Cost-effectiveness of virtual reality and wet laboratory cataract surgery simulation.

PURPOSE: To evaluate the cost-effectiveness of phacoemulsification simulation training in virtual reality simulator and wet laboratory on operating theater performance. METHODS: Residents were randomized to a combination of virtual reality and wet laboratory phacoemulsification or wet laboratory phacoemulsification. A reference control group consisted of trainees who had wet laboratory training without phacoemulsification. All trainees were assessed on operating theater performance in 3 sequential cataract patients. International Council of Ophthalmology Surgical Competency Assessment Rubric-phacoemulsification (ICO OSCAR phaco) scores by 2 masked independent graders and cost data were used to determine the incremental cost-effectiveness ratio (ICER). A decision model was constructed to indicate the most cost-effective simulation training strategy based on the willingness to pay (WTP) per ICO OSCAR phaco score gained. RESULTS: Twenty-two trainees who performed phacoemulsification in 66 patients were analyzed. Trainees who had additional virtual reality simulation achieved higher mean ICO OSCAR phaco scores compared with trainees who had wet laboratory phacoemulsification and control (49.5 ± standard deviation [SD] 9.8 vs 39.0 ± 15.8 vs 32.5 ± 12.1, P < .001). Compared with the control group, ICER per ICO OSCAR phaco of wet laboratory phacoemulsification was $13,473 for capital cost and $2209 for recurring cost. Compared with wet laboratory phacoemulsification, ICER per ICO OSCAR phaco of additional virtual reality simulator training was US $23,778 for capital cost and $1879 for recurring cost. The threshold WTP values per ICO OSCAR phaco score for combined virtual reality simulator and wet laboratory phacoemulsification to be most cost-effective was $22,500 for capital cost and $1850 for recurring cost. CONCLUSIONS: Combining virtual reality simulator with wet laboratory phacoemulsification training is effective for skills transfer in the operating theater. Despite of the high capital cost of virtual reality simulator, its relatively low recurring cost is more favorable toward cost-effectiveness.

Ophthalmic surgical training following modernising medical careers: regional variation in experience across the UK.

OBJECTIVES: To evaluate surgical experience among current doctors appointed into ophthalmology training posts since the introduction of the Modernising Medical Careers programme. Additionally, to identify regional variations in surgical experience and training programme delivery. DESIGN: A cross-sectional survey. SETTING: The UK's four largest deaneries (Schools of Ophthalmology). PARTICIPANTS: Trainee ophthalmologists, all having completed three or more years of training, who were appointed to the new ophthalmic specialty training programme. PRIMARY AND SECONDARY OUTCOME MEASURES: The mean annual surgical rate for each deanery in phacoemulsification cataract extractions and experience in other common elective and emergency surgical operations. Second, to calculate the mean timetabled clinical activity. RESULTS: The responses of 40 doctors were analysed, with a response rate of 83%. Overall, the phacoemulsification rate was 73.52±29.24 operations/year. This was significantly higher in the South Thames Deanery (99.69±26.16, p=0.0005) and significantly lower in the North Western Deanery (48.08±19.72, p=0.0008). The annual mean complex cataract rate was 5.21±4.38. Only 40% were confident in dealing with the most common complication of cataract surgery (vitreous loss). The mean trabeculectomy (surgery for glaucoma) rate was 0.47±1.16 and for squint surgery it was 3.54±2.82 operations/year. Regarding the common ocular trauma surgery, 42.5% had not sutured a corneal laceration and 60% a globe rupture. 50% thought the training programme would adequately prepare them surgically. The timetabled clinical activity was highest in the South Thames Deanery (48.17 h/week) and lowest in the North Western Deanery (40.82 h/week) due to variations in the European Working Time Directive implementation and on-call commitments. CONCLUSIONS: Significant regional variations in surgical training experience exist between UK deaneries, particularly with respect to cataract surgery, and they appear to be correlated to timetabled activity. Experience and confidence levels in managing complex cataract surgery and complications were low and experience with previously commonly performed elective and emergency operations was minimal. Although doctors from all the regions surveyed were very likely to achieve the minimum cataract extractions required for specialist training completion, we have identified shortcomings of the current training programme that need attention.

Congenital and infantile cataract: aetiology and management.

Congenital cataract is the commonest worldwide cause of lifelong visual loss in children. Although congenital cataracts have a diverse aetiology, in many children, a cause is not identified; however, autosomal dominant inheritance is commonly seen. Early diagnosis either on the post-natal ward or in the community is important because appropriate intervention can result in good levels of visual function. However, visual outcome is largely dependent on the timing of surgery when dense cataracts are present. Good outcomes have been reported in children undergoing surgery before 6 weeks of age in children with unilateral cataract and before 10 weeks of age in bilateral cases. Placement of an artificial intraocular lens implant after removal of the cataract has become established practice in children over 2 years of age. There remains debate over the safety and predictability of intraocular lens implantation in infants. Despite early surgery and aggressive optical rehabilitation, children may still develop deprivation amblyopia, nystagmus, strabismus, and glaucoma. The diagnosis and management of congenital cataracts has improved substantially over the past 30 years with a concurrent improvement in outcomes for affected children. Many aspects of the pre-, intra-, and postoperative management of these patients continue to be refined, highlighting the need for good quality data and prospective collaborative studies in this field.

Soft lens matter recurrence after congenital cataract surgery.

UNLABELLED: We report a case of soft lens matter recurrence 17 years after the original congenital cataract was removed. To our knowledge, this is the longest interval for soft lens matter to recur. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Anterior dislocation of a Morcher capsular tension ring.

We report the rare complication of anterior dislocation of a capsular tension ring (CTR) and a simple management option, with excellent results and no inflammatory or pressure-related sequelae.

Renal allograft C4d deposition in Chinese: Hong Kong perspective.

BACKGROUND: Acute rejection constitutes a significant proportion of renal allograft loss. Peritubular capillary deposition of C4d has been recognized as the footprint of humoral alloimmunity and proven to be a sensitive and specific marker for humoral rejection in the appropriate clinical context. Its presence in indication biopsies is the most important independent risk factor for graft failure. Data are, however, scarce among Chinese subjects. METHODS: We retrospectively reviewed all renal graft biopsies performed from 1 April 2002 to 31 March 2006 for unexplained acute renal dysfunction or delayed graft function. Renal outcomes were assessed at the time of renal biopsy and at 1 month, 3 months, 6 months and 1 year afterwards. Survival was assessed by Kaplan-Meier analysis. Multivariate analysis was used to determine if C4d positivity is an independent risk factor for poor renal outcome. RESULTS: Fifty-two biopsies were included, of which 16 were positive for peritubular capillary C4d. Peritubular capillary C4d was associated with lower glomerular filtration rate and higher serum creatinine at 6 and 12 months after renal biopsies. The C4d-positive group fares worse in terms of death-censored graft failure, doubling of serum creatinine and reaching 50% of glomerular filtration rate at the end of the study. Peritubular capillary C4d deposition was the only significant risk factor that predicts graft failure in multivariate analysis. CONCLUSION: Our findings confirmed the independent prognostic value of peritubular capillary C4d staining on renal allograft survival in Chinese.

Optical coherence tomography: an assessment of current training across all levels of seniority in 8 ophthalmic units in the United Kingdom.

BACKGROUND: Optical Coherence Tomography (OCT) is becoming an increasingly integral part of ophthalmological clinical practice. The accurate interpretation of OCT images is important both in terms of diagnosis and in directing subsequent management. The aim of this study was to determine the clinical competence in OCT image interpretation of ophthalmologists in different subspecialties and grades. METHODS: Eight OCT images demonstrating a single macular pathology and two normal scans were selected by case notes review. These ten images were shown to thirty doctors and 10 non-medical staff from eight units. They were asked to identify each lesion, the average thickness of the lesion, and the axis at which the OCT was taken. One point was awarded for each correct answer. RESULTS: The mean scores for the correct qualitative identification of the OCT lesion (with a maximum score of 10) for different grades of doctors and non-medical staff were as follows: medical retinal consultants (MRC), 9 (range, 8-10); vitreoretinal consultants (VRC), 7 (range, 6-9); non-retinal consultants (NRC), 4 (range, 2-6); vitreoretinal fellows (VRF), 4 (range, 3-7); specialist registrars (SpR), 3 (range, 2-5); senior house officers (SHO), 4 (range, 3-6); orthoptists, 1 (range, 0-1); ancillary staff, 2 (range, 0-3). CONCLUSION: A wide range in the ability to accurately interpret OCT images has been demonstrated. All doctors would thereby benefit from further training in the interpretation of OCT scans.

Idiopathic retinal holes in monozygotic twins.

It remains controversial whether there is a significant genetic contribution to the pathogenesis of idiopathic giant retinal tears or retinal dialysis. In contrast, the underlying molecular genetic basis of several inherited vitreoretinal dystrophies is now well established, with also an increasing recognition of genetic factors in the development of myopia. We describe asymptomatic female monozygotic twins who were identified as having identical retinal holes. These cases represent the first evidence to our knowledge of a potential role of inherited factors in the causation of idiopathic peripheral retinal holes. This observation raises the need to examine the twin of any patient presenting with a retinal break(s).