Virtual Reality in Ophthalmology Training

Effectiveness of the Eyesi Surgical Simulator for ophthalmology trainees: systematic review and meta-analysis

OBJECTIVE

The Eyesi Surgical Simulator (VRmagic, Mannheim, Germany) is the most commonly used ophthalmic virtual reality surgical simulator. While studies have demonstrated improved trainee skill acquisition with simulation-based training tools, a systematic review and meta-analysis evaluating Eyesi specifically has yet to be conducted. The aim of this study was to meta-analyze studies comparing Eyesi with other methods of technical skill teaching for trainees.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched. Articles included compared Eyesi Surgical Simulator use with alternative methods of technical skill training for medical students or residents. A pairwise meta-analysis using inverse variance random effects was performed. Standardized mean differences (SMDs) were used as the primary outcome measure to account for differences in surgical skill evaluation tools.

RESULTS

From 207 citations, 8 studies with 108 learners using Eyesi and 123 learners not using Eyesi were included. Improvements in technical skill scores were significantly greater with the use of Eyesi (3 studies; SMD = 2.02; 95% CI, 1.47-2.57; p < 0.001; I2 = 0%). There was a significant reduction in the number of learners experiencing post-training technical errors in the Eyesi group (5 studies: odds ratio = 0.43; 95% CI, 0.20-0.90; p = 0.03; I2 = 30%). There were no significant differences in post-training time to task completion between groups (3 studies; SMD = 1.96; 95% CI, -1.96-5.88; p = 0.33; I2 = 97%).

CONCLUSIONS

The Eyesi Surgical Simulator may improve technical skill acquisition (grade: low certainty of evidence) and decrease technical errors (grade: very low certainty of evidence) during cataract surgery among trainees. Further prospective studies evaluating Eyesi modules with standardized scoring systems is warranted.

Modern Image-Guided Surgery: A Narrative Review of Medical Image Processing and Visualization

Medical image analysis forms the basis of image-guided surgery (IGS) and many of its fundamental tasks. Driven by the growing number of medical imaging modalities, the research community of medical imaging has developed methods and achieved functionality breakthroughs. However, with the overwhelming pool of information in the literature, it has become increasingly challenging for researchers to extract context-relevant information for specific applications, especially when many widely used methods exist in a variety of versions optimized for their respective application domains. By being further equipped with sophisticated three-dimensional (3D) medical image visualization and digital reality technology, medical experts could enhance their performance capabilities in IGS by multiple folds. The goal of this narrative review is to organize the key components of IGS in the aspects of medical image processing and visualization with a new perspective and insights. The literature search was conducted using mainstream academic search engines with a combination of keywords relevant to the field up until mid-2022. This survey systemically summarizes the basic, mainstream, and state-of-the-art medical image processing methods as well as how visualization technology like augmented/mixed/virtual reality (AR/MR/VR) are enhancing performance in IGS. Further, we hope that this survey will shed some light on the future of IGS in the face of challenges and opportunities for the research directions of medical image processing and visualization.

"Can You Feel It": An Early Experience with Simulated Vibration to Recreate Glenoid Reaming

When developing educational simulators, meaningful haptic feedback is important. To our knowledge, no shoulder arthroplasty surgical simulator exists. This study focuses on simulating vibration haptics of glenoid reaming for shoulder arthroplasty using a novel glenoid reaming simulator.

Methods

We validated a novel custom simulator constructed using a vibration transducer transmitting simulated reaming vibrations to a powered nonwearing reamer tip through a 3D-printed glenoid. Validation and system fidelity were evaluated by 9 fellowship-trained shoulder surgeon experts performing a series of simulated reamings. We then completed the validation process through a questionnaire focused on experts' experience with the simulator.

Results

Experts correctly identified 52% ± 8% of surface profiles and 69% ± 21% of cartilage layers. Experts identified the vibration interface between simulated cartilage and subchondral bone (77% ± 23% of the time), indicating high fidelity for the system. An interclass correlation coefficient for experts' reaming to the subchondral plate was 0.682 (confidence interval 0.262-0.908). On a general questionnaire, the perceived utility of the simulator as a teaching tool was highly ranked (4/5), and experts scored "ease of instrument manipulation" (4.19/5) and "realism of the simulator" (4.11/5) the highest. The mean global evaluation score was 6.8/10 (range 5-10).

Conclusions

We examined a simulated glenoid reamer and feasibility of haptic vibrational feedback for training. Experts validated simulated vibration feedback for glenoid simulation reaming, and the results suggested that this may be a useful additional training adjuvant.

Level of Evidence

Level II, prospective study.

Ophthalmology Residency in the United States: The Case for a National Curriculum

To identify strategies for effective curriculum development and implementation in United States (US) ophthalmology residency training programs. A literature review was conducted for all English-language PubMed/Medline articles relating to ophthalmology residency education or curriculum/curricula. Despite ACGME-defined program requirements outlining curricular goals for US ophthalmology residency training programs, there is no comprehensive, national curriculum with detailed plans for instruction of necessary topics within the 36-month residency training period. Several articles identify a need for detailed curricula on various topics, propose ideas on how residency programs could create curricula, and explore ways of assessing resident competence. There is a paucity of literature evaluating how ophthalmology residents best learn various ophthalmology topics. We need to develop an intentional, comprehensive, and timely national curriculum for ophthalmology residency programs in the US, with detailed plans on how to meet curricular objectives and consideration of the most effective teaching strategies for different ophthalmology concepts.

Bionic eye system mimicking microfluidic structure and intraocular pressure for glaucoma surgery training

Among increasing eye diseases, glaucoma may hurt the optic nerves and lead to vision loss, the treatment of which is to reduce intraocular pressure (IOP). In this research, we introduce a new concept of the surgery simulator for Minimally Invasive Glaucoma Surgery (MIGS). The concept is comprised of an anterior eye model and a fluidic circulatory system. The model made of flexible material includes a channel like the Schlemm’s canal (SC) and a membrane like the trabecular meshwork (TM) covering the SC. The system can monitor IOP in the model by a pressure sensor. In one of the MIGS procedures, the TM is cleaved to reduce the IOP. Using the simulator, ophthalmologists can practice the procedure and measure the IOP. First, considering the characteristics of human eyes, we defined requirements and target performances for the simulator. Next, we designed and manufactured the prototype. Using the prototype, we measured the IOP change before and after cleaving the TM. Finally, we demonstrated the availability by comparing experimental results and target performances. This simulator is also expected to be used for evaluations and developments of new MIGS instruments and ophthalmic surgery robots in addition to the surgical training of ophthalmologists.

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.

Virtual Reality and Augmented Reality- Emerging Screening and Diagnostic Techniques in Ophthalmology: a Systematic Review

In healthcare, virtual reality (VR) and augmented reality (AR) have been applied extensively for many purposes. Similar to other technologies such as telemedicine and artificial intelligence, VR and AR may improve clinical diagnosis and screening services in ophthalmology by alleviating current problems, including workforce shortage, diagnostic error, and underdiagnosis. In the past decade a number of studies and products have used VR and AR concepts to build clinical tests for ophthalmology, but comprehensive reviews on these studies are limited. Therefore, we conducted a systematic review on the use of VR and AR as a diagnostic and screening tool in ophthalmology. We identified 26 studies that implemented a variety of VR and AR tests on different conditions, including VR cover tests for binocular vision disorder, VR perimetry for glaucoma, and AR slit lamp biomicroscopy for retinal diseases. In general, while VR and AR tools can become standardized, automated, and cost-effective tests with good user experience, several weaknesses, including unsatisfactory accuracy, weak validation, and hardware limitations, have prevented these VR and AR tools from having wider clinical application. Also, a comparison between VR and AR is made to explain why studies have predominantly used VR rather than AR.

Pretraining of basic skills on a virtual reality vitreoretinal simulator: A waste of time

PURPOSE

To investigate whether pretraining of basic skills in virtual vitreoretinal surgery affected the performance curve when proceeding to procedure-specific modules.

METHODS

This study was a prospective, randomized, controlled, two-centre study. Medical students were randomized into two groups: Group 1 pretrained basic psycho-motor skills (Navigation Training level 2 and Bimanual Training level 3) until they reached their performance curve plateau. Hereafter, both groups trained on the procedure-specific modules (Posterior Hyaloid level 3 and ILM Peeling level 3) until they reached their performance curve plateau. Plateau was defined as three consecutive sessions with the same score with an acceptable variation. The primary outcome was time used to reach performance curve plateau in the procedure-specific modules.

RESULTS

A total of 68 medical students were included, and equally randomized into two groups. The participants in Group 1 used a median time of 88 minutes to reach plateau in the basic skills modules but did not differ from Group 2 in time to reach plateau on the procedure-specific modules (183 min versus 210 min, p = 0.40) or in the amplitude of plateau. Group 1 and 2 differed significantly in the starting score of ILM peeling level 3 (0 (0-0) versus 3.5 (0-75), p = 0.03).

CONCLUSION

We were not able to show positive skill transfer from basic skills training to the procedure-specific modules in time, starting score or amplitude of plateau. Thus, we recommend that aspiring vitreoretinal surgeons proceed directly to simulation-based training of procedures instead of spending valuable training time on basic skills training.

The potential impact of 5G telecommunication technology on ophthalmology

Advances in information and communication technology (ICT) are having an increasing impact on the practice of ophthalmology. Successive generations of 4G networks have provided continued improvements in bandwidth and download speeds. Fibre-optic networks were promised as the next step in the development of a faster and more reliable network. However, due to considerable delays in their widespread implementation, original expectations have not been met. Currently, the new 5G network is on the verge of widespread release and aims to offer previously unparalleled bandwidth, speed, reliability and access. This review aims to highlight the potential profound impact near instantaneous communication (the 5G network) may have on ophthalmology and the delivery of eyecare to the global population. Conversely, if the new network fails to deliver as intended, the wireless network itself may become yet another obstacle to adopting next-generation technologies in eyecare.

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.

A Novel Virtual Reality Medical Image Display System for Group Discussions of Congenital Heart Disease: Development and Usability Testing

Background

The complex 3-dimensional (3D) nature of anatomical abnormalities in congenital heart disease (CHD) necessitates multidisciplinary group discussions centered around the review of medical images such as magnetic resonance imaging. Currently, group viewings of medical images are constrained to 2-dimensional (2D) cross-sectional displays of 3D scans. However, 2D display methods could introduce additional challenges since they require physicians to accurately reconstruct the images mentally into 3D anatomies for diagnosis, staging, and planning of surgery or other therapies. Virtual reality (VR) software may enhance diagnosis and care of CHD via 3D visualization of medical images. Yet, present-day VR developments for medicine lack the emphasis on multiuser collaborative environments, and the effect of displays and level of immersion for diagnosing CHDs have not been studied.

Objective

The objective of the study was to evaluate and compare the diagnostic accuracies and preferences of various display systems, including the conventional 2D display and a novel group VR software, in group discussions of CHD.

Methods

A total of 22 medical trainees consisting of 1 first-year, 10 second-year, 4 third-year, and 1 fourth-year residents and 6 medical students, who volunteered for the study, were formed into groups of 4 to 5 participants. Each group discussed three diagnostic cases of CHD with varying structural complexity using conventional 2D display and group VR software. A group VR software, Cardiac Review 3D, was developed by our team using the Unity engine. By using different display hardware, VR was classified into nonimmersive and full-immersive settings. The discussion time, diagnostic accuracy score, and peer assessment were collected to capture the group and individual diagnostic performances. The diagnostic accuracies for each participant were scored by two experienced cardiologists following a predetermined answer rubric. At the end of the study, all participants were provided a survey to rank their preferences of the display systems for performing group medical discussions.

Results

Diagnostic accuracies were highest when groups used the full-immersive VR compared with the conventional and nonimmersive VR (χ²₂=9.0, P=.01) displays. Differences between the display systems were more prominent with increasing case complexity (χ²₂=14.1, P<.001) where full-immersive VR had accuracy scores that were 54.49% and 146.82% higher than conventional and nonimmersive VR, respectively. The diagnostic accuracies provided by the two cardiologists for each participant did not statistically differ from each other (t=–1.01, P=.31). The full-immersive VR was ranked as the most preferred display for performing group CHD discussions by 68% of the participants.

Conclusions

The most preferred display system among medical trainees for visualizing medical images during group diagnostic discussions is full-immersive VR, with a trend toward improved diagnostic accuracy in complex anatomical abnormalities. Immersion is a crucial feature of displays of medical images for diagnostic accuracy in collaborative discussions.

Predictors of Manual Dexterity in Simulation-Based Cataract Surgery

Introduction The aim of this study is to determine if prior experience with fine motor hobbies influences a surgeon-in-training's performance on a cataract surgical simulator.

Materials and Methods Medical students (n = 70) performed navigation, forceps, and capsulorhexis simulations using the Eyesi Ophthalmosurgical Simulator. Participants were surveyed regarding fine motor hobby experiences, including musical instruments, video games, sewing, knitting, origami, painting, crafting, jewelry making, drawing, and extracurricular dissection.

Results Medical students with extracurricular dissection experience, including work in research laboratories involving microscopic animal dissection, did significantly better on the forceps simulator task (p = 0.009). Medical students with drawing experience performed better on capsulorhexis (p = 0.031). No other fine motor hobbies were significant for improving simulator scores.

Conclusion Drawing and extracurricular dissection lend to improved technical ability on the cataract surgical simulator. This research continues the conversation regarding fine motor hobbies that correlate with microsurgical ability and adds to the growing area of research regarding the selection and training of ophthalmology residents.

Simulation of advanced cataract surgery - validation of a newly developed test

PURPOSE

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 insertion - level 1, Iris Expansion Ring extraction - level 2, Capsulorhexis - level 3 and Anterior Vitrectomy - level 6.

RESULTS

Internal consistency reliability showed Cronbach's alpha of 0.63. Test-retest reliabilities were significant for Iris Expansion Ring extraction - level 2 (p = 0.012) and Capsulorhexis - level 3 (p = 0.018). Differences between the two groups were only significant in both repetitions for the Iris Expansion Ring extraction - level 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 insertion - level 1 (p = 0.021) and Capsulorhexis - level 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.

Design and development of model eye for retina laser by using additive manufacturing

Surgical skill of the surgeon can be improved by surgical simulation. Especially in ophthalmology, it is impossible to use real human/non-human primate eyes for ophthalmology surgery practice. However, surgical practice is most important for ophthalmologist. The retina laser surgery is one of the ophthalmology surgeries and it requires more surgical practice for surgeons to use the laser beam precisely to coagulate and fuse small areas of tissue. Dealing with the prospect of vision reduction or vision loss presents a peculiar problem and that can be highly stressful and frustrating for both doctors and patients. In this regard, training for indirect ophthalmoscopy and retinal photocoagulation is undergone using model eyes instead of real eyes. Properties and functioning of an existing model eye are huge and they differ from real human eye such as casings are completely rigid and focusing of retinal fundus is not completely covered. Therefore, this research concentrates to develop a model eye that assimilates close to the human eye by focussing on the maximum viewing area that is not done at the moment. Finally, the design and development of re-engineered model eye for retina laser is fabricated by additive manufacturing. Compared to existing plastic model eye, viewing area and viewing angle of the re-engineered model eye is increased by 16.66% and 6.14%, respectively. Due to design modifications and elimination of the insert, it can be reduced by 18.99% and 13.95% of height and weight of the top casing respectively. Developed re-engineered model eye will improve the surgical and diagnostic skill of the surgeon and increase their confidence and proficiency. It also augments the effective use of essential ophthalmic instruments. Additionally, it can reduce the surgical error and meet the existing demand of actual eyes for surgical practices.

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.

Simulation training in vitreoretinal surgery: a systematic review

Background

The purpose of this study was to perform a systematic review of the current literature on simulator-based training in vitreoretinal surgery (VRS). We examined the results regarding simulated VRS and provided an overview of how the current results may be employed in VRS training. Lastly, we evaluated the quality of these results.

Methods

The databases of Pubmed, Embase and Cochrane Library were searched for articles in English involving simulated VRS training. A qualitative analysis was performed, since the studies which met our inclusion criteria did not allow for a quantitative meta-analysis.

Results

We identified 203 articles of which seven met the inclusion criteria. Of these, six studies investigated simulation with EyeSi® Surgical (VRMagic, Mannheim, Germany). Six studies reported positive performance curves. Four studies showed construct validity. One study attempted to show skill transfer from simulator to vitrectomies performed on cadavers. Methodological quality of the included studies was moderate but lacking in instrument validation.

Conclusion

Simulator-based training in VRS can assess and possibly assist acquisition of a variety of VRS skills. Further research is needed to support transfer from simulator to operating room. Future studies should strive to follow established validation frameworks and streamline study designs.

Electronic supplementary material

The online version of this article (10.1186/s12886-019-1098-x) contains supplementary material, which is available to authorized users.

EYESI surgical simulator: validity evidence of the vitreoretinal modules

PURPOSE

To investigate the validity of six vitreoretinal modules on the Eyesi Surgical Simulator.

METHODS

Fifteen residents with no vitreoretinal experience and six trained vitreoretinal surgeons (>100 procedures per year) were included in the study. Four modules were selected in agreement with an experienced surgeon: the navigation (Nav), forceps (For), vitrector (Vit) and epiretinal membrane (ERM) peeling modules. The first level of the basic training modules (Nav1 and For1) and the first two levels of the more procedural modules (Vit1, Vit2, ERM1 and ERM2) were completed twice by both groups in the above order. The performance parameters for each task were calculated by the simulator software. The results from both iterations were recorded for analysis.

RESULTS

Experienced vitreoretinal surgeons outperformed residents with regard to the overall score on the Nav1 (p = 0.01), For1 (p < 0.01), ERM1 (p = 0.02) and ERM2 (p = 0.04) modules. No differences in overall score were found between the two groups on the Vit1 (p = 0.17) and Vit2 modules (p = 0.26).

CONCLUSION

Validity for the simulator metrics was found on four vitreoretinal modules not previously investigated, with regard to construct validity, content and the response process. These exercises could be included in a future competency-based training programme that could potentially be applied in the standard ophthalmological curriculum.

Cataract surgery training using surgical simulators and wet-labs: Course description and literature review

Cataract surgery is the most common surgery to face the ophthalmology training resident. To facilitate achieving surgical competency and reduce complication rates, wet laboratories and surgical simulators are used in surgical disciplines worldwide. We developed a simulator and wet-lab course that aims to build the microsurgery skills of trainees and improve safety during real surgical procedures. Herewith, we describe the standardized hands-on course that incorporates these tools for advanced training. Additionally, we review the literature on wet-lab and surgical simulators in ophthalmology, focusing on their importance in training centers. The course is offered four times per year since it started in December 2015, and t total of 88 trainees participated to date. Feedback received from the trainees' supervising surgeons showed that this course addresses a major training challenge, and that a permanent version of this course should be established at each training center. We suggest incorporating fixed wet-lab and surgical simulator competencies in ophthalmology training programs. Additionally, we recommend that residents be allowed to operate on real patients only after passing the course. We believe that these steps would foster ophthalmologists with advanced training, decrease their learning curve, and empower them to safely conduct cataract surgery with low complication rates.

Does Cataract Surgery Simulation Correlate with Real-life Experience?

Objectives:

To evaluate the correlation of cataract surgical simulator and real-life surgical experience and its contribution to surgical training.

Materials and Methods:

Sixteen doctors in our department were divided into three groups based on their surgical experience. After being familiarized with the device, the participants were evaluated while performing the navigation, forceps, bimanual practice, anti-tremor and capsulorhexis stages. The capsulorhexis stage was repeated five times. Participants were also assessed while performing capsulorhexis again with their non-dominant hand. The influence of repetition and surgical experience on the recorded points was evaluated. P values below 0.05 were considered statistically significant.

Results:

There was correlation between the participants’ surgical experience and their scores in the capsulorhexis module. Their dominant hand was more successful than the non-dominant hand in capsulorhexis (p=0.004). Capsulorhexis scores increased with repetition (p=0.001).

Conclusion:

Results achieved with the cataract surgery simulation device correlate with surgical experience. The increase in performance upon repeated practice indicates that the simulator supports surgical training.

Does the virtual refractor patient-simulator improve student competency when refracting in the consulting room?

BACKGROUND

The use of patient simulators in ophthalmic education appears limited. This study examines the effects of the addition of the 'Virtual Refractor' patient simulator learning activity into a short unit preparing students to determine the power of the spectacle lenses required by patients in a clinic.

METHODS

Twenty-four year one optometry students were randomly assigned to either the simulator-intervention group (n = 12) or the non-intervention group. All students attended tutorials on refraction and the use of a refractor-head. Simulator-intervention students additionally attended a tutorial on the Virtual Refractor. All answered a questionnaire concerning time spent studying, perceived knowledge and confidence. Twenty-four short-sighted patients were recruited. Two refractions per student were timed and the accuracy compared with that of an experienced optometrist.

RESULTS

Ten students from each group completed the study. Students who used the simulator were significantly (p < 0.05) more accurate at a clinical level (within 0.22 ± 0.22 DS, 95 per cent CI 0.12-0.32) than those who did not (within 0.60 ± 0.67 DS, 95 per cent CI 0.29-0.92) and 13 per cent quicker (4.7 minutes, p < 0.05). Students who used the simulator felt more knowledgeable (p < 0.05) and confident (p < 0.05), but had spent more time reading about refraction and practised on the Virtual Refractor at home for 5.7 ± 1.3 hours.

CONCLUSION

The Virtual Refractor has many features of high-fidelity medical simulation known to lead to effective learning and it also offers flexible independent learning without a concomitant increase in the student time-burden. The improved accuracy and speed on first patient encounters found in this study validates the use of this patient simulator as a useful bridge for students early in training to successfully transfer theoretical knowledge prior to entering the consulting room. The translational benefits resulting from compulsory learning activities on a patient simulator can lead to reduced demands on infrastructure and clinical supervision.

Development of a vibration haptic simulator for shoulder arthroplasty

PURPOSE

Glenoid reaming is a technically challenging step during shoulder arthroplasty that could possibly be learned during simulation training. Creation of a realistic simulation using vibration feedback in this context is innovative. Our study focused on the development and internal validation of a novel glenoid reaming simulator for potential use as a training tool.

METHODS

Vibration and force profiles associated with glenoid reaming were quantified during a cadaveric experiment. Subsequently, a simulator was fabricated utilizing a haptic vibration transducer with high- and low-fidelity amplifiers; system calibration was performed matching vibration peak-peak values for both amplifiers. Eight experts performed simulated reaming trials. The experts were asked to identify isolated layer profiles produced by the simulator. Additionally, experts' efficiency to successfully perform a simulated glenoid ream based solely on vibration feedback was recorded.

RESULTS

Cadaveric experimental cartilage reaming produced lower vibrations compared to subchondral and cancellous bones ([Formula: see text]). Gain calibration of a lower-fidelity (3.5 [Formula: see text] and higher-fidelity (3.4 [Formula: see text] amplifier resulted in values similar to the cadaveric experimental benchmark (3.5 [Formula: see text]. When identifying random tissue layer samples, experts were correct [Formula: see text] of the time and success rate varied with tissue type ([Formula: see text]). During simulated reaming, the experts stopped at the targeted subchondral bone with a success rate of [Formula: see text]. The fidelity of the simulation did not have an effect on accuracy, applied force, or reaming time ([Formula: see text]). However, the applied force tended to increase with trial number ([Formula: see text]).

CONCLUSIONS

Development of the glenoid reaming simulator, coupled with expert evaluation furthered our understanding of the role of haptic vibration feedback during glenoid reaming. This study was the first to (1) propose, develop and examine simulated glenoid reaming, and (2) explore the use of haptic vibration feedback in the realm of shoulder arthroplasty.

Surgical Workflow Management Schemata for Cataract Procedures

Objective: Workflow guidance of surgical activities is a challenging task. Because of variations in patient properties and applied surgical techniques, surgical processes have a high variability. The objective of this study was the design and implementation of a surgical workflow management system (SWFMS) that can provide a robust guidance for surgical activities. We investigated how many surgical process models are needed to develop a SWFMS that can guide cataract surgeries robustly.

Methods: We used 100 cases of cataract surgeries and acquired patient-individual surgical process models (iSPMs) from them. Of these, randomized subsets iSPMs were selected as learning sets to create a generic surgical process model (gSPM). These gSPMs were mapped onto workflow nets as work-flow schemata to define the behavior of the SWFMS. Finally, 10 iSPMs from the disjoint set were simulated to validate the workflow schema for the surgical processes. The measurement was the successful guidance of an iSPM.

Results: We demonstrated that a SWFMS with a workflow schema that was generated from a subset of 10 iSPMs is sufficient to guide approximately 65% of all surgical processes in the total set, and that a subset of 50 iSPMs is sufficient to guide approx. 80% of all processes.

Conclusion: We designed a SWFMS that is able to guide surgical activities on a detailed level. The study demonstrated that the high inter-patient variability of surgical processes can be considered by our approach.

Impact of a Strabismus Surgery Suture Course for First- and Second-Year Ophthalmology Residents

PURPOSE

To investigate the effectiveness of an eye muscle surgery course on first- and second-year postgraduate ophthalmology residents.

METHODS

This prospective cohort pilot study invited first- and second-year ophthalmology residents to participate in a 2-hour strabismus surgery course at Wills Eye Hospital. The course consisted of a didactic session followed by a wet laboratory session. The wet laboratory session simulated strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. A structured self-assessment evaluation form and a questionnaire in the validated Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) were used to assess the effectiveness of the course.

RESULTS

A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Following the course, most residents felt less anxious (73%). All residents responded that the course was helpful or somewhat helpful in preparation for strabismus surgery. Regarding the distribution of ratings on questions of subjective experience, knowledge of steps, and understanding of potential complications, the residents gave significantly higher ratings after the course (P < .029). The change in the modified ICO-OSCAR:strabismus assessment's mean score was statistically significant before and after training (P = .038).

CONCLUSIONS

A strabismus course can play an important role in preparing residents for strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2017;54(6):339-345.].

Comparison of training effect on tremor using 2 training modules

PURPOSE

To compare training effect of 2 training models-a surgical simulator anti-tremor module and a paper version-on tremor and time-to-task completion.

SETTING

Ophthalmology Department, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA.

DESIGN

Prospective crossover study.

METHODS

Trainees completed simulator and paper training modules (baseline test, 3 training sessions, posttraining test, and final test) with their dominant and nondominant hands. The change in tremor, number of paper errors, and time-to-task completion in dominant and nondominant hands were compared. The 2 training modules were compared using nonparametric tests.

RESULTS

The study comprised 19 trainees. There was a moderate correlation between average tremor values (simulator, 3-dimensional module) and paper errors (paper, 2-dimensional module) (Spearman ⍴ = 0.35, P < .0001). Practice on the simulator or paper modules did not reduce tremor significantly from baseline to final tasks for both hands combined (P = .12, simulator; P = .2, paper). Practice on the training modules improved time-to-task completion in the simulator module and paper module (both P < .0001). The improvement in time from baseline to final tasks was greater in the nondominant hands in the simulator module (improvement 64.5% over baseline time) than in the paper module (53.6% over baseline time).

CONCLUSION

Practice might not reduce tremor but improved the outcome measure of time, and results suggest that trainees can learn to compensate for tremor in both hands, which is important in bimanual microsurgery.

Individuals with severely impaired vision can learn useful orientation and mobility skills in virtual streets and can use them to improve real street safety

Virtual reality has great potential in training road safety skills to individuals with low vision but the feasibility of such training has not been demonstrated. We tested the hypotheses that low vision individuals could learn useful skills in virtual streets and could apply them to improve real street safety. Twelve participants, whose vision was too poor to use the pedestrian signals were taught by a certified orientation and mobility specialist to determine the safest time to cross the street using the visual and auditory signals made by the start of previously stopped cars at a traffic-light controlled street intersection. Four participants were trained in real streets and eight in virtual streets presented on 3 projection screens. The crossing timing of all participants was evaluated in real streets before and after training. The participants were instructed to say “GO” at the time when they felt the safest to cross the street. A safety score was derived to quantify the GO calls based on its occurrence in the pedestrian phase (when the pedestrian sign did not show DON’T WALK). Before training, > 50% of the GO calls from all participants fell in the DON’T WALK phase of the traffic cycle and thus were totally unsafe. 20% of the GO calls fell in the latter half of the pedestrian phase. These calls were unsafe because one initiated crossing this late might not have sufficient time to walk across the street. After training, 90% of the GO calls fell in the early half of the pedestrian phase. These calls were safer because one initiated crossing in the pedestrian phase and had at least half of the pedestrian phase for walking across. Similar safety changes occurred in both virtual street and real street trained participants. An ANOVA showed a significant increase of the safety scores after training and there was no difference in this safety improvement between the virtual street and real street trained participants. This study demonstrated that virtual reality-based orientation and mobility training could be as efficient as real street training in improving street safety in individuals with severely impaired vision.

Validation of an Arthroscopic Training Device

PURPOSE

To investigate the usefulness and conduct validation of a simulated arthroscopy training device to train basic arthroscopy skills.

METHODS

Forty-six participants including 12 novices, 12 intermediates, and 22 experts completed a questionnaire regarding demographics, previous arthroscopic experience, training potential, and statements about the device. Furthermore, participants performed a single task on the arthroscopic training device using the 0° camera and a probe. The task consisted of an attempt to carry a rubber ring across a helix inside a box as fast as possible. Construct validity was evaluated by comparing total task time and portal replacements of the camera and probe between all groups (median values [interquartile range]; Kruskal-Wallis test).

RESULTS

The median age was 35 (29-44) years. There were 4 female and 42 male participants. A total of 89% of the participants graded the overall training capacity ≥5 (35% graded it as 5, 39% as 6, and 15% as 7), and 83% believed that it is useful to improve any kind of arthroscopy. Ninety-three percent of the participants would recommend the arthroscopic training device to their colleagues. Sixty-one percent of the participants stated that there are certain disadvantages. The median time to complete the task was 108 (58-236) seconds. Novices (259 [123-435] seconds) performed tasks significantly slower than intermediates (169 [67-257] seconds) and experts (75 [49-132] seconds) (P = .005). Furthermore, portal changes were significantly more common in novices and intermediates than experts (P = .019).

CONCLUSIONS

High scores in training potential were achieved with this arthroscopy simulator box, and most study participants believed that practice with the arthroscopic training device is useful for any kind of arthroscopy. Construct validity was established since novices, intermediates, and experts in real arthroscopy were discriminated with the arthroscopic training device in terms of time to successful completion of a task. However, 61% of the participants stated that there were certain disadvantages.

CLINICAL RELEVANCE

In every training tool using simulation, it is crucial to pass the first steps in the validation cascade. This study provides this step for further evaluation of this arthroscopic training device.

Virtual vitreoretinal surgery: validation of a training programme

PURPOSE

To test the validity of the eyesi surgical simulator as an assessment tool in a virtual reality vitreoretinal training programme.

METHODS

In collaboration with an experienced vitreoretinal surgeon, a virtual vitreoretinal training programme was composed on the eyesi surgical simulator, software version 2.9.2 (VRmagic GmbH, Manheim, Germany). It was completed twice by three groups: 20 medical students, ten residents of ophthalmology and five trained vitreoretinal surgeons. The programme contained six training modules: navigation level 2 (Nav2), forceps training level 5 (ForT5), bimanual training level 3 (BimT3), laser coagulation level 3 (LasC3), posterior hyaloid level 3 (PostH3) and internal limiting membrane peeling level 3 (ILMP3). The scores in each module were assessed from two to five different factors (tissue treatment, efficiency, target achievement, instrument handling and microscope handling), and it was possible to achieve 100 points in each module.

RESULTS

At the final training session, the highest overall median score was found for the vitreoretinal surgeons (vitreoretinal surgeons: 434 points, residents: 394.5 points, medical students: 272.5 points, p < 0.01). This was also found in four of the six modules. These were Nav2 (p = 0.03), BimT3 (p < 0.01), PostH3 (p < 0.01) and ILMP3 (p < 0.01). On the other hand, the three groups did not differ regarding ForT5 (p = 0.16) or LasC3 (p = 0.75).

CONCLUSIONS

We developed a training programme with validity for the eyesi surgical simulator as an assessment tool for overall score and for four of six vitreoretinal modules. These findings could potentially make the programme a useful tool in the training of future vitreoretinal surgeons.

Perspective of ophthalmology residents in the United States about residency programs and competency in relation to the International Council of Ophthalmology guidelines

PURPOSE

To evaluate the perspective of ophthalmology residents in the US about their residency programs and compare the competency of residency programs to international competency levels set by the International Council of Ophthalmology (ICO).

METHODS

A cross-sectional web-based survey extracted from the ICO published competency standards was sent to program directors of ophthalmology residency programs in the US to forward it to current PGY-3, 4 residents, and residency graduates from 2011 to 2014.

RESULTS

Eighty-seven responses were received, comprising 61 residents and 26 graduates. Most respondents were highly satisfied with their programs (93.6%). Clinic-based training was rated satisfactorily. Insufficient exposure to low-vision rehabilitation (38.5%), refraction and contact lenses prescription (38.5%), and vitreo-retinal surgeries (38.5%) was reported. Respondents were satisfied with their overall surgical experiences, with the vast majority (>83%) rating case volume, complexity, and variety as satisfactory or better. A significant group stated they had insufficient exposure to extra-capsular cataract extraction (26.3%), refractive surgery (19.7%), and orbital surgery (64.5%). All graduates surveyed passed their Ophthalmic Knowledge Assessment Program (OKAP) examinations, and 72% felt their residency programs adequately prepared them for the examinations. All respondents reported insufficient training in certain nonclinical areas, such as practice management, staffing, and administration skills.

CONCLUSIONS

Ophthalmology residents in the US express high levels of satisfaction with their residency training programs. While most programs adequately address most ICO core objectives, certain curriculum modifications should be considered.

Validation of a virtual reality-based simulator for shoulder arthroscopy

PURPOSE

This study was to determine face and construct validity of a new virtual reality-based shoulder arthroscopy simulator which uses passive haptic feedback.

METHODS

Fifty-one participants including 25 novices (<20 shoulder arthroscopies) and 26 experts (>100 shoulder arthroscopies) completed two tests: for assessment of face validity, a questionnaire was filled out concerning quality of simulated reality and training potential using a 7-point Likert scale (range 1-7). Construct validity was tested by comparing simulator metrics (operation time in seconds, camera and grasper pathway in centimetre and grasper openings) between novices and experts test results.

RESULTS

Overall simulated reality was rated high with a median value of 5.5 (range 2.8-7) points. Training capacity scored a median value of 5.8 (range 3-7) points. Experts were significantly faster in the diagnostic test with a median of 91 (range 37-208) s than novices with 1177 (range 81-383) s (p < 0.0001) and in the therapeutic test 102 (range 58-283) s versus 229 (range 114-399) s (p < 0.0001). Similar results were seen in the other metric values except in the camera pathway in the therapeutic test.

CONCLUSION

The tested simulator achieved high scores in terms of realism and training capability. It reliably discriminated between novices and experts. Further improvements of the simulator, especially in the field of therapeutic arthroscopy, might improve its value as training and assessment tool for shoulder arthroscopy skills.

LEVEL OF EVIDENCE

II.

Clinical Efficacy of Simulated Vitreoretinal Surgery to Prepare Surgeons for the Upcoming Intervention in the Operating Room

PURPOSE

To evaluate the efficacy of the virtual reality training simulator Eyesi to prepare surgeons for performing pars plana vitrectomies and its potential to predict the surgeons' performance.

METHODS

In a preparation phase, four participating vitreoretinal surgeons performed repeated simulator training with predefined tasks. If a surgeon was assigned to perform a vitrectomy for the management of complex retinal detachment after a surgical break of at least 60 hours it was randomly decided whether a warmup training on the simulator was required (n = 9) or not (n = 12). Performance at the simulator was measured using the built-in scoring metrics. The surgical performance was determined by two blinded observers who analyzed the video-recorded interventions. One of them repeated the analysis to check for intra-observer consistency. The surgical performance of the interventions with and without simulator training was compared. In addition, for the surgeries with simulator training, the simulator performance was compared to the performance in the operating room.

RESULTS

Comparing each surgeon's performance with and without warmup trainingshowed a significant effect of warmup training onto the final outcome in the operating room. For the surgeries that were preceeded by the warmup procedure, the performance at the simulator was compared with the operating room performance. We found that there is a significant relation. The governing factor of low scores in the simulator were iatrogenic retinal holes, bleedings and lens damage. Surgeons who caused minor damage in the simulation also performed well in the operating room.

CONCLUSIONS

Despite the large variation of conditions, the effect of a warmup training as well as a relation between the performance at the simulator and in the operating room was found with statistical significance. Simulator training is able to serve as a warmup to increase the average performance.

Development of an interactive anatomical three-dimensional eye model

The discrete anatomy of the eye's intricate oculomotor system is conceptually difficult for novice students to grasp. This is problematic given that this group of muscles represents one of the most common sites of clinical intervention in the treatment of ocular motility disorders and other eye disorders. This project was designed to develop a digital, interactive, three-dimensional (3D) model of the muscles and cranial nerves of the oculomotor system. Development of the 3D model utilized data from the Visible Human Project (VHP) dataset that was refined using multiple forms of 3D software. The model was then paired with a virtual user interface in order to create a novel 3D learning tool for the human oculomotor system. Development of the virtual eye model was done while attempting to adhere to the principles of cognitive load theory (CLT) and the reduction of extraneous load in particular. The detailed approach, digital tools employed, and the CLT guidelines are described herein.

Evaluation of a virtual-reality-based simulator using passive haptic feedback for knee arthroscopy

PURPOSE

The aim of this work is to determine face validity and construct validity of a new virtual-reality-based simulator for diagnostic and therapeutic knee arthroscopy.

METHODS

The study tests a novel arthroscopic simulator based on passive haptics. Sixty-eight participants were grouped into novices, intermediates, and experts. All participants completed two exercises. In order to establish face validity, all participants filled out a questionnaire concerning different aspects of simulator realism, training capacity, and different statements using a seven-point Likert scale (range 1-7). Construct validity was tested by comparing various simulator metric values between novices and experts.

RESULTS

Face validity could be established: overall realism was rated with a mean value of 5.5 points. Global training capacity scored a mean value of 5.9. Participants considered the simulator as useful for procedural training of diagnostic and therapeutic arthroscopy. In the foreign body removal exercise, experts were overall significantly faster in the whole procedure (6 min 24 s vs. 8 min 24 s, p < 0.001), took less time to complete the diagnostic tour (2 min 49 s vs. 3 min 32 s, p = 0.027), and had a shorter camera path length (186 vs. 246 cm, p = 0.006).

CONCLUSION

The simulator achieved high scores in terms of realism. It was regarded as a useful training tool, which is also capable of differentiating between varying levels of arthroscopic experience. Nevertheless, further improvements of the simulator especially in the field of therapeutic arthroscopy are desirable. In general, the findings support that virtual-reality-based simulation using passive haptics has the potential to complement conventional training of knee arthroscopy skills.

LEVEL OF EVIDENCE

II.

Establishment of a validated training programme on the Eyesi cataract simulator. A prospective randomized study

PURPOSE

To establish and evaluate a systematic training programme to be included into the ophthalmologic resident curriculum.

METHODS

Medical students (n = 20) within a year from graduation and with no previous ophthalmic experience were included in this prospective study and randomized into two groups. Group A (n = 10) completed the Eyesi cataract simulator training programme once a week for 4 weeks, while Group B (n = 10) completed it once a week at the first and the last week. Two cataract surgeons were used to determine two different levels of reference scores. Score per analysed module [two different levels of Capsulorhexis (A and B), Hydromaneuver, Phaco divide and conquer], Overall score, Total time, Cornea injury, Capsule rupture and Capsule damage by ultrasound were recorded.

RESULTS

Group A outperformed Group B in several modules, reached a significant higher number of reference scores (p < 0.01) and caused fewer complications with regard to Capsule rupture (p = 0.01) and Capsule damage by ultrasound (p < 0.05). Both Groups A and B improved their performance and also became more time efficient (p < 0.01 for both groups). Group A showed positive learning curves for Overall score (p < 0.01), Capsulorhexis A (p < 0.01), Capsulorhexis B (p < 0.01) and Hydromaneuver (p = 0.01). Group B showed a significant improvement for Overall score (p < 0.01), Hydromaneuver (p = 0.02) and Phaco divide and conquer (p < 0.01).

CONCLUSION

Repetitive training with a systematic training programme, based on validated modules in the Eyesi simulator, was shown to improve simulated cataract surgery skills. Higher level of skills and more reference scores were reached with more training. Furthermore, the programme was optimized to be applied into the standard ophthalmological curriculum for cataract surgery 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.

Surgical simulators in cataract surgery training

BACKGROUND

Virtual simulators have been widely implemented in medical and surgical training, including ophthalmology. The increasing number of published articles in this field mandates a review of the available results to assess current technology and explore future opportunities.

METHOD

A PubMed search was conducted and a total of 10 articles were reviewed.

RESULTS

Virtual simulators have shown construct validity in many modules, successfully differentiating user experience levels during simulated phacoemulsification surgery. Simulators have also shown improvements in wet-lab performance. The implementation of simulators in the residency training has been associated with a decrease in cataract surgery complication rates.

CONCLUSIONS

Virtual reality simulators are an effective tool in measuring performance and differentiating trainee skill level. Additionally, they may be useful in improving surgical skill and patient outcomes in cataract surgery. Future opportunities rely on taking advantage of technical improvements in simulators for education and research.

A comparison of hand- and foot-activated surgical tools in simulated ophthalmic surgery

OBJECTIVE

To compare the performance characteristics of hand-activated surgical tools with those of foot-activated surgical tools using a virtual-reality simulator of intraocular surgery.

DESIGN

Prospective, unmasked, interventional cohort study.

PARTICIPANTS

Eighteen ophthalmology residents at the University of Toronto.

METHODS

The EYESi ophthalmic surgery simulator was used for the study. The surgical tool evaluated was a simulation of intraocular forceps activated by either a handpiece or a foot pedal. Each resident completed 2 modules-a dexterity module and a capsulorrhexis/cataract module. Each module was completed 4 times, alternating between the hand-activated forceps and the foot-activated forceps. An overall score was calculated for each task on the basis of the efficiency and accuracy of completion of the task, with 100 representing a perfect score. Overall scores were compared between hand and foot control for both modules.

RESULTS

For the dexterity module, there was no significant difference in the overall scores between the 2 groups (91 ± 6 and 93 ± 6 for the foot- and hand-activated forceps groups, respectively; p > 0.05, t test). For the capsulorrhexis module, overall scores were also similar for both groups, the scores being 50 ± 21 and 53 ± 16 for the foot- and hand-activated forceps groups, respectively (p > 0.05, t test). An exit survey of the study's participants revealed that subjects did not have a preference for the hand or foot modality of the forceps tool, with 10 preferring the hand-activated forceps tool and 8 preferring the foot-activated tool.

CONCLUSIONS

During simulated intraocular surgery, foot- and hand-activated surgical tools appear to have similar performance characteristics and are equally well received by residents.

PixEye Virtual Reality Training has the Potential of Enhancing Proficiency of Laser Trabeculoplasty Performed by Medical Students: A Pilot Study

OBJECTIVE

To compare the surgical proficiency of medical students who underwent traditional training or virtual reality training for argon laser trabeculoplasty with the PixEye simulator.

MATERIALS AND METHODS

The cohort comprised of 47 fifth year male medical students from the College of Medicine, King Faisal University, Saudi Arabia. The cohort was divided into two groups: students (n = 24), who received virtual reality training (VR Group) and students (n = 23), who underwent traditional training (Control Group). After training, the students performed the trabeculoplasty procedure. All trainings were included concurrent power point presentations describing the details of the procedure. Evaluation of surgical performance was based on the following variables: missing the exact location with the laser, overtreatment, undertreatment and inadvertent laser shots to iris and cornea.

RESULTS

The target was missed by 8% of the VR Group compared to 55% in the Control Group. Overtreatment and undertreatment was observed in 7% of the VR Group compared to 46% of the Control Group. Inadvertent laser application to the cornea or iris was performed by 4.5% of the VR Group compared to 34% of the Control Group.

CONCLUSION

Virtual reality training on PixEye simulator may enhance the proficiency of medical students and limit possible surgical errors during laser trabeculoplasty. The authors have no financial interest in the material mentioned in this study.

Sheep practice eye for ophthalmic surgery training in skills laboratory

Pig eyes are not available for surgical practice in the Middle East and Central Asia. We reviewed the literature to select an alternative animal practice eye based on biometry, availability, expense, and the ethical issue of animal sacrifice. Twenty enucleated sheep eyes were studied with an ultrasonography immersion technique, and a variety of techniques for globe harvesting were tested and compared. The sheep eye was judged to be the best practical choice for ophthalmic surgery practice and the "bone shattering" exenteration maneuver, the most efficient harvesting method. Several anterior segment procedures were performed in the sheep eyes. Introduction of this sheep model would be instrumental in the development of ophthalmology skills laboratories and surgical training in Middle Eastern and Central Asian regions.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Advances in medical robotic systems with specific applications in surgery--a review

Although robotics was started as a form of entertainment, it gradually became used in different branches of science. Medicine, particularly in the operating room, has been influenced significantly by this field. Robotic technologies have offered valuable enhancements to medical or surgical processes through improved precision, stability and dexterity. In this paper we review different robotics and computer-assisted systems developed with medical and surgical applications. We cover early and recently developed systems in different branches of surgery. In addition to the united operational systems, we provide a review of miniature robotic, diagnostic and sensory systems developed to assist or collaborate with a main operator system. At the end of the paper, a discussion is given with the aim of summarizing the proposed points and predicting the future of robotics in medicine.

Globe-fixation system for animal eye practice

We designed a globe-fixation system for use with animal eyes for surgical skills training. The system core is a cup with an adjustable aperture. Vacuum is exerted through the cup to capture the globe at the preequatorial region. The cup rides over a hollow base, sliding on its opening spurs. A ballast is screwed to the end of the thread of the cup to create tactile feedback and create a tendency to return to the primary position. The system provides optimum versatility for the practice of anterior segment procedures, namely stability, rotation, a tendency to return to the primary position, globe pressure adjustability, and a modifiable orbit size.

FINANCIAL DISCLOSURE

Disclosures are found in the footnotes.