Virtual phacoemulsification surgical simulation using visual guidance and performance parameters as a feasible proficiency assessment tool

Characterizing the untapped potential of virtual reality in plastic and reconstructive surgical training: A systematic review on skill transferability

Virtual reality (VR) integration into surgical education has gained immense traction by invigorating skill-building in ways that are unlike the traditional modes of training. This systematic review unites current literature relevant to VR in surgical education to showcase tool transferability, and subsequent impact on knowledge acquisition, skill development, and technological innovation. This review followed the PRISMA guidelines and included three databases. Among the 1926 studies that were screened, 31 studies met the inclusion criteria. ChatGPT assisted in generating variables for data extraction, and the authors reached unanimous consensus on 13 variables that provided a framework for assessing VR attributes. Surgical simulation was examined in 26 studies (83.9%). VR applications incorporated anatomy visualization (83.9%), procedure planning (67.7%), skills assessment (64.5%), continuous learning (41.9%), haptic feedback (41.9%), research and innovation (41.9%), case-based learning (22.6%), improved skill retention (19.4%), reduction of stress and anxiety (16.1%), and remote learning (12.9%). No instances of VR integration addressed patient communication or team-based training. Novice surgeons benefited the most from VR simulator experience, improving their confidence and accuracy in tackling complex procedural tasks, as well as decision-making efficiency. Enhanced dexterity compared to traditional modes of surgical training was also notable. VR confers significant potential as an adjunctive teaching method in plastic and reconstructive surgery (PRS). Studies demonstrate the utility of virtual simulation in knowledge acquisition and skill development, though they lack targeted approaches for augmenting training related to collaboration and patient communication. Given the underrepresentation of PRS among surgical disciplines regarding VR implementation in surgical education, longitudinal curriculum integration and PRS-specific technologies should be further investigated.

The Role of Technology in Ophthalmic Surgical Education During COVID-19

Purpose of Review

To describe the effect of COVID-19 on ophthalmic training programs and to review the various roles of technology in ophthalmology surgical education including virtual platforms, novel remote learning curricula, and the use of surgical simulators.

Recent Findings

COVID-19 caused significant disruption to in-person clinical and surgical patient encounters. Ophthalmology trainees worldwide faced surgical training challenges due to social distancing restrictions, trainee redeployment, and reduction in surgical case volume. Virtual platforms, such as Zoom and Microsoft Teams, were widely used during the pandemic to conduct remote teaching sessions. Novel virtual wet lab and dry lab curricula were developed. Training programs found utility in virtual reality surgical simulators, such as the Eyesi, to substitute experience lost from live patient surgical cases.

Summary

Although several of these described technologies were incorporated into ophthalmology surgical training programs prior to COVID-19, the pandemic highlighted the importance of developing a formal surgical curriculum that can be delivered virtually. Novel telementoring, collaboration between training institutions, and hybrid formats of didactic and practical training sessions should be continued. Future research should investigate the utility of augmented reality and artificial intelligence for trainee learning.

Phacoemulsification: Proposals for Improvement in Its Application

A cataract is defined as opacity of the crystalline lens. It is currently one of the most prevalent ocular pathologies and is generally associated with aging. The most common treatment for cataracts is surgery. Cataract surgery is a quick and painless process, is very effective, and has few risks. The operation consists of removing the opacified lens and replacing it with an intraocular lens. The most common intraocular lens removal procedure that is currently used is phacoemulsification. The energy applied in this process is generated by ultrasonic waves, which are mechanical waves with a frequency higher than 20 kHz. A great deal of research on the different ways to perform the stages of this surgical procedure and the analysis of the possible side effects of the operation has been published, but there is little information on the technical characteristics, the intensities applied, and the use of ultrasound-emitting (U/S) equipment for cataract removal. More studies on the method and depth of absorption of ultrasonic waves in our visual system when performing the phacoemulsification procedure are needed. It would be advisable for health authorities and medical professionals to develop guidelines for the handling and use of ultrasonic wave-emitting equipment, such as those that exist for ultrasound and physiotherapy. This could help us to reduce undesirable effects after the operation.

A practical continuous curvilinear capsulorhexis self-training system

Purpose

To describe a practical, self-assembled continuous curvilinear capsulorhexis (CCC) self-training system to facilitate resident self-training and shorten the CCC learning curve.

Methods

This was a prospective experimental study that included a total of 600 capsulorhexis cases. A device for CCC practice was self-assembled and used for training and testing. Based on capsulorhexis manipulation experience, three main groups of residents (A, capsulorhexis experience with <50 cases; B, capsulorhexis experience with 400-500 cases; and C, capsulorhexis experience with >1000 cases) were created. Furthermore, based on different capsulorhexis conditions, each main group was divided into four subgroups (1, CCC without an anterior chamber cover and capsulorhexis marker; 2, CCC with an anterior chamber cover without a capsulorhexis marker; 3, CCC with an anterior chamber cover and a capsulorhexis marker; and 4, CCC with an anterior chamber cover and a capsulorhexis marker under 2.5 times magnification). Three CCC-related parameters, including acircularity index (AI), axis ratio (AR), and capsulorhexis time, were statistically evaluated.

Results

We compared the differences in study parameters among 50 consecutively completed capsulorhexis cases by one trainee with different capsulorhexis experience in each subgroup. The CCC-related parameter values in subgroups 1 and 4 were significantly different among the three groups (P < 0.001). The capsulorhexis time in subgroup 2 was significantly different among the three groups (P < 0.001). The capsulorhexis time and AI in subgroup 3 were significantly different among the three groups (P < 0.001). Moreover, with increasing manipulation experience (from group A-C), the capsulorhexis time, the AI, and AR tended to decrease. With the help of the CCC marker, in subgroups 3 and 4, the AI and AR were closer to 1.0.

Conclusion

This self-assembled CCC self-training system is practical. The CCC marker seems helpful for size specification and centration during self-training.

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.

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.

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.

Intraoperative head drift and eye movement: two under addressed challenges during cataract surgery

PURPOSE

To objectively measure head drift during cataract surgery, and subjectively simulate eye movements and assess impact on surgical technique.

MATERIALS AND METHODS

Twelve consecutively recorded routine cataract operations in the Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, were reviewed. The speculum was used as a fixed point and correlated with a superimposed virtual ruler to measure maximum head drift in each direction throughout the operations. To simulate intraoperative eye movement, we attached string to the cataract surgical simulator (Eyesi) eye and manually induced abduction and adduction. A calibrated scale secured to the Eyesi head ensured 5 mm eye movements were consistently created. Ophthalmology trainees performed the continuous curvilinear capsulorhexis (CCC) exercise without and with sequential eye movements. Movements were induced every three seconds. Scores were compared using a paired Student's T-test.

RESULTS

Mean head drift in the surgical recordings was 3.1 mm medially (range 2-7 mm), 2.9 mm laterally (range 2-4 mm), 2.6 mm superiorly (range 1-5 mm), and 1.9 mm inferiorly (range 1-4 mm). In 11 of 12 cases, the operating microscope had to be adjusted for head drift. Six junior trainees completed the CCC module on the Eyesi without then with eye movements. After introducing eye movements the mean Eyesi score reduced from 92.7 to 76.9 (P = 0.014), 'roundness of rhexis' score reduced from 89.4 to 57.5 (P = 0.020), and trainees operated 17 s faster (P = 0.016).

CONCLUSION

This study objectively demonstrates the under-reported clinical scenario of head drift during cataract surgery. By manipulating the Eyesi we have shown that eye movements reduce the quality of cataract surgery.

Exploratory Application of Augmented Reality/Mixed Reality Devices for Acute Care Procedure Training

Introduction

Augmented reality (AR), mixed reality (MR), and virtual reality devices are enabling technologies that may facilitate effective communication in healthcare between those with information and knowledge (clinician/specialist; expert; educator) and those seeking understanding and insight (patient/family; non-expert; learner). Investigators initiated an exploratory program to enable the study of AR/MR use-cases in acute care clinical and instructional settings.

Methods

Academic clinician educators, computer scientists, and diagnostic imaging specialists conducted a proof-of-concept project to 1) implement a core holoimaging pipeline infrastructure and open-access repository at the study institution, and 2) use novel AR/MR techniques on off-the-shelf devices with holoimages generated by the infrastructure to demonstrate their potential role in the instructive communication of complex medical information.

Results

The study team successfully developed a medical holoimaging infrastructure methodology to identify, retrieve, and manipulate real patients’ de-identified computed tomography and magnetic resonance imagesets for rendering, packaging, transfer, and display of modular holoimages onto AR/MR headset devices and connected displays. Holoimages containing key segmentations of cervical and thoracic anatomic structures and pathology were overlaid and registered onto physical task trainers for simulation-based “blind insertion” invasive procedural training. During the session, learners experienced and used task-relevant anatomic holoimages for central venous catheter and tube thoracostomy insertion training with enhanced visual cues and haptic feedback. Direct instructor access into the learner’s AR/MR headset view of the task trainer was achieved for visual-axis interactive instructional guidance.

Conclusion

Investigators implemented a core holoimaging pipeline infrastructure and modular open-access repository to generate and enable access to modular holoimages during exploratory pilot stage applications for invasive procedure training that featured innovative AR/MR techniques on off-the-shelf headset devices.