In recent years, the medical community has benefited from technological advances that simulate surgical environments. Ophthalmologists now have access to commercially available virtual reality systems, including the Eyesi Ophthalmic Surgical Simulator (VRMagic, Mannheim, Germany). Aided by this system, ophthalmology residents at the Mayo Clinic in Rochester, Minnesota, are learning how to perform cataract surgery.
ALTERNATIVE EDUCATIONAL TECHNIQUE
VRMagic originally developed the Eyesi system to simulate vitreoretinal surgery. Recently, however, the company added a training module for the anterior segment (Figure 1). In addition to simulating the use of forceps, precise navigational tasks, the capsulorhexis' formation, and phacoemulsification, the Eyesi's anterior segment module evaluates the user's performance and measures instructor-defined, standardized surgical tasks in a virtual environment.1
Approximately 1 year ago, my colleagues and I incorporated the Eyesi system into our standardized, competency-based surgical training curriculum for ophthalmology residents.
The ophthalmic training system is based at the Mayo Clinic's Multidisciplinary Simulation Center (www.mayo.edu/simulationcenter), a 10,000-square foot clinical training facility dedicated to simulation-based clinical education and research.
Gone are the days when residents first learned the basics of handling intraocular instruments and a surgical microscope in the OR or a variable wet lab environment. Instead, they now complete a structured curriculum that combines one-on-one instruction and independent study with the Eyesi simulator. Instructors create courses that residents repeat and practice until they achieve passing scores. The surgeons-in-training then advance to the Eyesi system's higher levels of difficulty until they master all of the simulator's training tasks. Residents are enthusiastic about the technology and its constant availability (24 hours a day, 7 days a week).
HOW IT WORKS
In studies, the Eyesi Ophthalmic Surgical Simulator demonstrated construct validity (the ability to reliably distinguish between novice and expert surgeons) for training tasks in the posterior and anterior segments.2,3 Anecdotally, I have found that the device's stereoscopic view and foot-pedal controls are excellent proxies for the "real" environment of cataract surgery.
Using the anterior segment training module and the built-in forceps tool, residents learn how to manipulate instruments in the eye, pivot them at the wound, and avoid inadvertently injuring the cornea or crystalline lens. The simulator's scoring system rewards users for the efficiency of their intraocular manipulations and the precision with which they complete their tasks. The capsulorhexis training module (Figure 2) is actually more challenging than "the real thing," an acceptable and desirable quality for a surgical training system.
The posterior segment training modules simulate the manipulation of forceps, the precise movement of instruments in the posterior segment, antitremor training/control, and procedures such as vitrectomy, epiretinal membrane peeling, and internal limiting membrane peeling. Residents at the Mayo Clinic have reported that the Eyesi's retinal simulations "suspend reality" quite effectively. For example, my colleagues and I have watched inexperienced surgeons become so engrossed in virtually peeling an epiretinal membrane that they actually started sweating.
Thus far, VRMagic has provided regular software updates for the Eyesi system and has shown a dedication to continually developing and improving its products. I would therefore expect that the company's relatively new phaco module—the current version of which I find to be the least rigorous or realistic of the tasks available—to ultimately achieve the high caliber of simulation offered by the system's other more advanced ophthalmic training modules.
ARE WET LABS STILL RELEVANT?
Hands-on experience in traditional surgical wet labs is still the gold standard for training residents to perform corneal and scleral suturing techniques. Currently available surgical simulators do not attempt to replace the experience of working with real cadaveric eyes. Instead, the simulator provides a realistic, repeatable, and measurable intraocular surgical environment that is difficult to duplicate in the traditional wet lab setting.
In my experience, the Eyesi's on/off setup eliminates the significant time and effort typically involved in preparing and dismantling a wet lab. In addition, the surgical simulator measures and documents the user's efforts and performance.
Depending on which module is used during a training session, the system tracks and scores up to 74 different performance variables (Table 1). The Eyesi's screen displays the data for each trial, which can also be summarized and graphed at the end of each simulated surgical session or exported to a spreadsheet program for statistical analysis. I believe that, by allowing our residents to repeatedly perform standardized tasks and measuring their performance in a realistic environment, the Eyesi system helps us train surgeons to perform cataract surgery safely and competently without putting patients at risk.
CONCLUSION
Keeping up to date with the rapid advances and complexity of modern intraocular surgery is a challenging but ultimately satisfying and rewarding endeavor. Surgical simulators based in virtual reality allow residents to develop and hone their surgical skills so that they provide patients with the safest and highest-quality surgical outcomes possible. Currently, a barrier to the Eyesi's broad adoption appears to be the system's cost (between $100,000 and $200,000, depending on optional features and the date of purchase).
I encourage ophthalmologists who are passing through Rochester, Minnesota, to consider visiting the Mayo Clinic's Multidisciplinary Simulation Center to take the Eyesi system for a test drive.
To view a video of a simulated capsulorhexis rescue performed on the Eyesi Ophthalmic Surgical Simulator, visit the ESCRS's Video on Demand Web site at www.conference2web.com/escrs/Videos.aspx# or VRMagic's Web site at www.vrmagic.com/downloads/eyesi/videos/ESCRS Mahr.zip
If you are interested in testing the Eyesi Ophthalmic Surgical Simulator at the Mayo Clinic's Multidisciplinary Simulation Center, please contact Dr. Mahr.
Michael A. Mahr, MD, is Residency Program Director at the Mayo Clinic Department of Ophthalmology and Assistant Professor at the Mayo College of Medicine, both in Rochester, Minnesota. He acknowledged no financial interest in the product or company mentioned herein. Dr. Mahr may be reached at (507) 266-4918; mahr.michael@mayo.edu.
