A novel "video-game" simulator for training fetoscopic laser coagulation of anastomoses in twin-to-twin transfusion syndrome.

 : We have developed a high-fidelity interactive "video-game" simulator in order to teach fetoscopic laser ablation of placental anastomoses for twin-twin transfusion syndrome This simulator may be used by teachers in order to provide metrics-based simulator education to multiple trainees, in both hands-on and distanced learning settings WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: The use of simulation improves training of the fetoscopic laser techniques utilized in the treatment of twin-twin transfusion syndrome A number of mannequins have been developed to aid this education WHAT DOES THIS STUDY ADD?: Two new simulators are described for twin-twin transfusion syndrome training-silicone and digital The digital simulator is a novel digital video game virtual format This new format has enhanced interactivity and has the potential to enable distance learning.

Comparison of Mannequin Training Satisfaction with a Conventional Box Trainer and a Low-Fidelity Fetoscopic Surgical Simulator for Selective Fetoscopic Laser Photocoagulation.

BACKGROUND: A low-fidelity fetoscopic surgical simulator (FSS) for training of selective fetoscopic laser photocoagulation (SFLP) was developed. OBJECTIVE: To evaluate and compare training satisfaction with an FSS and with a conventional box trainer (BT). METHODS: The BT consisted of a cleaned human placenta attached to the inside of a plastic storage box with a watertight lock cover and an ultrasound-transparent rubber skin. The FSS consisted of the replica of a monochorionic twin placenta attached to the inside of a spherically shaped, ultrasound-transparent phantom. Tap water was used as an ultrasound conduction agent. Evaluation of the mannequin trainings was conducted on 8 junior maternal-fetal medicine (MFM) attending physicians and 22 MFM fellows. Training satisfaction was scored from 0 to 10 on 8 different domains. RESULTS: The mean satisfaction score (±SD) with the FSS was higher than with the BT in all domains (p < 0.05). The fellows' training satisfaction with the BT was greater than that of the attending physicians in 4 domains: tactile feedback, demonstration of chorionic vessels, feedback on performance, and overall value as learning aid (p < 0.05). CONCLUSIONS: As evaluated by a small group of trainees, our FSS is superior to the BT in mannequin training of SFLP. However, the BT may be more useful for trainees with limited clinical experience.

The Ophthalmology Surgical Competency Assessment Rubric for Panretinal Photocoagulation.

PURPOSE: To develop an internationally valid skill-based rubric that can be used as a global standardized platform for teaching, training, and evaluation of panretinal photocoagulation (PRP) in training programs. DESIGN: A panel of educators and experts in retinal lasers was assembled to develop a standardized objective skill-based rubric. PARTICIPANTS: Sixteen international educators and retina specialists. METHODS: The steps to performing slit-lamp delivery of PRP was described in detail. A group of 6 authors reviewed and agreed on the steps and assigned descriptors to expectation levels of novice, beginner, advanced beginner, and expert according to a modified Dreyfuss model. The tool then was vetted by an international panel of 10 retina specialists who are involved in training ophthalmologists in other countries. MAIN OUTCOME MEASURES: Final version of the tool agreed on by the international review panel. RESULTS: The consecutive steps to performing PRP were outlined and broken down into preparation, procedure, and postoperative care. Descriptive words explaining what to expect from a novice, beginner, advanced beginner, and expert were listed for each step of PRP. Expert comments were incorporated, establishing face and content validity. CONCLUSIONS: This group of authors clearly defined expectations of a trainee at 4 levels of training according to the modified Dreyfus model, and an international panel of retina specialists agreed to its accuracy. This tool, the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric for Panretinal Photocoagulation, has face and content validity. It can be used globally in training programs both to teach and assess this important comprehensive skill in ophthalmic training.

Fetoscopic laser coagulation in 1020 pregnancies with twin-twin transfusion syndrome demonstrates improvement in double-twin survival rate.

OBJECTIVE: To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid-trimester twin-twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single-center setting. METHODS: Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates. RESULTS: The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double-twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double-twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands-on and performed 174 of the last 400 procedures. CONCLUSIONS: We report the largest single-center experience of laser coagulation in TTTS. We observed a continuous increase in double-twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high-volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Operator competence in fetoscopic laser surgery for twin-twin transfusion syndrome: validation of a procedure-specific evaluation tool.

OBJECTIVES: Fetoscopic laser surgery for twin-twin transfusion syndrome is a procedure for which no objective tools exist to assess technical skills. To ensure that future fetal surgeons reach competence prior to performing the procedure unsupervised, we developed a performance assessment tool. The aim of this study was to validate this assessment tool for reliability and construct validity. METHODS: We made use of a procedure-specific evaluation instrument containing all essential steps of the fetoscopic laser procedure, which was previously created using Delphi methodology. Eleven experts and 13 novices from three fetal medicine centers performed the procedure on the same simulator. Two independent observers assessed each surgery using the instrument (maximum score: 52). Interobserver reliability was assessed using Spearman correlation. We compared the performance of novices and experts to assess construct validity. RESULTS: The interobserver reliability was high (Rs = 0.974, P < 0.001). Checklist scores for experts and novices were significantly different; the median score for novices was 28/52 (54%), whereas that for experts was 47.5/52 (91%) (P < 0.001). The procedure time and fetoscopy time were significantly shorter (P < 0.001) for experts. Residual anastomoses were found in 1/11 (9%) procedures performed by experts and in 9/13 (69%) procedures performed by novices (P = 0.005). Multivariable analysis showed that the checklist score, independent of age and gender, predicted competence. CONCLUSIONS: The procedure-specific assessment tool for fetoscopic laser surgery shows good interobserver reliability and discriminates experts from novices. This instrument may therefore be a useful tool in the training curriculum for fetal surgeons. Further intervention studies with reassessment before and after training may increase the construct validity of the tool. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Simulator training in fetoscopic laser surgery for twin-twin transfusion syndrome: a pilot randomized controlled trial.

OBJECTIVE: To evaluate the effect of a newly developed training curriculum on the performance of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) using an advanced high-fidelity simulator model. METHODS: Ten novices were randomized to receive verbal instructions and either skills training using the simulator (study group; n = 5) or no training (control group; n = 5). Both groups were evaluated with a pre-training and post-training test on the simulator. Performance was assessed by two independent observers and comprised a 52-item checklist for surgical performance (SP) score, measurement of procedure time and number of anastomoses missed. Eleven experts set the benchmark level of performance. Face validity and educational value of the simulator were assessed using a questionnaire. RESULTS: Both groups showed an improvement in SP score at the post-training test compared with the pre-training test. The simulator-trained group significantly outperformed the control group, with a median SP score of 28 (54%) in the pre-test and 46 (88%) in the post-test vs 25 (48%) and 36 (69%), respectively (P = 0.008). Procedure time decreased by 11 min (from 44 to 33 min) in the study group vs 1 min (from 39 to 38 min) in the control group (P = 0.69). There was no significant difference in the number of missed anastomoses at the post-training test between the two groups (1 vs 0). Subsequent feedback provided by the participants indicated that training on the simulator was perceived as a useful educational activity. CONCLUSIONS: Proficiency-based simulator training improves performance, indicated by SP score, for fetoscopic laser therapy. Despite the small sample size of this study, practice on a simulator is recommended before trainees carry out laser therapy for TTTS in pregnant women.

Simulation of laser retinopexy around retinal breaks for ophthalmologists in training.

PURPOSE: To describe a new method for training residents in ophthalmology in performing laser retinopexy around retinal breaks, and its practicality. METHODS: The simulator consists of a model eye that can be adjusted to fit any laser instrument, with a retinal break created in it. The retinal breaks are made of paper strips and can simulate tears and holes. The simulator is used with a three-mirror lens and real laser instrument. RESULTS: The simulator creates conditions simulating near-real laser retinopexy and has been used successfully in training 3 novice residents who have never performed this procedure before. CONCLUSIONS: This simulator is simple, reusable and inexpensive. We believe it may be a valuable instructional tool in training residents in performing laser retinopexy, shorten their learning curve and improve their efficiency it in.

Learning curve for fetoscopic laser surgery using cumulative sum analysis.

OBJECTIVE: To identify a learning curve and monitor operator performance for fetoscopic laser surgery for twin-to-twin transfusion syndrome using cumulative sum analysis. DESIGN: Retrospective cohort study. SETTING: National tertiary referral center for invasive fetal therapy. POPULATION: A total of 340 consecutive monochorionic pregnancies with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation between August 2000 and December 2010. METHODS: A learning curve was generated using learning curve cumulative sum analysis and cumulative sum methodology to assess changes in double survival across the case sequence. Laser surgery was initially performed by two operators, joined by a third and fourth operator after 1 and 2 years, respectively. MAIN OUTCOME MEASURES: Individual operator performance, double perinatal survival at 4 weeks. RESULTS: Overall survival of both twins occurred in 59% (201/340), median gestational age at birth was 32.0 weeks. Cumulative sum graphs showed that level of competence for double survival for the operators was reached after 26, 25, 26, and 35 procedures, respectively. Two operators kept their competence level and continued to improve after completing the initial learning process; two others went out of control at one point in time, according to the cumulative sum boundaries. A difference in learning effect was associated with number of procedures performed annually and previous experience with other ultrasound-guided invasive procedures. CONCLUSIONS: This study shows that all operators reached a level of competence after at least 25 fetoscopic laser procedures and confirms the value of using the cumulative sum method both for learning curve assessment and for ongoing quality control.

The use of digital imaging in the identification of skip areas after laser treatment for retinopathy of prematurity and its implications for education and patient care.

PURPOSE: To describe the utility of using wide-angle digital imaging in the training for retinopathy of prematurity with laser and in identifying common locations of skip areas that were present after initial panretinal photocoagulation with indirect ophthalmoscopy by ophthalmologists-in-training. METHODS: Retrospective review of digital retinal images of 22 eyes of 12 infants who had undergone laser treatment for retinopathy of prematurity performed by ophthalmologists-in-training. Presence of skip areas was determined by masked review of photographs. The location of skip areas was classified based on two axes: 1) circumferential (in one of six clock-hour regions) and 2) radial (adjacent to the retinal ridge, adjacent to the ora serrata, or isolated patches of greater than one laser burn width). RESULTS: A total of 30 skip areas were identified in the 22 eyes treated with laser photocoagulation. Based on the circumferential location, a significant difference in skip area distribution was found (P = 0.02). Regions with the highest percentage of skip areas were between the clock hours 11:00 to 1:00 (45%) and 5:00 to 7:00 (41%). Based on the radial location, 40% of all skip areas were found near the ora serrata, 17% near the ridge, and 43% as isolated patches (P = 0.14). CONCLUSION: Skip areas after indirect panretinal laser photocoagulation by ophthalmologists-in-training were easily visualized by wide-angle digital imaging, after being missed by the trainee during the initial treatment procedure. Most skip areas in this study occurred in the superior or inferior retina. Digital imaging can assist ophthalmologists in visualizing all regions of the retina, can identify inadequate areas of laser treatment, and may reduce the need for retreatment after initial laser for retinopathy of prematurity.

Pediatric ophthalmology fellowship training in laser ablation for retinopathy of prematurity.

PURPOSE: To assess the training received by pediatric ophthalmology fellows in retinopathy of prematurity (ROP) laser ablation surgery. METHODS: We surveyed recent graduates of 1-year pediatric ophthalmology fellowships to quantify the ROP laser training they received during their fellowship, the effect of fellowship training on their desire to treat ROP in practice, and interest in additional training modalities. Electronic questionnaires were distributed to all candidates-in-training of the American Association for Pediatric Ophthalmology and Strabismus. RESULTS: The response rate was 64%, and 54 respondents met inclusion criteria. The mean number of ROP laser procedures performed during fellowship was 6.4; the median, 4. Eight respondents (15%) reported having performed no ROP laser procedures during their fellowship. Of the 54, 29 (54%) felt that they were at least adequately trained to perform ROP laser surgery and reported a mean of 10 (± 6.6) cases performed during fellowship. Respondents reporting that fellowship training was less than adequate performed a mean of 1.7 (± 1.5) cases (P < 0.01). A Pearson correlation coefficient of 0.8 revealed a moderately strong correlation between the amount of ROP laser training during fellowship and desire to perform ROP treatment in practice after fellowship. Twenty-six (48%) were very or somewhat interested in further ROP laser training. CONCLUSIONS: The amount of laser experience during fellowship strongly influences the confidence in ROP laser skills of recently graduated pediatric ophthalmologists and the desire to perform laser procedures in their clinical practice. One-half of recently graduated pediatric ophthalmologists believe that their ROP laser training during fellowship was adequate for clinical practice.

Resident surgical practice patterns for vitreoretinal surgery in ophthalmic training programs in the United States.

PURPOSE: To assess resident surgical experience in vitreoretinal surgery (VRS) in the United States. DESIGN: Anonymous electronic survey over 2 consecutive years. PARTICIPANTS: A total of 287 third-year ophthalmology residents from US residency programs were included. METHODS: To determine the type and amount of surgical experience in VRS. Residents were contacted via e-mail to complete the survey. A series of follow-up e-mails were sent to nonresponders. E-mail correspondence was sent to program directors of the US residency programs to encourage survey participation. An electronic survey instrument (Survey Monkey) was used to distribute the survey and collect the results. Participants were asked about vitrectomy and scleral buckle procedures as primary surgeon and about office procedures (e.g., intravitreal injections and retinal laser procedures). Questions regarding the self-described "comfort" level of the resident and the Accreditation Council for Graduate Medical Education (ACGME) vitreoretinal requirements for ophthalmology were also included. MAIN OUTCOME MEASURES: Vitreoretinal office and surgical procedures. RESULTS: Of the 114 ophthalmology residency programs in the United States, 3 programs declined to participate and 103 of 228 programs (114 programs per year) did not respond to requests during a 2-year period. Of the 287 total respondents, approximately 59.1% had performed vitrectomy and 40.8% had performed a scleral buckle as the primary surgeon. In the survey of office procedures, 96.7% had performed intravitreal injections, 94.8% had performed macular laser therapy, and 99.6% had performed panretinal photocoagulation. In the self-reported resident "comfort" level section, 59% were "fairly comfortable" knowing the theoretic steps for VRS and 55.4% were "fairly satisfied" with VRS training. However, 72% of respondents were unaware of the correct ACGME minimum operative numbers for VRS. CONCLUSIONS: This self-reported electronic survey of third-year residents suggested that VRS experience at ACGME-accredited programs as primary surgeon was suboptimal for surgeries. A modest majority of residents reported comfort and satisfaction with VRS training for surgery, but a majority was satisfied and had adequate experience with office procedures such as intravitreal injection and laser treatment. Unfortunately, the majority of residents were unaware of the actual numeric ACGME VRS requirements for ophthalmology residency programs.