Simulator-Based Versus Traditional Training of Fundus Biomicroscopy for Medical Students: A Prospective Randomized Trial.

INTRODUCTION: Simulation training is an important component of medical education. In former studies, diagnostic simulation training for direct and indirect funduscopy was already proven to be an effective training method. In this prospective controlled trial, we investigated the effect of simulator-based fundus biomicroscopy training. METHODS: After completing a 1-week ophthalmology clerkship, medical students at Saarland University Medical Center (n = 30) were block-randomized into two groups: The traditional group received supervised training examining the fundus of classmates using a slit lamp; the simulator group was trained using the Slit Lamp Simulator. All participants had to pass an Objective Structured Clinical Examination (OSCE); two masked ophthalmological faculty trainers graded the students' skills when examining patient's fundus using a slit lamp. A subjective assessment form and post-assessment surveys were obtained. Data were described using median (interquartile range [IQR]). RESULTS: Twenty-five students (n = 14 in the simulator group, n = 11 in the traditional group) (n = 11) were eligible for statistical analysis. Interrater reliability was verified as significant for the overall score as well as for all subtasks (≤ 0.002) except subtask 1 (p = 0.12). The overall performance of medical students in the fundus biomicroscopy OSCE was statistically ranked significantly higher in the simulator group (27.0 [5.25]/28.0 [3.0] vs. 20.0 [7.5]/16.0 [10.0]) by both observers with an interrater reliability of IRR < 0.001 and a significance level of p = 0.003 for observer 1 and p < 0.001 for observer 2. For all subtasks, the scores given to students trained using the simulator were consistently higher than those given to students trained traditionally. The students' post-assessment forms confirmed these results. Students could learn the practical backgrounds of fundus biomicroscopy (p = 0.04), the identification (p < 0.001), and localization (p < 0.001) of pathologies significantly better with the simulator. CONCLUSIONS: Traditional supervised methods are well complemented by simulation training. Our data indicate that the simulator helps with first patient contacts and enhances students' capacity to examine the fundus biomicroscopically.

Efficacy of Simulator-Based Slit Lamp Training for Medical Students: A Prospective, Randomized Trial.

INTRODUCTION: Simulation training has an important role in medical education. In ophthalmology, simulation-based training has been shown to be significantly effective for surgical and diagnostic training in direct and indirect ophthalmoscopy. In this study, we analysed the effects of simulator-based slit lamp training. METHODS: In this prospective controlled trial, medical students in their eighth semester at Saarland University Medical Center (n = 24) who had attended a 1-week ophthalmological internship were randomized into two groups: The traditional group (n = 12) was examined directly after the 1-week internship; the simulator group (n = 12) was trained with the slit lamp simulator before passing an objective structured clinical examination (OSCE). A masked ophthalmological faculty trainer assessed the students' slit lamp skills (maximum total score 42 points [pts]): preparation (5 pts), clinical examination (9.5 pts), assessment of findings (9.5 pts), diagnosis (3 pts), commentary on the examination approach (8 pts), measurement of structures (2 pts) and recognition of five diagnoses (5 pts). All students completed post-assessment surveys. Examination grades and survey responses were compared between the groups. RESULTS: The overall performance of the slit lamp OSCE was significantly better (p < 0.001) in the simulator group than in the traditional group (29.75 [7.88] vs. 17.00 [4.75]) with significantly higher scores for the preparation and assessment of slit lamp controls (5.0 [0.0] vs. 3.0 [3.5]; p = 0.008) and localization of relevant structures (6.75 [3.13] vs. 4.0 [1.5]; p = 0.008). Consistently higher scores, but not significant, were assigned for the description of structures found (4.5 [3.38] vs. 3.25 [2.13]; p = 0.09) and the correct diagnosis (3.0 [0.0] vs. 3.0 [0.0]; p = 0.48). Surveys reflected the students' subjectively perceived knowledge gain during the simulator training for slit lamp illumination techniques (p = 0.002), recognition (p < 0.001), and assessment of the correct localization of pathologies (p < 0.001). CONCLUSION: Slit lamp examination is an important diagnostic method in ophthalmology. Simulator-based training improved students' examination techniques for localizing anatomical structures and pathological lesions. The transfer of theoretical knowledge into practice can be achieved in a stress-free atmosphere.

Safety and Efficacy of Hypersonic Vitrectomy for Retinal Reattachment Surgery in Proliferative Vitreoretinopathies.

Introduction: To investigate the safety and efficacy of the Vitesse hypersonic vitrectomy device for retinal reattachment surgery in proliferative vitreoretinopathy (PVR) or proliferative diabetic vitreoretinopathy (PDVR) cases. The Vitesse device utilizes hypersonic technology to liquefy instead of cutting the vitreous, providing an alternative to the traditional pneumatic guillotine cutter. Material and Methods: A prospective, one-armed, non-comparative, open-label study was performed. Sixteen patients with a diagnosis of PVR or PDVR that required retinal reattachment surgery were included. Severity of disease was classified using the Retina Society 1983 classification and Kroll Classification from 2007. Patient data was collected preoperatively, 2 days postoperatively, 1 month postoperatively, and 3 months postoperatively. Efficacy of hypersonic vitrectomy was evaluated, both subjectively using a questionnaire and objectively by means of Supplementary Video documentation, device settings, and data collection of the patients' medical history. Results: In all 16 cases, retinal reattachment surgery could be performed with Vitesse without conversion to a guillotine cutter. The vitreous could be separated from the detached retina completely with no iatrogenic tissue damage. Vitreous traction was documented in one case. In 6 cases, shaving of the vitreous base was performed after early fluid-air exchange with hypersonic vitrectomy without any complications. No adverse events suspected to be related to hypersonic vitrectomy were documented in the follow-up visits. Conclusion: The Vitesse has potential advantages including reduced vacuum volumes with limited amount of turbulence and avoidance vitreoretinal traction. Liquefaction directly in front of the probe entrance allows for continuous unrestricted fluid flow. These factors of hypersonic technology allow to carry out retinal reattachment surgery in PVR or PDVR cases successfully.

Implementation of microsurgery simulation in an ophthalmology clerkship in Germany: a prospective, exploratory study.

BACKGROUND: Microsurgery is a growing field which requires significant precision and skill. Eyesi Surgical, which is usually introduced during residency or fellowship, is an ophthalmologic microsurgery simulator which allows users to practice abstract microsurgical skills and more specialized skills. The purpose of this study was to assess the inclusion of microsurgical simulation training during medical school. METHODS: Seventy-nine German medical students in their 10th semester of education completed up to two days of training on the simulator during their ophthalmology clerkship. They received an objective numeric score based on simulator performance and completed pre and post training subjective questionnaires. RESULTS: There was no relationship found between students' Eyesi Surgical performance scores and their specialty interests (p = .8). The majority of students (73.4%) rated their microsurgical skills to be higher after simulator training than before training (p < 0.001). 92.4% of students found the Eyesi Surgical to be a useful component of the ophthalmology clerkship. Objective scores from Navigation Training Level 1 showed that students achieved better results in the criteria categories of Completing Objects and Tissue Treatment than in the categories of Instrument and Microscope Handling. The mean Total Score was 25.7 (± 17.5) out of a possible 100 points. CONCLUSION: The inclusion of surgical simulation in the ophthalmology clerkship led to increased confidence in the microsurgical skills of medical students. Offering surgical simulation training prior to residency can help to expose students to surgical fields, identify those that have particular talent and aptitude for surgery, and assist them in deciding which specialty to pursue.

Vitreous cytokine levels following the administration of a single 0.19 mg fluocinolone acetonide (ILUVIEN®) implant in patients with refractory diabetic macular edema (DME)-results from the ILUVIT study.

PURPOSE: To investigate the changes in vitreous inflammatory and angiogenic cytokine levels, primarily interleukin-(IL)-6, following intravitreal injection of the 0.19 mg fluocinolone acetonide (FAc, ILUVIEN®) implant in patients with diabetic macular edema. METHODS: A single-center phase IV study involving 12 patients' eyes with diabetic macular edema. Vitreous fluid samples were obtained prior to intravitreal injection of the fluocinolone acetonide implant and then again over a 6-month period. Vitreous samples were examined using a cytometric bead array to measure IL-6, IL-8, IP-10, MCP-1, VEGF, and CD54. PIGF and PEDF were measured using an enzyme-linked immunosorbent assay. Changes in the cytokine and chemokine expression patterns were analyzed. Clinical parameters such as BCVA and center point thickness (CPT) were also examined. RESULTS: There were mean reductions in all parameters between baseline and month 6. Significant changes (p < 0.05 versus baseline) were observed in the expression of IL-6, IP-10, MCP-1, and CD54 following the administration of fluocinolone acetonide implant. VEGF and PIGF increased at month 1 before declining at month 6, though this trend was not significant. CPT decreased rapidly between screening and the first follow-up visit, and this decrease was sustained. BCVA remained relatively stable throughout. CONCLUSION: This study demonstrated changes in vitreous inflammatory and angiogenic cytokine levels following intravitreal injection of the FAc implant in patients with diabetic macular edema. Data show that the fluocinolone acetonide implant led to rapid and sustained reductions of some inflammatory cytokines with improvement of the overall clinical picture.

[Combination of simulation-based and online learning in ophthalmology : Efficiency of simulation in combination with independent online learning within the framework of EyesiNet in student education]. / Kombination von simulationsbasiertem Lernen und Online-Learning in der Augenheilkunde : Effizienz von Simulation in Kombination mit eigenständigem Online-Learning im Rahmen von EyesiNet in der studentischen Ausbildung.

BACKGROUND: Ophthalmoscopy is part of the medical curriculum but the teaching of medical contents is often unsatisfactory. No systematic learning of pathologies and their treatment options is possible because appropriate patient populations are often unavailable; instead of that healthy students examine each other. For this reason, we have developed a project to improve teaching at the medical faculty of the JWG University in Frankfurt/Main, which offers the opportunity for training in ophthalmoscopy using a newly developed online platform (EyesiNet) in addition to simulator training. Defined learning contents are reproducible and made equally available to everyone. AIM: The aim of this study was to evaluate a format for improving the teaching of direct and indirect ophthalmoscopy for students. Practical exercises on virtual reality-based simulators were intertwined with newly developed theoretical content adapted to the teaching catalog in the online platform EyesiNet. MATERIAL AND METHODS: On the first and last days of the internship, the students worked on cases in Eyesi Direct and Eyesi Indirect. In the meantime, they were able to deal with the theoretical basics of these ophthalmological clinical pictures in the web-based EyesiNet on a voluntary basis. RESULTS: Eyesi Direct: with p = 0.29, both groups had the same state of knowledge and did not have significantly different results in case processing on the first day of the internship. In the group without training (n = 54), a significant improvement in simulator training was observed on the last day of the practical training with p = 0.02 but with a small effect size of 0.1. Among the trainees (n = 32) a highly significant improvement with an effect size of 0.3 was observed with p = 0.0004. Eyesi Indirect: both groups had no significant difference in the stage of knowledge in the Eyesi Indirect at the beginning of the training period (p = 0.10). After training both groups performed slightly better but without significance (without training p = 0.41/with training p = 0.17). CONCLUSION: The online platform EyesiNet supports the learning of the most important disease patterns. Learning contents are made available in a reproducible and standardized way for all students. The skills of direct ophthalmoscopy can be learned much faster than those of indirect ophthalmoscopy.

Vitreous expression of cytokines and growth factors in patients with diabetic retinopathy-An investigation of their expression based on clinical diabetic retinopathy grade.

Diabetic retinopathy (DR) is an inflammatory condition that affects the posterior of the eye; yet, there are limited published data on techniques measuring the expression of growth and inflammatory factors (GIF) from the posterior segment. The purpose of the current study was two-fold: to sample the vitreous fluid from the eyes of patients with DR and assess the expression of GIF. As DR is an inflammatory disease, the second objective of this study was to determine the relationship between the status of DR and the expression of vitreous GIF. This non-randomized clinical trial was approved by BfARM for the analysis and evaluation of 12 eyes from patients with diabetic macular edema. Vitreous sampling was performed before treatment with fluocinolone acetonide and the extracted vitreous material was examined for the determination of GIF including interleukins 6 (IL-6) and 8 (IL-8), interferon gamma-inducible protein (IP-10), monocyte chemoattractant protein-1 (MCP-1), placental growth factor (PIGF), pigment epithelium-derived factor (PEDF), VEGF (vascular endothelial growth factor) and intercellular adhesion molecule (CD54). These were linearly compared with the grade of inflammation in the vitreous assessed via DR score and ART. Additionally, all eyes were grouped based on their diabetic retinopathy status. All cytokine levels, except MCP-1 and PEDF, were numerically higher in DME patients with proliferative DR than those with non-proliferative DR. DR grade was found to linearly correlate with the expression of CD54 (p = 0.02, rho = 0.64), IL-8 (p = 0.03, rho = 0.64) and PIGF (p = 0.007, rho = 0.76). A correlation was found between ART and CD54 (p = 0.02, rho = 0.66) and also between ART and IL-8 (p = 0.04, rho = 0.60). A trend was found between ART and PIGF (p = 0.08, rho 0.52). For IL-6, there appeared to be a trend with DR grade (p = 0.14, rho = 0.45) and ART (p = 0.09, rho = 0.51). Proliferative DR was shown to be associated with a significant higher expression of CD54, IL-8 and PIGF, thus suggesting that they are potentially important in defining and monitoring the effectiveness of a patients' therapy. Vitreous probes may be helpful in deciding which therapy to administer (i.e. anti-VEGF or corticosteroid or both) based on the expression of GIF. Registry EudraCT number: 2016-004488-38; DRKS-ID: DRKS00014915.

[Pars plana vitrectomy-from suction cutting systems to ultrasound technology : Vitesse-a new form of vitrectomy based on ultrasound technology]. / Pars-plana-Vitrektomie ­ von Saug-Schneide-Systemen bis hin zur Ultraschalltechnik : Vitesse ­ eine neuartige Form der Vitrektomie mittels einer Ultraschalltechnik.

In the 1970s a cutting device into which an infusion and an aspiration channels were integrated, the so-called vitreous infusion suction cutter (V.I.S.C), was used for the first time for the removal of the vitreous body. These cutting systems have continued to constantly evolve since then; however, sonic energy remained reserved for anterior segment surgery for a long time. In 2020, this form of energy could also be used for the posterior segment in form of Vitesse™. In this liquification technique, ultrasonic energy is transferred to a single, large inner lumen design that mechanically vibrates the needle's port. These high-speed vibrations shear the vitreous body at the port edges before it enters the needle. This mechanism reduces traction to a minimal level and enables faster aspiration at lower vacuum levels compared to conventional cutters. These advantages can promote a safer and more efficient vitreoretinal surgery.

Pressure dependent direct transtissue transmission of eyewall, sclera and vitreous body in the range of 350-1050nm.

PURPOSE: For transscleral application of optical radiation or light to the eye, it is important to know the transmission and absorbance of the tissue layers of the eyewall. The impact of photochemical energy to the retina located directly at the point of contact with the radiation emitter must be considered as well as the absorbance in choroid and retina. Therefore, the direct transmission of ex vivo porcine eyewalls and vitreous body were measured in this study. METHODS: At ex vivo porcine eyes (N=221) pressure dependent transmission measurements were performed with a pressure inducing setup. Pressure and wavelength dependent direct transmission of eyewall and vitreous body of porcine eyes were described for different applied pressures (23mmHg, 78mmHg and 132mmHg). The transmissions were investigated within the spectral range of 350-1050nm. In addition to the complete eyewall transmission measurements, the transmission of sclera, vitreous body and water was measured individually and the transmission of retina and choroid was calculated. RESULTS: With increasing wavelength and pressure, a significant transmission increase of the eyewall could be achieved (p<0.05). At 400nm and 132mmHg the transmission raised to 0.10%. At 1050nm it increased up to a value of 12.22%. In the visible spectrum, the direct transmission was always below 3.17%. The differences in eyewall transmission of eyes with different iris colors were significant at low pressure. With increasing pressure, the effect strength decreased and the differences lost their significance. CONCLUSIONS: The pressure and wavelength dependent direct transmission of the eyewall and the vitreous body significantly increased with increasing pressure. This results are benefical for technical and clinical safety, research and development of illumination devices. It is necessary to know the intraocular brightness in the eye during diaphanoscopy, photocoagulation application to determine hazards.

Unusual Primary Ocular Manifestation of Sarcoidosis.

A 23-year-old male patient presented with very mild visual disturbances, but a distinct prominence of the optic discs, more pronounced in the right than in the left eye. The ophthalmic symptoms initially seemed trivial, but a large-scale interdisciplinary workup later identified them as the presenting symptoms of sarcoidosis affecting lung and eyes. A standard steroid monotherapy successfully caused regression of the ophthalmic findings.

Key Factors to Improve the Outcome of Retinal Reattachment Surgery in Proliferative Vitreoretinopathy and Proliferative Diabetic Retinopathy.

INTRODUCTION: For management of complicated retinal detachments, a pars plana vitrectomy with temporary silicone oil (SO) fill is the method of choice. According to literature, the retinal redetachment rate varies between <10% and >70% with around 36% in our own group (retrospective data analysis, n = 119 eyes). METHODS: The main goal was to reduce the retinal redetachment rate. Standard operating procedures (SOPs) and evaluation protocols (EVALPs) were developed to prospectively analyse risk factors. Lab analysis of SO was performed, and the role of surgical experience was evaluated and investigated with Eyesi®. RESULTS: We achieved a significant reduction of the retinal redetachment rate (to 6.80%, n = 101, p = 0.002). After surgery with SO injection, neither further membrane peeling (in 16.5%) nor retinal laser coagulation (in 100%) during revision surgery had a significant effect on the reattachment rate (p = 0.167, p = 0.23), while extensive additional laser coagulation reduced visual acuity (p = 0.01). A 3-port approach had to be set up to complete SO removal. A difference in success rate depending on surgical experience was confirmed, and the performance in Eyesi correlated with that in the patients' eye. CONCLUSIONS: A SOP- and EVALP-based management and new strategies to secure the surgical performance seem to be essential for successful surgery.

Dealings between Cataract and Retinal Reattachment Surgery in PVR.

Introduction. To evaluate the impact of the eye lens status and oil side effects on the outcome of vitreoretinal surgery in retinal detachment with proliferative vitreoretinopathy (PVR) and a temporary silicone oil tamponade (SOT). Methods. 101 eyes were analyzed retrospectively and 103 eyes prospectively in regard to their retinal reattachment success rate and key factors for the outcome. Subgroup analysis of 27 eyes with Scheimpflug lens photography (SLP) before and after retinal reattachment service with SOT was performed. For SLP (65% phakic eyes) a Pentacam densitometry reference body with 3 mm diameter was chosen and 3 segments (anterior/mid/posterior) were evaluated separately after a quality check. Results. The retinal reattachment rate was highest in the prospective pseudophakic group (p = 0.039). Lens transparency loss occurred earlier in middle aged patients than in younger patients. Besides the nucleus, layers posterior and anterior to it showed specific transparency changes. The emulsification rate was higher when eyes had been operated on in the anterior chamber before retinal reattachment service. Conclusions. Retinal reattachment surgery seems to benefit from preoperative cataract removal. We found significant lens changes in the nucleus as well as in the layers anterior and posterior to it. This corresponds to the histology of the lens epithelium published before.

Clinical Efficacy of Simulated Vitreoretinal Surgery to Prepare Surgeons for the Upcoming Intervention in the Operating Room.

PURPOSE: To evaluate the efficacy of the virtual reality training simulator Eyesi to prepare surgeons for performing pars plana vitrectomies and its potential to predict the surgeons' performance. METHODS: In a preparation phase, four participating vitreoretinal surgeons performed repeated simulator training with predefined tasks. If a surgeon was assigned to perform a vitrectomy for the management of complex retinal detachment after a surgical break of at least 60 hours it was randomly decided whether a warmup training on the simulator was required (n = 9) or not (n = 12). Performance at the simulator was measured using the built-in scoring metrics. The surgical performance was determined by two blinded observers who analyzed the video-recorded interventions. One of them repeated the analysis to check for intra-observer consistency. The surgical performance of the interventions with and without simulator training was compared. In addition, for the surgeries with simulator training, the simulator performance was compared to the performance in the operating room. RESULTS: Comparing each surgeon's performance with and without warmup trainingshowed a significant effect of warmup training onto the final outcome in the operating room. For the surgeries that were preceeded by the warmup procedure, the performance at the simulator was compared with the operating room performance. We found that there is a significant relation. The governing factor of low scores in the simulator were iatrogenic retinal holes, bleedings and lens damage. Surgeons who caused minor damage in the simulation also performed well in the operating room. CONCLUSIONS: Despite the large variation of conditions, the effect of a warmup training as well as a relation between the performance at the simulator and in the operating room was found with statistical significance. Simulator training is able to serve as a warmup to increase the average performance.

An extraocular non-invasive transscleral LED-endoilluminator for eye speculum integration.

PURPOSE: Conventional chandelier-endoilluminators used for pars-plana vitrectomy consist of a light-emitting tip attached to an optical fibre. The tip requires introduction into the ocular space through an incision. To achieve complete illumination of the intraocular space, the introduction of more than just one tip is sometimes necessary. An extraocular vitreoretinal LED-endoilluminator discussed in this paper represents a new approach to illuminate the intraocular space. The light source is integrated into a speculum and firmly apposed to the sclera. This approach offers the advantage of effectively illuminating the interior of the eye even though the procedure is non-invasive. Furthermore, this approach significantly reduces the risk of damage to the retina by phototoxic effects. METHODS: A round white LED was used as a light source. By integrating the light source into a speculum, the LED was firmly held against the sclera. Thus, the ocular space was illuminated transsclerally. As a result, indirect uniform illumination of the complete intraocular space was achieved. The prototype was developed considering the relevant international standards. Porcine eyes were used because their properties are similar to those of human eyes. RESULTS: Porcine eyes could be acceptably illuminated with the selected LED. The LED-endoilluminator conforms with international standards for endoillumination. Thus, possible photochemical and thermal risks are considered and reduced to a minimum. CONCLUSIONS: A novel LED-endoilluminator which can be attached to a speculum was developed. The system does not need any connection to an external light source and, consequently, also avoids usage of an optical fibre. Regular and uniform illumination of the intraocular space was achieved by transmitted and scattered visible irradiation, avoiding an incision. The duration of potential light exposure, compared to existing illumination systems, can be significantly increased. This is also true when the illuminator is not directly placed over the pars-plana and the distance to the retina is reduced. Only a part of the light reaches the retina and the fraction of short wavelength becomes very small. Increased safety of the system results from now being able to increase the exposure time and reduce phototoxic stress to the retina.