Learning curves of novice residents on cataract surgery simulator: the E3CAPS pedagogic study.

INTRODUCTION: Training novice ophthalmology residents on the EyeSi® simulator increases cataract surgery safety. However, there is no consensus regarding how much training residents should perform before their first time on patients. We evaluated the French national training program through the analysis of the learning curves of novice residents. METHODS: This prospective multicentric pedagogic study was conducted with French novice residents. Each resident completed the recommended four two-hour training sessions and performed a standardized assessment simulating standard cataract surgery before the first session (A0), at the end of the first (A1), second (A2), third (A3) and fourth (A4) sessions. For each surgical step of each attempt, the following data were collected: score, odometer, completion time, posterior capsular rupture and cumulative energy delivered (ultrasounds) during phacoemulsification. A performance threshold was set at a score of 80/100 for each surgical step, 400/500 for the overall procedure. Only descriptive statistics were employed. RESULTS: Sixteen newly nominated ophthalmology residents were included. Median score progressively increased from 95 [IQR 53; 147]) at A0 to 425 [IQR 411; 451] at A4. Despite a significant progression, the "emulsification" step had the lowest A4 scores 86 [IQR 60; 94] without reduction in completion time, odometer or ultrasounds delivered. The rate of posterior capsular rupture decreased linearly from 75% at A0 to 13% at A4 during "emulsification" and from 69 to 0% during "irrigation and aspiration". At A4, only 25% [8; 53] of residents had > 80 at each step and only 75% [47; 92] had > 400/500 overall. CONCLUSION: A training program consisting of four two-hour sessions on the EyeSi simulator over four consecutive days effectively enhances the surgical skills of novice ophthalmology residents. Undergoing more training sessions may improve scores and decrease the incidence of surgical complications, particularly at the emulsification step of cataract surgery. The learning curves presented here can reassure residents who are progressing normally and help identify those who need a further personalized training program.  TRIAL REGISTRATION: ClinicalTrials registration number: NCT05722080 (first submitted 22/12/2022, first posted 10/02/2023).

Assessing the surgical competency of novice surgeons by using a three-dimensional heads-up display microscope.

PURPOSE: To evaluate the surgical performance of novice surgeons operating on a three-dimensional (3D) heads-up display system compared to those using a traditional microscope (TM). METHODS: Prospective study design in a private practice setting. Twenty novice surgeons with similar experiences in cataract surgery were selected. Each surgeon performed 20 phacoemulsification cataract surgeries: 10 surgeries on the 3D heads-up display microscope, and 10 surgeries using a TM system. Data were collected from a total of 400 patients operated on by 20 surgeons. Outcome measures were recorded and graded according to the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric-Phacoemulsification system. The main outcome measure was mean surgical competency scores. RESULTS: Overall, 400 data points were equally distributed between TM (200) and 3D (200) surgeries. The mean surgical competency scores were 60.19 (11.41) for TM surgeries and 62.99 (11.11) for 3D surgeries. 3D surgeries had significantly higher surgical competency scores than TM surgeries ( P = 0.013). The mean surgical duration for TM and 3D surgeries was 35.98 (6.02) min and 34.31 (7.12) min, respectively. 3D surgeries took significantly less time than TM surgeries ( P = 0.012). The overall mean best corrected visual acuity in the logarithm of the minimum angle of resolution units was 0.27 (0.42); in TM and 3D surgeries, it was 0.28 (0.43) units and 0.26 (0.41) units, respectively. CONCLUSION: The 3D heads-up display system enhances stereopsis in cataract surgery, making it a valuable training tool for novice surgeons in phacoemulsification procedures.

Cataract phacoemulsification performed by resident trainees and staff surgeons: intraoperative complications and early postoperative intraocular pressure elevation.

PURPOSE: To determine the incidence of intraoperative complications of phacoemulsification cataract surgery in a teaching hospital and to compare the intraoperative complication rate between resident trainees and staff ophthalmologists, to ascertain the overall rate of intraocular pressure (IOP) elevation on postoperative day 1 (POD1), and, again, to compare this value between resident trainees and staff surgeons. SETTING: Centro Hospitalar São João, Oporto, Portugal. DESIGN: Retrospective study. METHODS: This study included eyes submitted for phacoemulsification cataract surgery from January 1, 2017, to December 31, 2017. There were no exclusion criteria. Data collected included the type of surgeon, level of resident training, case complexity, and intraoperative complications. From all noncomplicated surgeries, preoperative IOP and IOP-POD1 were collected. RESULTS: A total of 2937 surgeries were included; 25.6% were performed by resident trainees. The complication rate was 6.3% with resident trainees and statistically significantly lower (3.3%) in staff surgeons. The complication rate of resident trainees did not differ according to their level of residency. There was a significantly increased incidence of IOP-POD1 elevation in the resident trainee group compared with the staff surgeon group. Surgeries performed by resident trainees, a preexisting history of glaucoma, and pseudoexfoliation were significant risk factors for IOP elevation. CONCLUSIONS: To our knowledge, this is the first European study comparing the incidence of intraoperative and postoperative complications in cataract surgery performed by resident trainees and staff surgeons. We report a significantly higher rate of intraoperative complications and IOP elevation on POD1 in resident trainees vs staff surgeons.

Postoperative Blepharoptosis After Modern Phacoemulsification Procedure.

PURPOSE: To investigate the frequency of transient (1 month) and persistent (at least 6 months) postoperative ptosis following clear corneal sutureless phacoemulsification and to analyze the factors affecting them. DESIGN: Cohort study. METHODS: Patients who underwent phacoemulsification cataract surgery from October 2016 to June 2018 in a tertiary center were enrolled. Margin reflex distance 1 (MRD1), MRD2, and levator function were measured and facial photography was taken before, 1 month, and at least 6 months after the surgery. Clinical ptosis was defined as any postoperative drop of MRD1 and clinically significant ptosis as MRD1 drop of ≥2 mm. Photo-based ptosis was assessed by a masked oculofacial plastic surgeon at the end of the study. RESULTS: A total of 234 patients (313 eyelids) were included. The majority of surgeries were performed by senior residents (65.5%, 205/313) and under topical anesthesia (78.0%, 244/313). Persistent clinical, clinically significant, and photo-based ptosis were 25.4% (71/279), 3.2% (9/279), and 3.3% (9/276). Eyelids with persistent postoperative ptosis showed a significantly (P = .03) lower preoperative levator function (13.9 vs 15.8 mm). No other factor was significantly different between the eyelids with and without postoperative ptosis. CONCLUSION: Persistent clinically significant ptosis was observed in more than 3% of patients undergoing clear corneal sutureless phacoemulsification cataract surgery. It should be counseled preoperatively. Lower preoperative levator function was significantly associated with a higher frequency of postoperative ptosis. Duration of surgery, level of surgeons, and other variables did not have any significant effect on the frequency of postoperative ptosis.

[Virtual simulation for learning cataract surgery]. / Simulation virtuelle pour l'apprentissage de la chirurgie de cataracte.

INTRODUCTION: The training in phacoemulsification cataract surgery in our context requires a long learning curve for a novice surgeon starting from the observation period to the realization of the different operating stages being supervised by a senior surgeon, all under stressful conditions. Topical or locoregional anesthesia limits the communication in the operating room between the novice surgeon and his mentor; thus, increasing the risk of having more operative complications. To reduce the teaching time of cataract surgery, our department has introduced virtual simulator trainings for phacoemulsification. PURPOSE OF THE STUDY: To assess the impact of surgical simulator training on residents' performances. MATERIAL AND METHODS: We conducted a prospective comparative study in our department in partnership with a private ophthalmology clinic where the simulator is installed. Twelve residents were included in this study, six of them were randomly selected to participate in the phacoemulsification surgical simulator training while the others never used the simulator. The training lasted 30 hours in total. No residents had previous training in phacoemulsification. The parameters studied were: the operating time, the achievement of a circular capsulorhexis of 5-6mm in diameter and well centered, the number of capsular breaks with or without an anterior vitrectomy and finally the accumulated dissipated energy (EDC). The cataract surgery was performed on an Alcon Centurion platform. RESULTS: In the operating room, each resident operated 25 cataracts; we compared the two user groups including the simulator and non simulator user and we noticed a statistically significant difference (P<0.05) in terms of average operating time respectively 20 minutes and 37 minutes. Regarding the realization of capsulorhexis; 22 cases of rhexis wandering and 12 poorly centred rhexis on 150 operated cataracts were identified (22.7%) in the group of residents who received no simulator training versus 10 cases in the simulator user group (6.7%). The cumulative dissipated energy (EDC) was significantly lower in the simulator user group (8.1 versus 18.7). The same is true for the rate of posterior capsular rupture, which is higher in the non-user group of simulator 37 cases (24.6%) versus 10 cases (8%) in the second group. DISCUSSION: Ophthalmic surgery has benefited from the introduction of endo-ocular surgical simulation tools through simulators of vitreoretinal surgery and phacoemulsification; whose main role is primarily pedagogical because a simulator allows young residents to acquire dexterity and autonomy over a shortened period of time in addition to minimizing the risk of complications. CONCLUSION: Initial learning of phacoemulsification cataract surgery should be an integral part of the virtual simulator program before moving to the real conditions of the operating room as it allows for better operative performance with a minimal complication rate.

Complications in the first 10 phacoemulsification cataract surgeries with and without prior simulator training / Complicações nas 10 primeiras cirurgias de catarata por facoemulsificação com e sem treinamento prévio em simulador

ABSTRACT Purpose: To evaluate whether training medical residents with the Eyesi® cataract surgery simulator reduces the occurrence of intraoperative complications. Methods: This was a retrospective study in which the first 10 phacoemulsification surgeries performed by two groups of second-year ophthalmology residents were evaluated, during 2014 and 2015. The first Group consisted of seven residents from 2014 who had not had previous training with the simulator. The second Group was formed of seven residents in 2015, who had completed the C-level (intermediate) training with the simulator before beginning surgery on patients. We then compared these two groups regarding the frequency of occurrence of the four main intraoperative surgical complications: posterior capsule rupture, aphakia, and nucleus fragment dislocation into the vitreous, and extracapsular conversion. Results: A total of 140 surgeries were performed, 70 by Group 1 and 70 by Group 2. The total number of complications was 19 (27.14%) in Group 1 and nine (12.86%) in Group 2, and this reduction was significant (p=0.031). Fourteen (20%) surgeries in Group 1 and seven (10%) in Group 2 had complications. The complications were 13 posterior capsule ruptures (18.57%) in Group 1 and seven (10%) in Group 2; three eyes had nucleus fragment dislocations (4.29%) in Group 1, but only one (1.43%) in Group 2; two extracapsular conversions (2.86%) occurred in Group 1 and one (1.43%) in Group 2; and there was one aphakia (1.43%) in Group 1. Conclusions: The training with the Eyesi® cataract surgery simulator significantly reduced the total number of intraoperative complications in the first 10 phacoemulsification cataract surgeries performed by ophthalmology residents.

RESUMO Objetivo: Avaliar se o treinamento de residentes médicos com o simulador de cirurgia de catarata Eyesi® reduz a ocorrência de complicações intraoperatórias. Métodos: Estudo retrospectivo em que foram avaliadas as primeiras 10 cirurgias de facoemulsificação realizadas por dois grupos de residentes de Oftalmologia do segundo ano, no período de 2014 a 2015. O primeiro Grupo foi formado por sete residentes de 2014 que não tiveram treinamento prévio no simulador. O segundo Grupo foi formado por sete residentes de 2015, que completaram o treinamento até o nível C (intermediário) no simulador antes de iniciar a cirurgia em pacientes. Em seguida, comparamos esses dois grupos em relação à frequência de ocorrência das quatro principais complicações cirúrgicas intraoperatórias: ruptura da cápsula posterior, afacia e deslocamento de fragmentos de núcleo para o vítreo e conversão para extracapsular. Resultados: Foram realizadas 140 cirurgias, sendo 70 pelo Grupo 1 e 70 pelo Grupo 2. O número total de complicações foi de 19 (27,14%) no Grupo 1 e nove (12,86%) no Grupo 2, e esta redução foi significativa (p=0,031). Quatorze (20%) cirurgias no Grupo 1 e sete (10%) no Grupo 2 tiveram complicações. As complicações foram 13 rupturas de cápsula posterior (18,57%) no Grupo 1 e sete (10%) no Grupo 2, três olhos com luxação de fragmento de núcleo para o vítreo (4,29%) no Grupo 1 e um (1,43%) no Grupo 2, duas conversões extracapsulares (2,86%) no Grupo 1 e uma (1,43%) no Grupo 2 e uma afacia (1,43%) no Grupo 1. Conclusões: O treinamento com o simulador de cirurgia de catarata Eyesi® reduziu significativamente o número total de complicações intraoperatórias nas primeiras 10 cirurgias de catarata por facoemulsificação realizadas por residentes de oftalmologia.