You are here

Article Text

Article menu

Download PDFPDF

Clinical science
The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology
  1. George M Saleh1,2,3,
  2. Julia Lamparter2,4,
  3. Paul M Sullivan2,
  4. Fiona O'Sullivan3,
  5. Badrul Hussain2,
  6. Ioannis Athanasiadis2,5,
  7. Andre S Litwin2,
  8. Stewart N Gillan2
  1. 1NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
  2. 2Moorfields Eye Hospital, London, UK
  3. 3School of Ophthalmology, The London Deanery, London UK
  4. 4Department of Ophthalmology, University Medical Centre, Mainz, Germany
  5. 5Ophthalmologiko iatreio, Thessaloniki, Greece
  1. Correspondence to George M Saleh, National Institute of Health Research Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, 162 City Road, London EC1V 2PD, UK; George.saleh{at}moorfields.nhs.uk

Abstract

Background To investigate the effect of a structured, supervised, cataract simulation programme on ophthalmic surgeons in their first year of training, and to evaluate the level of skill transfer.

Methods Trainees with minimal intraocular and simulator experience in their first year of ophthalmology undertook a structured, sequential, customised, virtual reality (VR) cataract training programme developed through the International Forum of Ophthalmic Simulation. A set of one-handed, bimanual, static and dynamic tasks were evaluated before and after the course and scores obtained. Statistical significance was evaluated with the Wilcoxon sign-rank test.

Results The median precourse score of 101.50/400 (IQR 58.75–145.75) was significantly improved after completing the training programme ((postcourse score: 302/400, range: 266.25–343), p<0.001). While improvement was evident and found to be statistically significant in all parameters, greatest improvements were found for capsulorhexis and antitremor training ((Capsulorhexis: precourse score=0/100, range 0–4.5; postcourse score=81/100, range 13–87.75; p=0.002), (antitremor training: precourse score=0/100, range 0–0; postcourse score=80/100, range 60.25–91.50; p=0.001)).

Conclusions Structured and supervised VR training can offer a significant level of skills transfer to novice ophthalmic surgeons. VR training at the earliest stage of ophthalmic surgical training may, therefore, be of benefit.

  • Eye (Globe)
  • Medical Education
  • Lens and zonules
  • Optics and Refraction
  • Treatment Surgery

https://doi.org/10.1136/bjophthalmol-2012-302764

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Introduction

    The regular use of virtual reality (VR) simulators has become essential in high-risk fields where errors must be avoided and human or economic risk must be minimised.1 Occupations such as aviation, nuclear power and the military use simulation as a core part of their training.1–3 Individuals work through a structured programme where they can achieve manual, cognitive and technical skills along with facing realistic problems in a controlled setting. Similarly, simulators for medical training have increasingly become available with special emphasis on invasive surgical procedures such as fibreoptic bronchoscopy, laparoscopy, or endovascular operations.1 ,4–6

    High-fidelity simulation has become available in ophthalmology only in the more recent past. Evidence for its usefulness in training is now beginning to emerge, for instance, in retrobulbar injections,7 tactile feedback8 ,9 and basic ophthalmic microsurgical skills.10 At present, however, there is no clear evidence as to when and where VR simulation should fit in with current ophthalmic training programmes. A global collaborative programme, The International Forum of Ophthalmic Simulation (IFOS), has been established, so an evidence-based platform can be produced to answer this question. The ultimate aim is to deliver a syllabus which accelerates and augments surgical training, imparting maximal skills transfer in the most time-efficient and cost-efficient manner. The current study set out to objectively investigate what the effect of a structured, supervised VR ophthalmic simulation programme would have on first-year eye trainees, and evaluate the level of skill transfer.

    Material and methods

    Study design

    This prospective cohort study was carried out at Moorfields Eye Hospital NHS Foundation Trust London, UK in conjunction with the IFOS and the London Deanery. IRB approval was awarded for this study.

    Study cohort and inclusion criteria

    Study participants were entry-level trainees in ophthalmology with minimal background experience (less than 2 h) in both intraocular surgery and simulation. Participants with more than 2 h of intraocular or ophthalmic intraocular surgical simulator experience were excluded. All the trainees had undergone a basic microsurgical skills course at the point of entry (as required by the training syllabus of the Royal College of Ophthalmology).

    Personalised accounts were created for each participant, and thus, the training history and scores could be tracked along with a progression report.

    Customised training programme

    The study was conducted on the VRMagic EYESi Ophthalmic Surgical Simulator (VRmagic Holding AG, Mannheim, Germany).

    For the first time, a structured, sequential, customised, training programme has been developed through the IFOS. IFOS is an open and inclusive venture, which now has participants from across the world and is administered through a networked cloud of EYESi Simulators. This cloud allows both software upgrades and data exchange to be transferred via the internet, and is hosted by EYESi in Germany. This system allows members of the group to seamlessly extract and analyse research data.

    All candidates were required to complete the course within 1 year. Before entering the training programme, every participant had a 2 h formal and structured induction with the consultant attending trainer (GS). They were given standardised instructions with regard to how to use the simulator. Live theatre training necessitates direct consultant supervision, and in this course, trainees had a minimum of three sessions of 2 h each where a consultant attending trainer was supervising. However, a portion of the course was self-directed followed by a structured debrief, thus facilitating experiential learning. To avoid fatigue, all sessions were booked for 3 h or less. The entire syllabus was set up for at least 10 h training, including a minimum of 6 h of directly supervised time.

    Initially, participants had to complete four entry tasks. These were a mix of generic 3-dimensional (3D) and cataract-specific, static and dynamic tasks in order to capture a full range of dexterity and skill as measured and trained by the simulator. Three of them were single-handed tasks (cataract navigation training (intracapsular), level 3; cataract antitremor training (intracapsular), level 2; capsulorhexis training, level 1), and one of them was a bimanual task (cataract cracking and chopping training, level 2). For each task, participants could achieve a maximum score of 100, resulting in a maximum course score of 400. Capsulorhexis training and antitremor training were chosen since construct validity for these two tools had been demonstrated previously.11 ,12 After completing the entry baseline tasks, trainees passed through the structured sequential programme. Cat A: anterior chamber navigation, intracapsular navigation, bimanual navigation, instruments; and Cat B: navigation and instruments, capsulorhexis, intracapsular tissue, stop and chop. Finally, all participants had to complete the exit baseline, which included the same four tasks as the entry baseline (matched tasks) in order to compare entry and exit results. Entry and exit baseline modules consisted of intracapsular navigation training, intracapsular antitremor training, cracking and chopping training and capsulorhexis training.

    Results

    A total of 17 subjects entered the training curriculum, with one participant leaving the programme shortly after induction. The other 16 participants were tested before and after completion of the course.

    Data was analysed using IBM SPSS Statistics, V.20, and a graphical representation of the results before and after training is presented in the box plot in figure 1. The primary outcome measure was: total score obtained on entry to the course, and compared with the candidate's score after the supervised training on exiting the course. Comparisons before and after the course were analysed using the Wilcoxon signed-rank test set at a significance level of 0.05. Summary statistics for the four measured parameters are represented as median and inter quartile range (IQR) in table 1, as well as the total score obtained.

    View this table:
    Table 1

    Summary statistics for the training course

    Figure 1
    Figure 1

    Box plot showing total score before and after training. The line within the boxes indicates mean values; limit lines are 95% CIs (±2 SDs; the edge of the boxes is ±1 SD).

    Improvement after the course was evident in all parameters and found to be statistically significant, representing a marked improvement in these skills after completing the curriculum. The greatest improvements could be found for capsulorhexis and antitremor training. These were also the tasks with lowest precourse scores. All the trainees started with a precourse score of 0 for antitremor training, and none of the participants had a precourse score higher than 5 for capsulorhexis training.

    Discussion

    In this study, we quantitatively evaluate the level of skills transfer in first-year ophthalmology trainees as captured by the EYESi VR simulator. The results presented here suggest that very significant levels of skills transfer can be achieved with trainees starting out in ophthalmology through a structured supervised simulation syllabus. Trainees at the start of their training have the highest rates of complications,13 and thus, any system which can accelerate their progression up the competency and skills curve10 is of potential benefit.

    Future studies should aim to evaluate whether the incidence of surgical complications is reduced in early trainees who have completed the course compared with published rates.

    Since the introduction of simulation in ophthalmology, there has been little evidence of the potential benefits at an early stage of training. Current surgical training in ophthalmology is mainly based on the traditional Halsted model where the novice surgeon achieves surgical competence by reading, observing and performing surgery on ‘real patients’ under the supervision of an experienced surgeon. The number of procedures performed is often used as a benchmark for the trainee's level of skill with a minimum number of surgical cases serving as the evidence of surgical competence.14 Highly structured, supervised and assessed wet-lab sessions on animal models and compulsory microsurgical skill courses offer an additional training environment. This model, however, has a more limited ability to objectively track improvement.15 The more frequent use of VR simulators for surgical training could address some of these limitations. The current study shows that structured simulation at a very early stage imparts a significant degree of skill to novice ophthalmic surgeons.

    Several novel aspects to ophthalmic simulation were introduced in the course of this study, and it will be difficult to extrapolate the precise contribution each has had on the skills transfer. Two features most notably stand out, however; the first being the structured courseware which necessitates all candidates to pass through the exact same set of tasks in the same order. This facilitates many aspects of the training and ensures they are exposed to the full breadth of modules as opposed to unstructured training. The other key feature was the consultant (attending) supervision with periodic structured debriefs. These sessions ensured that any problems encountered were fully addressed allowing for breakdown of task, specific enhancement of the skills set and potentially broader teaching around the task in question. Structured debriefing has been found to be useful in other scenarios.16 The supervision and structured debriefs conducted here are likely to be a key element contributing to the significant level of skills transfer found in the study usage.

    The described programme was tailored for novice surgeons at the beginning of their surgical career since it was hypothesised that this group would benefit the most. This hypothesis was, in part, based on evidence that beginners can experience significant amounts of extra stress in the operative environment, and this can actually impact negatively on performance slowing down their functioning and learning process.15 ,17 In addition, trainers frequently describe the training of the most junior surgeons as one of the most stressful aspects of their role, and so a programme, as the one described here, may prove more broadly beneficial.

    A selection of generic 3D and cataract-specific tasks, including capsulorhexis and antitremor training, were chosen for entry and exit baseline examinations. There is evidence that capsulorhexis is a particularly important and difficult step to learn for ophthalmic residents at the beginning of their surgical training.18–21 This can be underlined by the current study where trainees had the lowest precourse scores for capsulorhexis and antitremor training, implying that these are the most difficult tasks. Construct validity has been shown for the capsulorhexis tool, the anterior segment forceps and the antitremor modules of the EYESi simulator. This signifies that the simulator is able to differentiate between different skill levels of inexperienced and experienced surgeons and, therefore, any difference in performance found with these tasks offers more robust evidence of improvement.11 ,12 Highly statistically significant improvements were found for all modules, including one-handed, two-handed, static and dynamic course tasks. Since the simulator provides purely objective and quantitative parameters and scores, the results are not open to subjective interpretation and bias like it would be as for a subjective score system. An improvement on the simulator, as shown in the current study can, therefore, be interpreted as significant degree of skill transfer and, therefore, improvement of skill level. Further studies will help better define the level of skills transfer that is translated into the theatre environment.

    This is the first study showing the significant beneficial effects of a structured sequential supervised ophthalmic simulation training programme. The results also suggest that this model of high-fidelity VR eye surgical teaching has prospective validation. Despite increasing accessibility to VR systems, there is still great variance as to how they are used, if at all, in different regions. One factor that is, however, likely to be critical in whichever model emerges as most effective, is the involvement of a senior trainer offering guided supervision. Ultimately, the knowledge gained from this and other work will go towards establishing VR programmes, which aim to accelerate trainee learning, benefit trainers and, most importantly, improve patient safety in surgical training.

    References

    1. ↵
      1. Ikonen TS,
      2. Antikainen T,
      3. Silvennoinen M,
      4. et al
      . Virtual reality simulator training of laparoscopic cholecystectomies—a systematic review. Scand J Surg 2012;101:5–12.
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Jonassen DH,
      2. Peck KL,
      3. Wilson BG
      . Learning with technology: a constructivist perspective. UpperSaddle River, NJ; Pearson/Merrill/Prentice Hall, 1999.
    3. ↵
      1. Kolb A,
      2. Kolb D
      . The learning way: meta-cognitive aspects of experiential learning. Simulation Gaming 2009;40:297–327.
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. Colt HG,
      2. Crawford SW,
      3. Galbraith O III.
      . Virtual reality bronchoscopy simulation: a revolution in procedural training. Chest 2001;120:1333–9.
      OpenUrlCrossRefPubMedWeb of Science
    5. ↵
      1. Denson JS,
      2. Abrahamson S
      . A computer-controlled patient simulator. JAMA 1969;208:504–8.
      OpenUrlCrossRefPubMedWeb of Science
    6. ↵
      1. Aggarwal R,
      2. Black SA,
      3. Hance JR,
      4. et al
      . Virtual reality simulation training can improve inexperienced surgeons’ endovascular skills. Eur J Vasc Endovasc Surg 2006;31:588–93.
      OpenUrlCrossRefPubMed
    7. ↵
      1. Merril JR,
      2. Notaroberto NF,
      3. Laby DM,
      4. et al
      . The Ophthalmic Retrobulbar Injection Simulator (ORIS): an application of virtual reality to medical education. Proc Annu Symp Comput Appl Med Care 1992:702–6.
    8. ↵
      1. Sinclair MJ,
      2. Peifer JW,
      3. Haleblian R,
      4. et al
      . Computer-simulated eye surgery. A novel teaching method for residents and practitioners. Ophthalmology 1995;102:517–21.
      OpenUrlPubMedWeb of Science
    9. ↵
      1. Webster R,
      2. Sassani J,
      3. Shenk R,
      4. et al
      . A haptic surgical simulator for the continuous curvilinear capsulorhexis procedure during cataract surgery. Stud Health Technol Inform 2004;98:404–6.
      OpenUrlPubMed
    10. ↵
      1. Solverson DJ,
      2. Mazzoli RA,
      3. Raymond WR,
      4. et al
      . Virtual reality simulation in acquiring and differentiating basic ophthalmic microsurgical skills. Simul Healthc 2009;4:98–103.
      OpenUrlCrossRefPubMed
    11. ↵
      1. Privett B,
      2. Greenlee E,
      3. Rogers G,
      4. et al
      . Construct validity of a surgical simulator as a valid model for capsulorhexis training. J Cataract Refract Surg 2010;36:1835–8.
      OpenUrlCrossRefPubMed
    12. ↵
      1. Mahr MA,
      2. Hodge DO
      . Construct validity of anterior segment anti-tremor and forceps surgical simulator training modules: attending versus resident surgeon performance. J Cataract Refract Surg 2008;34:980–5.
      OpenUrlCrossRefPubMed
    13. ↵
      1. Oetting TA
      . Surgical competency in residents. Curr Opin Ophthalmol 2009;20:56–60.
      OpenUrlCrossRefPubMed
    14. ↵
      1. Osborne MP
      . William Stewart Halsted: his life and contributions to surgery. Lancet Oncol 2007;8:256–65.
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      1. Oetting TA,
      2. Lee AG,
      3. Beaver HA,
      4. et al
      . Teaching and assessing surgical competency in ophthalmology training programs. Ophthalmic Surg Lasers Imaging 2006;37:384–93.
      OpenUrlPubMedWeb of Science
    16. ↵
      1. Mariani B,
      2. Cantrell MA,
      3. Meakim C,
      4. et al
      . Structured debriefing and students’ clinical judgment abilities in simulation. Clin Simulation Nursing 2012;in press.
    17. ↵
      1. Arora S,
      2. Sevdalis N,
      3. Nestel D,
      4. et al
      . The impact of stress on surgical performance: a systematic review of the literature. Surgery 2010;147:318–30, 330 e1–6.
      OpenUrlCrossRefPubMedWeb of Science
    18. ↵
      1. Unal M,
      2. Yucel I,
      3. Sarici A,
      4. et al
      . Phacoemulsification with topical anesthesia: Resident experience. J Cataract Refract Surg 2006;32:1361–5.
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      1. Dooley IJ,
      2. O'Brien PD
      . Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg 2006;32:604–8.
      OpenUrlCrossRefPubMedWeb of Science
    20. ↵
      1. Olali CA,
      2. Ahmed S,
      3. Gupta M
      . Surgical outcome following breach rhexis. Eur J Ophthalmol 2007;17:565–70.
      OpenUrlPubMed
    21. ↵
      1. Prakash G,
      2. Jhanji V,
      3. Sharma N,
      4. et al
      . Assessment of perceived difficulties by residents in performing routine steps in phacoemulsification surgery and in managing complications. Can J Ophthalmol 2009;44:284–7.
      OpenUrlCrossRefPubMed

    Footnotes

    • Contributors Concept and design: PMS, FOS, GMS. Acquisition of data: GMS, BH, SNG. Analysis and interpretation of data: GMS, ASL, IA, JL. Manuscript writing: JL, GMS. Editing, critical review and final approval: all authors.

    • Funding GMS acknowledges a proportion of his financial support from the Department of Health through the award made by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. The authors acknowledge the Special Trustees of Moorfields Eye Hospital for their unrestricted financial support towards this work. The authors acknowledge support from The London Deanery School of Ophthalmology and the Simulation and Technology-enhanced Learning Initiative (STeLI) who have supported the development of ophthalmic simulation programmes in the region.

    • Competing interests None.

    • Ethics approval Moorfields Eye Hospital.

    • Provenance and peer review Not commissioned; externally peer reviewed.