Cataract surgery is difficult to learn, often both for the surgeon and patient. The holy grail for educators in this area has been a simulator that would allow practice without placing patients or attending coronary arteries at risk. The first versions of simulators are rolling off the lines now and we were fortunate that the VAMC in Iowa City purchased one of the EyeSi devices from VR Magic for our residents. Here we will describe how this fits into our curriculum and show a few videos that demonstrate its capabilities.
The first step for, I suppose any educational project is to establish stages of development and objectives for each stage. Much like the boy scouts have cub scouts, boy scouts, eagle...; we developed stages for our program using Dreyfus stages of novice, beginner, advanced beginner, proficient, and expert. We assumed that almost no resident will make expert in only 3 short years and that almost all will make the proficient stage. The objectives for each stage are measurable and we established resources to allow stage progression http://webeye.ophth.uiowa.edu/eyeforum/pdf/580oett.pdf .
Our objectives for the beginner (typically a first year at iowa) include the use of the wet lab and the simulator with a focus on developing a facilty with instruments within the eye. Our residents begin to do the easier parts of cases which we call "backing in" where residents do the last steps of a perfect case started by a senior resident. The might just fold the lens the first week, then fold and inset the lens, then fold and insert and also remove the OVD.. The simulator in this phase requires a set of tasks simulating the use of instruments within the eye, the capsulorhexis, and some basic steps of phacoemulsification.
Our objectives for the advanced beginner (typically a second year at iowa) is to use the simulator for more advanced practice and to begin to do whole cases. Our goal during this year is for the resident to be able to do whole cases in less than 45 minutes but do not expect them to be able to use both hands and the attending will typically control the paracentesis instrument.
The objectives for the proficient stage (third year at iowa) are more difficult and involve increasingly efficient and complex surgical tasks. The simulator has been less imortant so far for us in this regard however it does at times prompt discussion. The video below shows a simulator case where the lens fell due to zonular stress which prompts a discussion on what to do next and what are the risk factors for droppin the nucleus.
While we are thinking about it what are the risks for dropping the nucleus? Zonular issues such as pseudoexfoliation, RP, h/o uveitis, h/o trauma, and marfans are certainly important. Other risky situations where you must be very careful with hydrodissection include radial tear, posterior polar cataract, penetrating lens trauma, and early cataract after vitrectomy. This reminds me of the following video:
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