August 2019


Eyeing a new simulation system

by Liz Hillman EyeWorld Senior Staff Writer

The Simulation Systems technology in use
Source: Simulation Systems


A trainee pilot would never take control of an aircraft without first proving his or her skills in a flight simulator. The stakes are just too high.
Surgery is similar. The consequences of surgical errors are severe, so intensive training is required before operating on patients. Training via traditional laboratory techniques, however, is expensive, time consuming, and requires the use of human and animal tissue. Thus, simulators have been used to facilitate surgical training. Ophthalmology is no exception, with virtual reality simulators like the Eyesi Surgical System (VRmagic) providing cataract and vitreoretinal surgery training.
But there is still an unmet need for microsurgery, according to Joseph Sassani, MD, and Brian Smith, PhD, who hope their virtual reality simulation technology, which is still a prototype under development at their startup, Simulation Systems, can fill the need.
With more than 3 decades spent teaching residents, Dr. Sassani has seen ophthalmic surgery change. Cataract surgery, for example, went from having a large incision with multiple microsurgically placed sutures to a small incision procedure with, in most cases, no sutures needed at all. But, he added, residents today still need to employ microsuturing techniques when faced with situations such as cataract wounds that don’t self-seal, corneal lacerations, or open globe injuries. Unfortunately, getting that training remains very resource intensive. As such, he thinks virtual reality-based simulation will be useful.
Overall, microsurgical suture training can be difficult due to practical considerations of using pig eyes or other biologic models, Dr. Sassani said. There’s also the factor of objective performance measurement.
“The whole educational environment is changing, both in the availability of learning material and the requirements placed on the teaching institution by regulatory bodies regarding what criteria they have to meet […] in order to move a resident forward to sit for board certification and to participate in human surgical procedures,” Dr. Sassani said. “[Simulation is] going to increase the uniformity of resident education, so that there will be specific skill sets that everyone will know residents have mastered because the simulator provides objective evidence of that mastery. These educational innovations are going to lead to increased surgical quality.”
In addition to training and testing proficiency for residents, Drs. Sassani and Smith envision simulation being used for refreshers for experienced surgeons. Military surgeons who are set to deploy, for example, might need to brush up on procedures they haven’t performed in years. Simulation also allows surgeons to experience a variety of real-world wound situations. Corneal lacerations, for example, come in a variety of shapes and sizes.
“With a simulator, you can present model injuries for a surgeon to attempt to repair, over and over again, and become proficient. Then if they are ever faced with that injury, they can be confident in the operating room,” Dr. Sassani said. “They will not only have the objective skill, but they will have the confidence that they have mastered the skill, and that’s very important.”
Dr. Smith said they are still gaining understanding about metrics that can be recorded by the system.
“With computer-based simulation, you can measure parameters that you would not be able to measure in the real world, for example, the depth of the suture when passing a needle,” Dr. Smith said. “What we still don’t know is what is important to measure and which measurements correlate with user proficiency or competency. But that’s the most exciting piece: helping learners understand what they are doing right and specifically where they need to focus on improving.”
Dr. Smith envisioned a hospital system using simulators to assess skills for internal credentialing. If you could show that surgeons who perform well on a standardized simulated task have better performance in real life, for example a lower complication rate or decreased operating time, that could translate to improved surgical quality as well as cost savings, he suggested.
Compared to other simulation systems, Drs. Sassani and Smith said theirs does not employ haptic feedback in the instruments, which they consider a benefit. Eliminating bulky haptic hardware, Dr. Sassani said, allows for more realistic placement and movement of the surgeon’s hands, and it’s less expensive, making it accessible to a wider range of institutions. Drs. Sassani and Smith also don’t think haptic feedback is the most important factor for effective microsurgery training.
“The forces experienced by a surgeon during microsuturing are minuscule. It’s more about training and conditioning hand-eye coordination,” Dr. Smith said.
While Drs. Sassani and Smith chose microsurgical suturing in the setting of a corneal laceration as the first simulation task for their system, they think it will have utility in other specialties beyond ophthalmology.
“Virtually any place where microsurgery is required, this simulator can assist in teaching or evaluating surgical skills,” Dr. Sassani said.

About the sources

Joseph Sassani, MD
Founder and president
Simulation Systems
Hummelstown, Pennsylvania
Penn State Health Milton S. Hershey Medical Center
Hershey, Pennsylvania

Brian Smith, PhD
Simulation Systems
Hummelstown, Pennsylvania

Financial interests

: Simulation Systems
Smith: Simulation Systems

Contact information


“They will not only have the objective skill but they will have the confidence that they have mastered the skill, and that’s
very important.”
—Joseph Sassani, MD

Eyeing a new simulation system Eyeing a new simulation system
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