience, eight senior residents with prior experience in cataract surgery and five vitreoretinal surgeons were included in the study. The test consisted of seven modules and was completed twice by all groups during a single session. Validity evidence was evaluated using Messick's validity framework. Senior residents completed four additional test sessions and were retested 3 months after to assess skill acquisition and retention.

RESULTS

Content was aligned with vitreoretinal surgical skills as evaluated by expert surgeons. Response process was ensured through standardized instruction and data collection. The test showed satisfactory internal consistency with Cronbach's α = 0.76 (internal structure) and significant discriminative ability between the residents and the experienced surgeons (relation to other variables). A pass/fail level was determined at 596 using the contrasting groups' method. Consequences of applying this standard resulted in no false positive and no false negative. Senior residents significantly improved their simulator skills over time, reaching a plateau at the fifth iteration and equalling expert performance (p = 0.420). This level of competency was retained during the post-3-month retention testing (p = 0.062).

CONCLUSION

We established a performance test with solid evidence for assessment of vitreoretinal surgical skills on the EyeSi Simulator and determined a benchmark criterion that may be used for future implementation of proficiency-based training for novices.

Virtual Reality and Augmented Reality in Ophthalmology: A Contemporary Prospective

PURPOSE

Most published systematic reviews have focused on the use of virtual reality (VR)/augmented reality (AR) technology in ophthalmology as it relates to surgical training. To date, this is the first review that investigates the current state of VR/AR technology applied more broadly to the entire field of ophthalmology.

METHODS

PubMed, Embase, and CINAHL databases were searched systematically from January 2014 through December 1, 2020. Studies that discussed VR and/or AR as it relates to the field of ophthalmology and provided information on the technology used were considered. Abstracts, non-peer-reviewed literature, review articles, studies that reported only qualitative data, and studies without English translations were excluded.

RESULTS

A total of 77 studies were included in this review. Of these, 28 evaluated the use of VR/AR in ophthalmic surgical training/assessment and guidance, 7 in clinical training, 23 in diagnosis/screening, and 19 in treatment/therapy. 15 studies used AR, 61 used VR, and 1 used both. Most studies focused on the validity and usability of novel technologies.

CONCLUSIONS

Ophthalmology is a field of medicine that is well suited for the use of VR/AR. However, further longitudinal studies examining the practical feasibility, efficacy, and safety of such novel technologies, the cost-effectiveness, and medical/legal considerations are still needed. We believe that time will indeed foster further technological advances and lead to widespread use of VR/AR in routine ophthalmic practice.

The User Experience on a 3-Dimensional Heads-Up Display for Vitreoretinal Surgery Across All Members of the Health Care Team: A Survey of Medical Students, Residents, Fellows, Attending Surgeons, Nurses, and Anesthesiologists

Purpose:

This work assesses the educational use of a 3-dimensional (3D) heads-up visualization system for vitreoretinal surgery.

Methods:

A cross-sectional survey was performed among 18 medical students, 18 residents, 7 VR fellows, 6 nurses, 4 anesthesiologists, and 3 surgeons on their experience with the Ngenuity 3D Visualization System (TrueVision and Alcon) compared with the standard microscope.

Results:

Most medical students (88%) reported better identification of surgical landmarks; 63% ranked the Ngenuity as their preferred method of learning (vs microscope or 2-dimensional display). Residents reported a superior understanding of anatomy (69%), an increased ability to ask questions (63%), and improved ergonomics (94%). Epiretinal membrane peel, internal limiting membrane peel, and core vitrectomy were most enhanced (69% to 77%) for residents. Fellows’ experience with trocar placement, vitrectomy, and oil/gas insertion was the same as before (67% to 100%), whereas endolaser and closing were worse (67% to 100%). Regarding autonomy, 83% of fellows reported no change, whereas 17% reported increased levels. Nurses were better able to track case progress (67%) and anticipate which tools were needed (50%). All anesthesiologists reported the same or worse engagement in cases, noting it was difficult to switch between the 3D screen and the anesthesia equipment. All surgeons reported a better awareness of trainees in the room and an improved ability to point out landmarks; 67% reported being more comfortable with resident and fellow autonomy.

Conclusions:

The Ngenuity is most helpful to students and residents. Integrating 3D displays into the surgical curriculum is beneficial, with care to ensure nurse and anesthesiologist satisfaction.

The Utility of Virtual Reality Simulation in Cataract Surgery Training: A Systematic Review

Introduction Cataract surgery is a fundamental intraocular procedure with a steep learning curve. Virtual reality simulation offers opportunity to streamline this aspect of ophthalmic education by exposing trainees to operative techniques in a controlled setting.

Materials and Methods A systematic review of the PubMed database was conducted through December 2019 for English language studies reporting on use of virtual reality simulation in cataract surgery training to assess usefulness. Studies meeting inclusion criteria were examined for pertinent data: study design, number of subjects and live cases, simulator model, training regimen, surgical skills assessed, and overall outcomes.

Results Of the 41 analyzed studies, 15 investigated the impact of virtual reality simulation-based training on performance in live surgery or wet laboratories; 20 used simulation as a device for direct assessment of operative proficiency; 6 explored simulation-based training's effect on performance in simulated surgery. Thirty-seven studies employed an iteration of the Eyesi simulator, though methodologies varied widely with a few randomized trials available. The literature endorsed validity of simulator-based assessment and benefits of structured training on live complication rates, operative times, and self- and faculty-perceived competency, particularly in novice surgeons.

Discussion The literature surrounding simulation in cataract surgery training is characterized by significant heterogeneity in design. However, most works describe advantages that may outweigh the costs of implementation into training curricula. Collaborative efforts at establishing a structured, proficiency-based cataract surgery curriculum built around virtual reality and wet laboratory simulation have the potential to improve outcomes and enhance future surgical training.

A systematic review of simulation-based training tools for technical and non-technical skills in ophthalmology

To evaluate all simulation models for ophthalmology technical and non-technical skills training and the strength of evidence to support their validity and effectiveness. A systematic search was performed using PubMed and Embase for studies published from inception to 01/07/2019. Studies were analysed according to the training modality: virtual reality; wet-lab; dry-lab models; e-learning. The educational impact of studies was evaluated using Messick's validity framework and McGaghie's model of translational outcomes for evaluating effectiveness. One hundred and thirty-one studies were included in this review, with 93 different simulators described. Fifty-three studies were based on virtual reality tools; 47 on wet-lab models; 26 on dry-lab models; 5 on e-learning. Only two studies provided evidence for all five sources of validity assessment. Models with the strongest validity evidence were the Eyesi Surgical, Eyesi Direct Ophthalmoscope and Eye Surgical Skills Assessment Test. Effectiveness ratings for simulator models were mostly limited to level 2 (contained effects) with the exception of the Sophocle vitreoretinal surgery simulator, which was shown at level 3 (downstream effects), and the Eyesi at level 5 (target effects) for cataract surgery. A wide range of models have been described but only the Eyesi has undergone comprehensive investigation. The main weakness is in the poor quality of study design, with a predominance of descriptive reports showing limited validity evidence and few studies investigating the effects of simulation training on patient outcomes. More robust research is needed to enable effective implementation of simulation tools into current training curriculums.

Can simulators be applied to improve cataract surgery training: a systematic review

Objective

The purpose of this paper was to conduct a systematic review of existing literature on simulation-based training of cataract surgery. Available literature was evaluated and projections on how current findings could be applied to cataract surgery training were summarised. The quality of included literature was also assessed.

Methods and analysis

The PubMed, Embase and Cochrane Library databases were searched for articles pertaining to simulation training in cataract surgery on 18 November 2019. Selected articles were qualitatively analysed.

Results

A total of 165 articles were identified out of which 10 met inclusion criteria. Four studies reported construct validity of the EyeSi simulator. Six studies demonstrated improved surgical outcomes corresponding to training on the simulator. Quality assessment of included studies was satisfactory.

Conclusion

Current studies on simulation training in cataract surgery all point towards it being an effective training tool with low risk of study biases confounding this conclusion. As technology improves, surgical training must embrace and incorporate simulation technology in training.

Predictive and construct validity of virtual reality cataract surgery simulators

This review was conducted to assess the current literature on virtual reality (VR) simulation in cataract surgery training. Studies evaluating the construct and predictive validity of VR simulators, such as the EyeSi simulator, were compiled and compared. Two databases, PubMed and Scopus, were systematically searched, and 20 articles were determined to meet the study inclusion criteria (full-length articles written in English). Of these, 11 studies examined construct validity, and 9 studies examined predictive validity. Although the construct validity of some VR simulators is yet to be established by multiple studies, many of the modules within the EyeSi simulator have been repeatedly validated. Furthermore, several studies have shown that VR simulator training improves overall cataract surgery performance. This review demonstrated the ability of cataract surgery VR simulators to differentiate surgical experience levels and improve operating room performance, which supports the use of VR simulators in ophthalmology residency training.

Validation of a novel strabismus surgery 3D-printed silicone eye model for simulation training

PURPOSE

To demonstrate the validity of a new 3D-printed silicone model for practicing strabismus surgery, compared with the rabbit head, in terms of simulator fidelity.

METHODS

In this multicenter study, a validated questionnaire was developed to assess fidelity of the model and rabbit head. Participants were asked to rate overall globe, conjunctiva, muscle, and scleral fidelity using a 5-point scale. The survey instrument was disseminated at three strabismus instruction courses: at two meetings, participants practiced on the model and rabbit head prior to completing the questionnaire; at the third, instructors demonstrated advanced surgical skills using only the model and then completed the questionnaire. Repeated measures analysis of variance compared ratings. Pearson's or Spearman's correlation evaluated correlation between years of experience to participants' responses. Qualitative data were coded into themes.

RESULTS

A total of 47 participants completed the questionnaire. The model rated 18% higher than rabbit head for anatomical accuracy (mean difference, 0.667; P = 0.001) and 25% higher for position of eyes within the head (mean difference, 0.867; P = 0.006). More experienced participants were more likely to strongly agree that the silicone conjunctiva effectively mimics real conjunctiva (ρ = 0.337; P = 0.036) and that scleral tissue effectively mimics real sclera (ρ = 0.298, P = 0.042). Qualitative data supported the model.

CONCLUSIONS

This study demonstrated the validity of the surgical model in terms of fidelity compared to the rabbit head.

[Evaluation of a virtual reality simulator for learning direct ophthalmoscopy in student teaching]

BACKGROUND

The use of direct ophthalmoscopy in non-ophthalmological specialties seems to be decreasing in the clinical routine. This could be due to a lack of training and thus an uncertain assessment.

OBJECTIVE

The aim of this study was to evaluate the effectiveness and acceptance of learning direct ophthalmoscopy on a simulator in comparison to the classical teaching method among students.

MATERIAL AND METHODS

Within the framework of the student block internship for ophthalmology, a total of 34 students took part in the project. The first group received classical training, the second group received simulator training. The learning success was assessed by an objective structured clinical examination (OSCE).

RESULTS

The simulator training group showed a significantly higher points score in individual disciplines. The subjects in the classical group achieved a learning success in the OSCE of 78%. In the simulator-based group a higher score of 91% was achieved with a lower scatter in all subdisciplines.

DISCUSSION

The patient and instructor-independent availability of the teaching materials, a reduction of light exposure for patients and test subjects, as well as a standardized and controlled mediation of physiological and pathological findings can be emphasized as advantages of the tested simulator.

CONCLUSION

The simulator-based training for learning direct funduscopy is effective. The virtual reality simulator evaluated in this project can improve the training of students and residents.

Comparison of two popular nuclear disassembly techniques for cataract surgeons in training: divide and conquer versus stop and chop

PURPOSE

To compare two common phacoemulsification techniques in the learning curve phase, and their effect on ultrasound energy dissipation.

METHODS

One hundred and ten consecutive patients scheduled for cataract surgery with the same surgeon in training were prospectively enrolled. Study was divided in two parts. In the first one, 60 patients were stratified for cataract grade [nuclear opalescence (NO) grade 2-4] and divided in two groups receiving surgery with the divide-and-conquer technique (Group-1) and with the stop-and-chop technique (Group-2). In the second part, 50 patients were stratified according to cataract grade (NO2-6), and the surgeon had to choose one of the two techniques according to personal preference. The primary outcome was the cumulative dissipated energy (CDE).

RESULTS

Significant differences of CDE were observed between the NO3 and NO4 cataracts in Group-1. In Group-2, this difference was not significant, suggesting that with more advanced cataracts, the stop-and-chop technique allows less ultrasound use. In the second part of the study, the stop and chop was most frequently used for more advanced cataracts. When considering harder cataracts (NO5-NO6), patients receiving surgery with the divide-and-conquer technique had higher CDE values compared to stop and chop.

CONCLUSIONS

Both divide-and-conquer and stop-and-chop techniques are efficient in the learning curve. Stop and chop dissipates less energy in harder nuclei. Once surgeons reach sufficient experience with both techniques, they should switch to a stop-and-chop technique, allowing lower levels of ultrasound energy.