October 2007




Virtual success

by Maxine Lipner EyeWorld Senior Contributing Editor



Using a computer simulator, residents can gain valuable surgical experience

Residents can practice their cataract removal technique using a virtual system.

Source: Simulution

It’s the moment of truth for residents—performing cataract surgery on a living patient. Some trepidation is, of course, natural. Residents at Ohio State University, Columbus, however, are a likely a little more confident than most going into the first procedure. These students get a “dress rehearsal” for surgery without actually touching a patient, by using a virtual simulator, according to Thomas F. Mauger, M.D., chairman of ophthalmology. The virtual simulator fills an unmet in the training regimen, Dr. Mauger believes. “I think that most residency programs struggle with how to give residents appropriate training in order to bridge the gap from a novice first-year resident to someone who can actually get in the OR and operate on patients safely,” he said. While wet labs continue to provide residents with valuable hands-on experience, training on a simulator provides something extra. “I think that virtual reality systems offer a way to validate some of our training systems because they have quantitative and qualitative parameters that we can measure and teach some of the basic skills of intraocular surgery with 3D imaging, simultaneously using hands and feet,” Dr. Mauger said. He sees current virtual reality systems as bridging an important gap.

Virtual confidence booster

Virtual reality systems are well designed for boosting confidence. “They certainly can’t mimic, at least at this point, the variety of tissue difference between one eye and the other and some unexpected things that can happen in surgery,” he said. “But they can certainly get us a real way to where we want to go as far as having the resident comfortable in the OR with the microscope and instruments and in a very safe environment.”

The Melerit PhacoVision system (Simulution, Prior Lake, Minn.), which students in the program use, is designed to simulate phacoemulsification. “It has a simulated microscope with images in both eyes that allow three-dimensional imaging of a virtual eye and has two instruments—one is a phacoemulsifier and the other is put through a separate side port,” Dr. Mauger said. “We then are able to perform the phacoemulsification of the lens using different techniques such as divide-and-conquer or splitting techniques.” One drawback to the system, however, is that it doesn’t allow users to gain experience in making an incision or in inserting implants. “It’s basically at this point limited to the phacoemulsification part of the procedure,” Dr. Mauger said. Another simulator available in the ophthalmic arena, the EyeSi (VR Magic, Mannheim, Germany) is currently programmed to mimic vitrectomies. At Ohio State, they opted for the Melerit system based upon the strength of its cataract surgery modules, which they felt was important for their particular residents. Dr. Mauger sees the simulator as filling an important need in the resident education program. “It certainly helps with confidence because they can see their improvement statistically on the machine and realize that they’re improving,” he said. “Sometimes in surgery it’s a little hard to tell that you’re improving because each case is so different.” However, the simulator is not designed to replace wet labs or foster cataract assessment. “It’s just meant to add to that experience and get a little bit more concrete evaluation before they hit the ORs,” he said.

Improved surgical times

Anecdotally speaking, the system has showed great promise, and results have been far better than Dr. Mauger dared anticipate. “The residents who have really put forth the effort and done six or more cases have had dramatically improved surgical times when they first started doing surgeries,” Dr. Mauger said. “They’re operating at maybe half the time that they would have if they hadn’t used it.” With the latest crop of residents who started in July, Dr. Mauger has begun a formal study of the effectiveness of the simulator, which he hopes will ultimately provide some definitive data on this. So far, his experience with the system has been only positive. It extends the amount of time that residents can practice surgery and makes their time more efficient. “It’s available 24/7, and residents can come in anytime and get started using it within five minutes,” he said. “Whereas, with a wet lab it might take an hour or so to get things ready and set up and have to worry about availability of tissue.” Some concerns that Dr. Mauger has, however, is that there may be those who look to the program to try to replace traditional teaching methods, or that at some point the government might step in and require use of simulators in place of tried-and-true training techniques. “I look at this more like a pilot might use a simulation of flight training,” he said. “Certainly he still needs to get up in the air with an experienced pilot next to him to really learn what’s going on.”

For the future, Dr. Mauger hopes to see improvements in the program. “We can change the parameters of the eye to try to make it more lifelike, we can change the size of the pupil, and we can have air bubbles form during the procedure, but it certainly doesn’t have the wide range of variability that a normal eye would have in the OR,” he said. “I look forward in the future to getting more abilities to adapt it and add things like what happens if the patient were taking Flomax (tamsulosin hydrochloride, Boehringer Ingelheim GmbH, Germany), and the pupil responds unexpectedly.” He sees this as the next step and also thinks that it may one day also benefit more experienced surgeons as well. “I think that it would be a wonderful instrument for experienced surgeon’s to practice new techniques on,” he said. “When you’re already done training, it’s hard to gain that kind of experience with new procedures, and this would allow us to do that, I think, in a very effective way.”

Editors’ note: Dr. Mauger has no financial interests related to his comments.

Contact Information

Mauger: 614-293-6919, Thomas.mauger@osumc. edu

Virtual success Virtual success
Ophthalmology News - EyeWorld Magazine
283 110
283 110
True, 10