Feasibility and Potential for Real-Time 3D Vitreoretinal Surgery Telementoring.

PURPOSE: To demonstrate the potential for real-time, three-dimensional (3D) surgical telementoring to enhance vitreoretinal surgical education. METHODS: The 3D video feed from a high dynamic range surgical camera (NGENUITY) was run through a 4K video capture device (Magewell USB 4K) and set as the video input for a video conferencing application (Zoom). Remote surgical viewing was then performed in two-dimensions (2D) on a computer or in 3D with a virtual reality headset (Oculus Quest 2). RESULTS: Ten surgical cases were successfully live streamed in real time to two separate surgeons in the United States. Specific details of the case were visualized with low latency and interaction with the operating surgeon was possible without affecting the surgical display quality. Excluding the NGENUITY system and personal computers, ancillary equipment costs (video capture card and virtual reality headset) were kept to below $1,000. CONCLUSION: Our study demonstrates that 3D surgical video streaming can be achieved in real time with minimal latency through the use of low-cost video capture equipment and video conferencing/streaming software. The use of this technology gives educators the ability to mentor trainees without the traditional geographic and physical constraints of in-person surgical viewing.

RetiSurge - Enabling "Dry Lab" vitreoretinal surgical training during COVID-19 pandemic.

The COVID-19 pandemic has resulted in reduction of patient volumes in Ophthalmology. With only emergency surgical procedures being performed with few elective surgical procedures, surgical volumes are at an all-time low. This has resulted in decreased surgical training opportunities for trainee surgeons. We developed a simple, cost-effective, 3D printed model eye - RetiSurge - for "Dry Lab" vitreoretinal surgery training. The model incorporates a retinal film that can be changed, making it suitable for multiple uses. The RetiSurge model can be used to practice visualization, instrument manipulation and endolaser photocoagulation. RetiSurge can be sterilized by ethylene oxide and is safe for use inside the operating room. RetiSurge is a simple, cost-effective, and reusable model eye for early training in Vitreoretinal surgery.

The learning curve of robot-assisted vitreoretinal surgery - A randomized trial in a simulated setting.

PURPOSE: To investigate the learning curve of robot-assisted vitreoretinal surgery compared to manual surgery in a simulated setting. METHODS: The study was designed as a randomized controlled longitudinal study. Eight ophthalmic trainees in the 1st or 2nd year of their specialization were included. The participants were randomized to either manual or robot-assisted surgery. Participants completed repetitions of a test consisting of three vitreoretinal modules on the Eyesi virtual reality simulator. The primary outcome measure was time to learning curve plateau (minutes) for total test score. The secondary outcome measures were instrument movement (mm), tissue treatment (mm2 ) and time with instruments inserted (seconds). RESULTS: There was no significant difference in time to learning curve plateau for robot-assisted vitreoretinal surgery compared to manual. Robot-assisted vitreoretinal surgery was associated with less instrument movements (i.e. improved precision), -0.91 standard deviation (SD) units (p < 0.001). Furthermore, robot-assisted vitreoretinal surgery was associated with less tissue damage when compared to manual surgery, -0.94 SD units (p = 0.002). Lastly, robot-assisted vitreoretinal surgery was slower than manual surgery, 0.93 SD units (p < 0.001). CONCLUSIONS: There was no significant difference between the lengths of the learning curves for robot-assisted vitreoretinal surgery compared to manual surgery. Robot-assisted vitreoretinal surgery was more precise, associated with less tissue damage, and slower.

EyeSi Surgical Simulator: validation of a proficiency-based test for assessment of vitreoretinal surgical skills.

PURPOSE: To develop and investigate an evidence-based performance test for assessment of vitreoretinal surgical skills on the EyeSi Surgical Simulator. METHODS: Ten junior residents without any surgical experience, eight senior residents with prior experience in cataract surgery and five vitreoretinal surgeons were included in the study. The test consisted of seven modules and was completed twice by all groups during a single session. Validity evidence was evaluated using Messick's validity framework. Senior residents completed four additional test sessions and were retested 3 months after to assess skill acquisition and retention. RESULTS: Content was aligned with vitreoretinal surgical skills as evaluated by expert surgeons. Response process was ensured through standardized instruction and data collection. The test showed satisfactory internal consistency with Cronbach's α = 0.76 (internal structure) and significant discriminative ability between the residents and the experienced surgeons (relation to other variables). A pass/fail level was determined at 596 using the contrasting groups' method. Consequences of applying this standard resulted in no false positive and no false negative. Senior residents significantly improved their simulator skills over time, reaching a plateau at the fifth iteration and equalling expert performance (p = 0.420). This level of competency was retained during the post-3-month retention testing (p = 0.062). CONCLUSION: We established a performance test with solid evidence for assessment of vitreoretinal surgical skills on the EyeSi Simulator and determined a benchmark criterion that may be used for future implementation of proficiency-based training for novices.

Perceptions of Occupational Risk and Changes in Clinical Practice of United States Vitreoretinal Surgery Fellows during the COVID-19 Pandemic.

PURPOSE: To assess perceptions of occupational risk and changes to clinical practice of ophthalmology trainees in the United States during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: An anonymous, nonvalidated, cross-sectional survey was conducted online. Data were collected from April 7 through 16, 2020. PARTICIPANTS: Second-year U.S. vitreoretinal surgery fellows in two-year training programs were invited to participate. METHODS: Online survey. MAIN OUTCOME MEASURES: Survey questions assessed policies guiding COVID-19 response, exposure to severe acute respiratory syndrome coronavirus 2, changes in clinical duties, and methods to reduce occupational risk, including availability of personal protective equipment (PPE). RESULTS: Completed responses were obtained from 62 of 87 eligible recipients (71.2% response rate). Training settings included academic (58.1%), hybrid academic/private practice (35.5%), and private practice only settings (6.5%). Overall, 19.4% of respondents reported an exposure to a COVID-19-positive patient, 14.5% reported self-quarantining due to possible exposure, and 11.3% reported being tested for COVID-19. In regards to PPE, N95 masks were available in the emergency room (n = 40 [64.5%]), office (n = 35 [56.5%]), and operating room (n = 35 [56.5%]) settings. Perceived comfort level with PPE recommendations was significantly associated with availability of an N95 respirator mask in the clinic (P < 0.001), emergency room (P < 0.001), or operating room (P = 0.002) settings. Additional risk mitigation methods outside of PPE were: reduction in patient volume (n = 62 [100%]), limiting patient companions (n = 59 [95.2%]), use of a screening process (n = 59 [95.2%]), use of a slit-lamp face shield (n = 57 [91.9%]), temperature screening of all persons entering clinical space (n = 34 [54.84%]), and placement of face mask on patients (n = 33 [53.2%]). Overall, 16.1% reported additional clinical duties within the scope of ophthalmology, and 3.2% reported being re-deployed to nonophthalmology services. 98.4% of respondents, 98.4% expected a reduction in surgical case volume. No respondents reported loss of employment or reduction in pay or benefits due to COVID-19. CONCLUSIONS: Suspected or confirmed clinical exposure to COVID-19-positive patients occurred in approximately one fifth of trainee respondents. Perceived comfort level with PPE standards was significantly associated with N95 respirator mask availability. As surgical training programs grapple with the COVID-19 pandemic, analysis of trainees' concerns may inform development of mitigation strategies.

Virtual vitreoretinal surgery: effect of distracting factors on surgical performance in medical students.

PURPOSE: We aimed to investigate the effect of four distracting factors on surgical performance in virtual vitreoretinal surgery. METHODS: Nineteen novice surgeons completed a validated training programme on the Eyesi surgical simulator (VRmagic GmbH, Manheim, Germany; software version 2.9.2) until a calculated target score was reached. The training programme consisted of four modules: navigation level 2 (Nav2), bimanual training level 3 (BimT3), posterior hyaloid level 3 (PostH3) and internal limiting membrane peeling level 3 (ILMP3). When properly trained, the participants completed the training programme once without distraction to generate reference scores and times. Next, they conducted the training programme under the influence of each of the following: auditory distraction, 12 hr of fasting, interrupted sleep and 24 hr of sleep deprivation. Wilcoxon signed-rank test was used to compare the distraction-induced results to the participants' reference scores and times. RESULTS: As compared to reference score (328), a lower performance was found for all four distractions: auditory distraction (289, p = 0.0012), fasting (302, p = 0.02), sleep interruption (304, p = 0.02) and sleep deprivation (300, p = 0.0006). In particular, PostH3 performance was influenced by all four interventions. (86 versus 50, p = 0,0012, 65, p = 0.05, 72, p = 0.05, 54, p = 0.0007 respectively). CONCLUSIONS: Virtual vitreoretinal surgery is an important tool for practicing complex surgical skills without compromising patient safety. In this study, deleterious effects on surgical performance were induced by four independent distracting factors. This knowledge is useful to optimize surgeons' work conditions and ensuring the best possible treatment of patients.

Simulation training in vitreoretinal surgery: a systematic review.

BACKGROUND: The purpose of this study was to perform a systematic review of the current literature on simulator-based training in vitreoretinal surgery (VRS). We examined the results regarding simulated VRS and provided an overview of how the current results may be employed in VRS training. Lastly, we evaluated the quality of these results. METHODS: The databases of Pubmed, Embase and Cochrane Library were searched for articles in English involving simulated VRS training. A qualitative analysis was performed, since the studies which met our inclusion criteria did not allow for a quantitative meta-analysis. RESULTS: We identified 203 articles of which seven met the inclusion criteria. Of these, six studies investigated simulation with EyeSi® Surgical (VRMagic, Mannheim, Germany). Six studies reported positive performance curves. Four studies showed construct validity. One study attempted to show skill transfer from simulator to vitrectomies performed on cadavers. Methodological quality of the included studies was moderate but lacking in instrument validation. CONCLUSION: Simulator-based training in VRS can assess and possibly assist acquisition of a variety of VRS skills. Further research is needed to support transfer from simulator to operating room. Future studies should strive to follow established validation frameworks and streamline study designs.

OUTCOMES OF PNEUMATIC RETINOPEXY PERFORMED BY VITREORETINAL FELLOWS.

PURPOSE: To evaluate the anatomical and visual outcomes of patients who underwent pneumatic retinopexy by vitreoretinal fellows. METHODS: We included 198 eyes (198 patients) that underwent pneumatic retinopexy by vitreoretinal fellows at a single academic institution between November 2002 and June 2016. Main outcomes were single-operation success and final anatomical success in retinal reattachment, as well as visual acuity at 3 months and 6 months after treatment. RESULTS: Single-operation success rate was 63.6% at 3 months and 59.5% at 6 months. Final anatomical reattachment was achieved in 92.9% (n = 184) and 96.6% (n = 143) at 3 months and 6 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.72 ± 0.1 (∼20/100 Snellen) at baseline to 0.36 ± 0.06 (∼20/40 Snellen) at 6 months (P < 0.001). There was no statistical difference in anatomical success rates or visual outcomes between cases performed by first- or second-year fellows (P > 0.50). Single-operation success was associated only with size of detachment (P = 0.01). Visual outcome was associated with macula status at baseline (P = 0.032) and number of reoperations (P < 0.001). CONCLUSION: Anatomical and visual outcomes of fellow-performed pneumatic retinopexy are comparable with those reported in the previous literature.

EYESI surgical simulator: validity evidence of the vitreoretinal modules.

PURPOSE: To investigate the validity of six vitreoretinal modules on the Eyesi Surgical Simulator. METHODS: Fifteen residents with no vitreoretinal experience and six trained vitreoretinal surgeons (>100 procedures per year) were included in the study. Four modules were selected in agreement with an experienced surgeon: the navigation (Nav), forceps (For), vitrector (Vit) and epiretinal membrane (ERM) peeling modules. The first level of the basic training modules (Nav1 and For1) and the first two levels of the more procedural modules (Vit1, Vit2, ERM1 and ERM2) were completed twice by both groups in the above order. The performance parameters for each task were calculated by the simulator software. The results from both iterations were recorded for analysis. RESULTS: Experienced vitreoretinal surgeons outperformed residents with regard to the overall score on the Nav1 (p = 0.01), For1 (p < 0.01), ERM1 (p = 0.02) and ERM2 (p = 0.04) modules. No differences in overall score were found between the two groups on the Vit1 (p = 0.17) and Vit2 modules (p = 0.26). CONCLUSION: Validity for the simulator metrics was found on four vitreoretinal modules not previously investigated, with regard to construct validity, content and the response process. These exercises could be included in a future competency-based training programme that could potentially be applied in the standard ophthalmological curriculum.

Success Rates for Retinal Detachment Repair in Alberta: A Physician Learning Program Initiative.

OBJECTIVE: To identify primary surgical success rates for retinal detachment repair in Alberta and compare functional outcomes of methods of repair. METHODS: Data was retrospectively extracted from the Alberta Health Services Discharge Abstract Database and the National Ambulatory Care Reporting System for all patients diagnosed with retinal detachment and vitreoretinal procedures during the 2008/09 to 2012/13 fiscal years. RESULTS: Of the 5,433 surgeries for retinal detachment identified, 279 were excluded due to invalid provincial health numbers, unidentified procedure location, and/or treating physician other than an Alberta retina surgeon. The final analysis included 4,336 detachments in 4,020 patients. The average primary retinal detachment success rate was 84.9% (3,680/4,336). Primary success rates varied between vitrectomy only (84.9%, 2,149/2,532), vitrectomy and scleral buckle (85.5%, 818/957), and scleral buckle (84.4%, 702/832). CONCLUSIONS: Alberta retina surgeons have an average primary success rate of 84.9% (3,680/4,336) for repair of retinal detachments. This result is in keeping with other published retinal detachment success rate studies.

Human/robotic interaction: vision limits performance in simulated vitreoretinal surgery.

PURPOSE: Compare accuracy and precision in XYZ of stationary and dynamic tasks performed by surgeons with and without the use of a tele-operated robotic micromanipulator in a simulated vitreoretinal environment. The tasks were performed using a surgical microscope or while observing a video monitor. METHOD: Two experienced and two novice surgeons performed tracking and static tasks at a fixed depth with hand-held instruments on a Preceyes Surgical System R0.4. Visualization was through a standard microscope or a video display. The distances between the instrument tip and the targets (in µm) determined tracking errors in accuracy and precision. RESULTS: Using a microscope, dynamic or static accuracy and precision in XY (planar) movements were similar among test subjects. In Z (depth) movements, experience lead to more precision in both dynamic and static tasks (dynamic 35 ± 14 versus 60 ± 37 µm; static 27 ± 8 versus 36 ± 10 µm), and more accuracy in dynamic tasks (58 ± 35 versus 109 ± 79 µm). Robotic assistance improved both precision and accuracy in Z (1-3 ± 1 µm) in both groups. Using a video screen in combination with robotic assistance improved all performance measurements and reduced any differences due to experience. CONCLUSIONS: Robotics increases precision and accuracy, with greater benefit observed in less experienced surgeons. However, human control was a limiting factor in the achieved improvement. A major limitation was visualization of the target surface, in particular in depth. To maximize the benefit of robotic assistance, visualization must be optimized.

Association of Mentor-to-Program Contact and Applicant Rank Disclosure With Vitreoretinal Fellowship Applicant's Final Match Outcome in 2016 and 2017.

Importance: Communication between applicants, mentors, and training programs is common before the residency and fellowship match. Few studies have examined the association of prematch communication on final match outcomes. Objectives: To report various characteristics of the vitreoretinal surgery fellowship match and to examine the association of mentor-to-program communication and applicant disclosure of their number 1 ranking with the probability of matching number 1. Design, Setting, and Participants: In this cross-sectional study of the 2016 and 2017 vitreoretinal surgery fellowship matches, an online survey examined (1) number of applications submitted, (2) number of programs ranked, (3) rank order of final match, (4) total application and interview-related costs, (5) mentor-to-program contact, (6) applicant disclosure of number 1 ranking, and (7) mentor disclosure of number 1 ranking. A link to an anonymous online survey was sent to 198 matched fellows (105 fellows from the 2016 match and 93 from the 2017 match). Main Outcomes and Measures: Survey responses regarding the vitreoretinal surgery fellowship application process. Results: The survey was sent to 198 matched fellowship applicants, and 152 (77%) completed the survey. Of the 105 matched applicants in 2016, 21 (20%) were women. Of the 93 matched applicants in 2017, 24 (26%) were women. Matched applicants applied to a mean (SD) of 34 (17) programs (range, 1-85) and ranked a mean (SD) of 12 (4) programs (range, 1-27). Of 152 applicants, 66 (43%) matched at their number 1 ranked program, 23 (15%) matched number 2, and 21 (14%) matched number 3. The mean (SD) total cost was $5500 ($2776) (range, $500-$13 500). Two-sided χ2 testing found no association (odds ratio, 0.70; 95% CI, 0.34-1.4; P = .33) between mentor-to-program contact and the probability of applicants matching at their number 1 ranked program. Matched applicants who revealed their number 1 ranking either personally or via a mentor matched at a program ranked lower (more desirable) on their rank list (mean match ranking, 2.8) compared with those who did not reveal their number 1 ranking (mean match ranking, 4.2; 95% CI, 0.2-2.5; P = .01). Applicant disclosure of their intention to rank a program number 1, either personally or via a mentor, was associated with matching number 1 (odds ratio, 2.6; range, 1.1-6.0; P = .03). Conclusions and Relevance: Vitreoretinal fellowship applicants who disclosed their number 1 ranking, either personally or via a mentor, were associated with improved match outcomes compared with their cohorts who did not make such disclosures.

COMPARISON OF 2D AND 3D VIDEO DISPLAYS FOR TEACHING VITREORETINAL SURGERY.

PURPOSE: To compare medical students' learning uptake and understanding of vitreoretinal surgeries by watching either 2D or 3D video recordings. METHODS: Three vitreoretinal procedures (tractional retinal detachment, exposed scleral buckle removal, and four-point scleral fixation of an intraocular lens [TSS]) were recorded simultaneously with a conventional recorder for two-dimensional viewing and a VERION 3D HD system using Sony HVO-1000MD for three-dimensional viewing. Two videos of each surgery, one 2D and the other 3D, were edited to have the same content side by side. One hundred UMass medical students randomly assigned to a 2D group or 3D, then watched corresponding videos on a MacBook. All groups wore BiAL Red-blue 3D glasses and were appropriately randomized. Students filled out questionnaires about surgical steps or anatomical relationships of the pathologies or tissues, and their answers were compared. RESULTS: There was no significant difference in comprehension between the two groups for the extraocular scleral buckle procedure. However, for the intraocular TSS and tractional retinal detachment videos, the 3D group performed better than 2D (P < 0.05) on anatomy comprehension questions. CONCLUSION: Three-dimensional videos may have value in teaching intraocular ophthalmic surgeries. Surgical procedure steps and basic ocular anatomy may have to be reviewed to ensure maximal teaching efficacy.

Wet laboratory training using porcine eyes with eyelids.

OBJECTIVE: This study aimed to evaluate the usefulness of a new wet laboratory (wet lab) system using porcine eyes with eyelids. DESIGN: Teaching device trial. PARTICIPANTS: Porcine eyes with orbital tissues and eyelids. METHODS: Twenty porcine eyes with orbital tissues and eyelids were enucleated from pigs butchered at age 6 months. These eyes were positioned in the eye sockets of a model head and stabilized with a pin. Eye draping, dressing with tape, and speculum placement were conducted. The vertical and horizontal widths of the palpebra under the speculum setting were compared with those of 55 patients who underwent cataract surgery. The rotation and torsion of the porcine eye in the new wet lab system were also compared with those of a conventional wet lab system. For comparison with actual cataract surgery, 5 ophthalmologists, including residents, were asked to respond to a questionnaire survey. RESULTS: The horizontal widths of the palpebra under the speculum setting were 27.5 ± 3.1 mm in porcine eyes and 28.6 ± 5.1 mm in human eyes, and the vertical widths were 16.9 ± 1.3 mm and 16.1 ± 1.5 mm (p = 0.53, 0.05). The amounts of rotation and torsion were significantly greater with the new wet lab system. Ophthalmologists evaluated the new wet lab system as being more realistic than the conventional system, in terms of both natural eye movement and restriction of the surgical field by the eyelid and the speculum. CONCLUSIONS: Wet lab training using porcine eyes with eyelids is more practical than older systems as it reproduces an ocular surgical field very similar to that of humans.

Análisis de la curva de aprendizaje en cirugía vitreorretiniana / Analysis of the vitreoretinal surgery learning curve

Objetivo: Describir la evolución de las complicaciones intraoperatorias y postoperatorias, así como la evolución en la técnica quirúrgica, en los 4 primeros años de un cirujano de retina y poder evaluar el tiempo de aprendizaje necesario para reducir el número de complicaciones, objetivando aquellas patologías que debieran seguir derivándose a otros centros hasta conseguir una mayor experiencia quirúrgica. Métodos: Se revisaron los pacientes intervenidos de cirugía retiniana por un cirujano novel en Tarragona, entre el 23 de octubre de 2007 y el 31 de diciembre de 2011. Se evaluaron el diagnóstico principal, el tiempo de aprendizaje del cirujano, la técnica quirúrgica, las complicaciones intraoperatorias y las postoperatorias. Resultados: Se revisaron 247 cirugías. El porcentaje de uso de los calibres 20G y 23G durante el tiempo denota un cambio hacia la cirugía transconjuntival a partir del noveno trimestre (98 cirugías realizadas). Las complicaciones descienden a partir del trimestre 12 (130 cirugías), con un incremento en los meses anteriores. Conclusiones: El cambio de tendencia hacia la técnica 23G alrededor de las 100 cirugías se interpreta como una mayor comodidad y seguridad en la cirugía. El aumento de complicaciones quirúrgicas durante los meses siguientes hasta el descenso a partir de las 130 cirugías se puede interpretar como un «exceso de confianza». Puede afirmarse que la curva de aprendizaje es más lenta de lo que el cirujano cree, siendo recomendable el análisis individual de las propias complicaciones y de la evolución quirúrgica para poder determinar en qué situación de la curva de aprendizaje se encuentra (AU)

Objective: To describe intra- and post-operative complications, as well as the evolution of the surgical technique in first 4years of work of a novice retina surgeon, and evaluate minimal learning time required to reduce its complications, deciding which pathologies should still be referred to higher level hospitals, until further experience may be achieved. Methods: A study was conducted on patients that had undergone vitreoretinal surgery by a novice surgeon in Tarragona between 23rd October 2007 and 31st December 2011. The primary diagnosis, surgeon learning time, surgical technique, intra-operative and post-operative complications were recorded. Results: A total of 247 surgeries were studied. The percentage of use of 20G and 23G calibres during the time, marks a change towards trans-conjunctival surgery from the ninth trimester (98 surgeries). Surgical complications decreased towards twelfth trimester (130 surgeries) with an increase in the previous months. Conclusions: The shift towards 23G technique around 100 surgeries is interpreted as greater comfort and safety by the surgeon. Increased surgical complications during the following months until its decline around 130 surgeries can be interpreted as an ‘overconfidence’. It is arguable that the learning curve is slower than what the surgeon believes. An individual analysis of the complications and surgical outcomes is recommended to ascertain the status of the learning curve (AU)