July 2012




Cataract tips from the teachers

Of synthetics and simulators: Part 1


Sherleen Chen, M.D.

Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary

Roberto Pineda, M.D.

Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary

The rehearsal, solidification, and polishing of surgical techniques before entering the operating room is crucial to performing efficient and elegant surgery. While practice on tissues as close to the real thing is ideal, this is not always possible. Human cadaver eyes are a precious gift not readily or widely available. As such, many models have been developed to simulate the human eye and the experience of performing surgery. This two-part series will focus on the use of surgical simulators and synthetic eye models in training for cataract surgery. In this column, we invite three experts to discuss the benefits and use of surgical simulators in developing the manual, as well as cognitive, skills required to successfully prepare for cataract surgery

Sherleen Chen, M.D., and Roberto Pineda, M.D.



Mary K. Daly, M.D.

Chief of ophthalmology, Veterans Affairs Boston Healthcare System Associate professor of ophthalmology, Boston University School of Medicine Lecturer, Harvard Medical School

The word "surgeon" comes from the Greek "cheir," which means hand, and "ergon," which means work. Ability in surgery, "chiurgery," or handwork, depends on many factors. Few would argue that one key ingredient to prime performance is practice. Dr. Shin'ichi Suzuki (1898-1998) said, "You don't have to practice every day, only on the days you eat." His point is well taken and can be easily transferred from his specialty of music to our field of surgery. Practice and commitment to our trade should be as integral to our daily experience as activities we cannot live without. Ophthalmology programs have a duty to provide adequate skills training and acquisition for residents and fellows in an environment that is safe for patients. Simulators, which have been available in general surgery for some time, have shown faster adaptation to psychomotor and perceptual skills, improved learning curves, and better OR performance. VRmagic (Mannheim, Germany) has now made simulation in ophthalmology available through its Eyesi Surgical Simulator. This ophthalmic simulator offers amazingly life-like surgical experience in a risk-free environment. Formal evaluations are provided after each task, a feature critical to the user's learning process. VRmagic has designed a set of consecutive courses for beginner and advanced surgeons that we have incorporated into our rotation at VA Boston. The program begins with modules introducing residents to the handling of instruments and sequentially leads to ones for performing surgical procedures. Junior and intermediate residents must pass the beginner cataract course before they are allowed to perform intraocular surgery at our institution, and senior residents are expected to complete the advanced program during their third year. The feedback from trainees has been overwhelmingly positive. They report the simulator not only to be a great learning tool, but fun to use. They appreciate its accessibility, as they can use it at their discretion, with or without attending mentorship, receiving immediate feedback after every task. They rejoice when they achieve high scores and try harder when they don't, motivated and energized by this high technology teaching tool. The Eyesi provides a safe, accessible, and engaging environment for skills acquisition and repetition of tasks, with quantifiable evaluation data that can be reviewed by the trainee and supervisor alike. It is a wonderful addition to traditional training (wet lab, hands-on) and when united, increases the comprehensiveness of teaching programs to ensure our trainees develop the skills they need to become quality ophthalmic surgeons.

Ayman Naseri, M.D.

Associate professor, vice chair, University of California, San Francisco (UCSF) Residency program director, UCSF Chief of ophthalmology, San Francisco VA Medical Center

Virtual reality simulation has the potential to offer numerous benefits to surgical educators. In an effort to try to traverse the surgical learning curve without putting patients at risk, a validated simulation device can offer trainees the opportunity to improve surgical skills with deliberate and repetitive practice over a range of difficulty in a controlled environment. For this reason, many ophthalmology programs have acquired virtual reality simulation in order to assist in the training of residents who are learning cataract surgery. One of the virtual reality simulation devices, the Eyesi Surgical Simulator, has already been acquired at almost 60 sites in North America and over 160 locations worldwide.

Despite the increasing popularity of simulation in ophthalmology, the evidence demonstrating the effectiveness of this technology at improving patient outcomes is limited. Two recent retrospective studies found no statistical difference in the cataract surgery complication rate of ophthalmology residents who trained on a simulator versus those who did not. But these studies did demonstrate one other potential benefit of simulator training: In both studies, residents who trained on a simulator performed cataract surgery more efficiently than those who did not use a simulator. The study from George Washington University revealed a statistically significant difference in the phaco time and power used by simulator-exposed residents, while the study from the University of Iowa revealed a shorter total operative time.

To be fair, studies demonstrating the effect of simulator training on patient outcomes are difficult to conduct due to challenges of sample size, randomization, and control of the many potential variables that can affect resident performance. But the benefits of simulator training may lie in other qualitative arenas such as improved trainee confidence, decreased teacher/learner stress, or the opportunity for structured remediation and evaluation. One of the greatest challenges for surgical educators is the resident who struggles in the operating room. This situation creates significant anxiety for the trainee and for the instructors responsible for his/ her surgical education. In an era of minimum surgical case numbers mandated by the Accreditation Council for Graduate Medical Education (ACGME), simulators may prove to be a welcome asset for this uncommon yet difficult scenario.

Virtual reality simulation for cataract surgery is still a relatively new tool, and we can likely expect iterative technologic improvements over time. The challenge for surgical educators is to determine how to best use simulation, when it should be used, and where this and other innovative tools fit into a modern surgical curriculum.


1. Mahr MA, Hodge DO. Construct validity of anterior segment antitremor and forceps surgical simulator training modules; attending versus resident surgeon performance. J Cataract Refract Surg. 2008;34:980-985.

2. Feudner EM, Engel C, Neuhann IM, Petermeier K, Bartz-Schmidt K-U, Szurman P. Virtual reality training improves wet-lab performance of capsulorhexis: Results of a randomized, controlled study. Graefes Arch Clin Exp Ophthalmol. 2009;247:955-963.

3. Belyea DA, Brown SE, Rajjoub LZ. Influence of surgery simulator training on ophthalmology resident phacoemulsification performance. J Cataract Refract Surg. 2011;37: 1756-1761.

4. Privett B, Greenlee E, Rogers G, Oetting TA. Construct validity of a surgical simulator as a valid model for capsulorhexis training. J Cataract Refract Surg. 2010;36:1835-1838.

5. Watts CE, Oetting TA. Surgical simulator improves early resident learning curve for cataract surgery. Association of University Professors of Ophthalmology, Annual Meeting, Jan 25, 2012, Miami, Fla.

Bonnie An Henderson, M.D.

Assistant clinical professor of ophthalmology, Harvard Medical School Partner, Ophthalmic Consultants of Boston

Surgical competency is included by the American Board of Ophthalmology as an adjunctive core competency to the six others that are required by the ACGME for resident training accreditation in ophthalmology.1,2 Becoming a competent surgeon cannot be done passively by reading textbooks or videos alone. The resident must obtain hands-on surgical training in the operating room, wet laboratory, or with a simulator. In fact, the ACGME has mandated that residents must have access to either a wet lab or to simulators for skills development.1

Although commonly performed, cataract surgery is considered one of the most difficult surgeries to learn with nearly a 10-fold increase in complications during surgeries performed by residents compared to surgeries performed by experienced surgeons.3 Learning how to perform cataract surgery in a real operating room is preferred. However, with the rising costs of teaching, increased expectations in patient outcomes, and increased time constraints, educators are forced to seek out surrogates for operating room training experience. Surgical simulators have recently become a viable option for some teaching programs. There are several advantages of simulator training. Similar to a wet laboratory, human cost in the form of adverse patient outcomes is minimized and residents can practice in a non-stressful learning environment at their own pace.3 Additionally, training on surgical simulators can be incorporated into a curriculum that can be available to residents at any time.4 Surgical preceptor presence or absence need not be a limiting factor in the learning process. This is not to say that simulator training can serve as a substitute for individualized training with supervising surgeons. Other surgical specialties attempting to exclusively use a simulator have failed.5 Rather, it can serve as a complementary tool for resident education. Simulators are already being utilized in many different fields of surgical education, from neurosurgery6 to obstetrics and gynecology.7

The currently available surgical physical simulators (e.g., Eyesi Surgical Simulator) afford practice for microsurgery by familiarizing the resident with maneuvers performed under a microscope with both hands and both feet. However, training a successful cataract surgeon involves more than practicing the physical movements; it involves imparting cognitive knowledge, visual-spatial knowledge, and technical skill. Dividing the learning process into respective components can greatly benefit residents, enabling them to master one step at a time. A cognitive simulator, the Cataract Master computer program (Massachusetts Eye and Ear Infirmary, Boston), has been developed to provide the intellectual training that is usually offered by a surgical mentor.8 A prospective multicenter masked trial of a prototype of this program was performed, and a statistically significant improvement in knowledge accumulation after use of this program compared to that with traditional teaching tools was found.9 The Cataract Master is currently available and distributed on the ASCRS website, www.ascrs.org. The introduction of new technology such as a surgical simulator can often be met with skepticism. Koch F. et al surveyed trainees and experienced surgeons participating in a dry lab with a simulator. The authors evaluated the participants' acceptance of a simulator as a training method. The aspects scored included quality, complexity, clinical impact, learning effect, and overall impression. The majority of both groups accepted and highly appreciated the simulator as a training tool.10

The development of physical and cognitive surgical simulators offers a different approach to learning than that of the traditional apprenticeship model. Simulators cannot be substituted for experienced surgical preceptors, but they are fast becoming an attractive and acceptable adjunct in surgical curricula. As the technology improves, the simulations become more realistic and hence the experience will become more valuable. Simulation programs will continue to play a greater role in future surgical education.


1. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education In Ophthalmology. July 1, 2007.

2. Mills R, Mannis M. Report of the American Board of Ophthalmology Task Force on the Competencies. Ophthalmology. 2004;111(7): 1267-1268.

3. Tarbet KJ, Mamalis N, Theurer J, et al. Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg. 1995;21(6):661-5.

4. Sandrick K. Virtual reality surgery: Has the future arrived? Bull Am Coll Surg. 2001;86: 42-3, 63.

5. Gerson LB, Van Dam J. A prospective randomized trial comparing a virtual reality simulator to bedside teaching for training in sigmoidoscopy. Endoscopy. 2003;35:569-575.

6. Spicer MA, van Velsen M, Caffrey JP, Apuzzo ML. Virtual reality neurosurgery: A simulator blueprint. Neurosurgery. 2004;54:783-97; discussion 797-8.

7. Letterie GS. Medical education as a science: The quality of evidence for computer-assisted instruction. Am J Obstet Gynecol. 2003;188: 849-853.

8. Henderson BA, Neaman A, Kim BH, Loewenstein J. Virtual training tool. Ophthalmology. 2006;113:1058-1059.

9. Henderson BA, Kim JY, Golnik KC, Oetting TA, Lee AG, Volpe NJ et al. Evaluation of the Virtual Mentor Cataract Training Program. Ophthalmology. 2010;117(2):253-258.

10. Koch F, Koss MJ, Singh P, Naser H. Virtual reality in ophthalmology. Klin Monbl Augenheilkd. 2009 Aug;226(8):672-6.

Editors' note: The doctors have no financial interests related to this article.

Contact information

Daly: mary.daly2@va.gov
Henderson: bahenderson@eyeboston.com
Naseri: ayman.naseri@va.gov

Of synthetics and simulators: Part 1 Of synthetics and simulators: Part 1
Ophthalmology News - EyeWorld Magazine
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