New Technologies in Ophthalmology
Ophthalmologica
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
Received: July 7, 2014 Accepted: September 1, 2014 Published online: November 26, 2014
Simulation of Laser Retinopexy around Retinal Breaks for Ophthalmologists in Training Elad Moisseiev Anat Loewenstein
Key Words Laser retinopexy · Simulation · Retinal break · Retinal tear
Abstract 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. © 2014 S. Karger AG, Basel
Introduction
Posterior vitreous detachment is an age-related event that occurs at some point during most people’s lives [1, 2]. Although usually benign, posterior vitreous detach© 2014 S. Karger AG, Basel 0030–3755/14/2331–0051$39.50/0 E-Mail [email protected] www.karger.com/oph
ment may cause tractional forces on the retina that result in full-thickness retinal breaks (tears and holes) [2]. It has been shown that 33–46% of untreated retinal tears may progress to retinal detachment, a significant complication that requires surgical intervention and may result in irreversible visual loss [2–5]. Additional predisposing factors for retinal breaks include high myopia, trauma, lattice degeneration, and pseudophakia or aphakia [5]. The fact that photocoagulation therapy prevents retinal breaks from progressing to retinal detachment has been established over 50 years ago [6]. Current recommended management includes prompt laser retinopexy around symptomatic retinal tears. Traumatic retinal tears are also usually treated by laser retinopexy, while retinal holes and asymptomatic retinal tears may be followed without treatment [7, 8]. Prophylactic laser retinopexy around retinal breaks is achieved by surrounding these lesions with rows of contiguous laser burns. This is a common procedure, which requires some experience and expertise. A recent study has shown that only 53.5% of patients treated by laser retinopexy were adequately treated in a single session, and the remainder required repeated laser applications or additional interventions such as cryotherapy or surgery [9]. Laser retinopexy is very often performed in an emergency setting in emergency rooms, by residents in ophthalmology who may still be at an early stage of their training, yet very little information has been reported on Elad Moisseiev, MD Department of Ophthalmology Tel Aviv Medical Center, Weitzman 6 Street Tel Aviv 64239 (Israel) E-Mail elad_moi @ netvision.net.il
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/13/2015 2:35:43 PM
Department of Ophthalmology, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Fig. 1. The model eye. a Frontal view, showing the 6-mm-wide pupil. b Internal view, showing the painted fundus details. c Side view, showing the flap that has been cut (edges marked in red).
a
this subject. Levin et al. [10] have shown that 15% of laser retinopexy procedures performed by residents were inadequate and required retreatment. Ghosh et al. [11] have reported that 24% of laser retinopexy procedures performed by residents were inadequate and required retreatment. Additionally, 8% of the patients with retinal breaks who were treated by residents had progressed and required surgery within a few weeks of the prophylactic laser treatment, a much higher rate than that reported for experienced ophthalmologists (3.8% in over 5 years of follow-up) [12]. The purpose of this study is to describe a novel method for simulating retinal defects and for instructing residents in performing laser retinopexy around them under semirealistic conditions.
b
a
c
b
Fig. 2. a Two orange-colored paper strips used to simulate retinal
defects. The top strip features a horseshoe flap, the bottom strip features a hole. b Enlarged view of the elevated horseshoe flap.
Methods This report describes a simulation of retinal breaks that can be used by ophthalmologists in training to perform laser retinopexy around them under simulation of realistic conditions. The model includes several components: an adjustable mechanical arm that enables the model to be mounted up on the laser slitlamp, a model eye, and a replaceable simulated retinal break inside it.
Simulation of Retinal Breaks A 5-mm-wide strip of paper is prepared and colored orange using a permanent marker. Using a surgical blade, a simulation of a retinal break is fashioned at the center of the paper strip – either a retinal tear or a retinal hole can be made (fig. 2). The strip of paper is then placed with the simulated retinal break under the flap that had been made in the model eye (fig. 3), and the excess edges of the paper strip are cut away or folded back.
52
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
Fig. 3. The paper strip inserted under the flap that has been cut at the side of the model eye. The simulated retinal break is placed directly under the flap, and excess edges are then cut away or folded back.
Placing the Model An adjustable mechanical arm was fashioned, which holds the model eye with the simulated retinal break inside it (fig. 4). This arm had been previously described and may also be used with a simulator for Nd:YAG posterior capsulotomy that we have developed [13]. The arm can fit any laser instrument, it is attached to the headrest and adjusted so that the model eye is placed exactly where a patient’s eye would be.
Moisseiev/Loewenstein
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/13/2015 2:35:43 PM
Model Eye This simulator is based on a model plastic eye, which is approximately 3 cm in diameter and has a 6-mm-wide pupil (fig. 1a). The inside of this model eye has been painted like a normal fundus, containing an optic disk, orange retina and retinal vessels that extend anteriorly (fig. 1b). The model eye is commercially available and may be used repeatedly for the purpose of this simulator. A 5-mm-wide square flap has been cut at the side of the model eye (fig. 1c).
lar in size and appearance to those encountered in clinical practice and can be surrounded by rows of contiguous laser burns just like in reality (fig. 5). The only differences are that the laser burns appear black and not white as in a real patient and require slightly higher laser energy settings (the burns shown in this article are 300 μm in diameter and have been achieved by using 400 mW with 0.2 s duration). To prove the usefulness of our model, we have used it for the training of 3 first-year residents who have never performed laser retinopexy before. After a brief explanation of the procedure and familiarization with the laser instrument, the three-mirror lens and the simulated retinal break model, the residents practiced locating the breaks and performing laser retinopexy around them. After a single day of training, which included several hours of repeated attempts, all 3 residents could perform an adequate laser retinopexy around the simulated retinal breaks. Fig. 4. The adjustable mechanical arm used places the model in the
Discussion
This model allows conditions simulating near-real laser retinopexy. The same three-mirror lens and laser instrument will be used by a resident trained by this method when treating a real patient in the future, and the experience gained in the simulator will be easily translated into clinical skills. The simulated retinal defects are very simi-
Guidance and evaluation of the residents’ performance is crucial for their training in any procedure. Performing laser retinopexy around retinal breaks is a difficult skill to master, and training in it in the real clinical scenario is limited for several reasons. First, training opportunities are dependent on incoming patients, whose number and frequency cannot be controlled, making it impossible to establish a fixed learning curve for residents. Additionally, some patients may not be suitable for treatment by inexperienced residents, due to retinal breaks that are difficult to find or treat, additional ocular morbidities, low tolerability to the examination with a three-mirror lens, or anxiety. Second, a supervising expert is not always available for the residents when a laser retinopexy needs to be performed. Finally, even under expert supervision, the laser procedure still carries risk for complications. The studies on prophylactic laser retinopexy performed by residents [10, 11] demonstrated a high rate of cases requiring repeated or additional treatment and indicate the need for structured supervised training of residents in performing this procedure. Review of the literature revealed few studies focused on designing simulators for retinal laser photocoagulation, based on virtual reality technology [14–16]. One of these studies has also shown that training residents to perform the procedure using a simulator is as effective as the conventional method and may shorten the duration of training [16].
Simulation of Laser Retinopexy for Ophthalmologists in Training
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
The Procedure Once the model is assembled, it includes a model eye with a simulated retinal break inside it. The mechanical arm may be adjusted to fit the model into any laser instrument. To perform laser retinopexy, a three-mirror lens is held against the model eye, and its internal surface is viewed through the mirrors. The orange color of the paper strip is identical to that of the retina painted inside the eye, and the model eye may be rotated so the retinal break may be placed anywhere along the circumference. This way, the retinal break is first sought after until it is located. When seen through the mirror, the laser beam is activated, and a retinopexy treatment surrounding the break can be planned and performed (fig. 5). The laser creates black burns when applied to the orange paper strip. No burns are achieved if it is out of focus or if it is applied to the plastic model eye.
Results
53
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appropriate location for performing laser on it. A = Adjustable connector that attaches to the headrest of the slitlamp and controls the vertical location of the model; B = adjustable connector that controls the horizontal location of the model; C = a wooden plate holding the model eye, that can be rotated 360° in it. The edges of the paper strip simulating the retinal break may be seen at the 10:30 position.
b
c
d
e
Fig. 5. Sequence of performing a laser retinopexy around a simulated retinal tear. a The tear prior to laser treatment. b A single 300-μm burn made at the posterior edge of the tear. c The tear sur-
rounded by a single row of laser burns. d The tear fully treated and surrounded by three rows of contiguous laser burns. e A different example of a simulated retinal hole surrounded with laser burns.
The presented simulator allows residents to perform laser retinopexy around retinal breaks, using the same threemirror lens and laser apparatus they would later use on real patients, as often and as many times as they should desire. Their performance can be evaluated by senior ophthalmologists at their convenience, and feedback may be provided for each attempt, even days later. Additionally, there is no risk of any complications or patient discomfort when using the simulator. Another significant advantage of this model is its low cost. The only cost is that of the model eye, which may be used repeatedly and is not damaged by the laser, while the simulated retinal breaks are made of small strips of paper (a single A4 sheet may be cut into over 400 such strips, so their cost is negligible). In contrast with the previously described training models [14–16], this simulator is simple to understand, construct and use and does not require advanced technology or computer skills. It offers a better simulation of the laser retinopexy procedure, as it involves use of the actual three-mirror lens and laser apparatus on a model eye, without an artificial complicated user-software interface. This simplicity of this simulator makes it more realistic, much cheaper and virtually impossible to malfunction or require any maintenance. Therefore, it is likely that residents and senior ophthalmologists will find it easy to use and adapt it for the training process. We acknowledge that the model eye has no eyelids and does not require use of a lubricating gel on the three-mirror lens. Also, the laser settings required to achieve burns in the simulator are higher than those used in reality and the laser burns are black. Despite these limitations, our model is the closest approximation available for training in this important procedure. A proper laser burn will not be created unless it is accurately focused, or if the energy settings are too low, just like in reality. Residents may use this simulator to practice their examination skills with a three-mirror lens, learn to find retinal breaks, as well as to plan and apply laser around them. By using it, the learning curve of laser retinopexy by residents may be significantly shortened. We have successfully used this model on 3 novice residents who have never performed
laser retinopexy before, who were all able to perform adequate laser retinopexy around the simulated retinal breaks after a single day of training. This is a much faster rate of training than that possible when training on real patients, which has been reported to be 42 days in one study [16], but may be even much longer in reality. In summary, using this model can improve the training process of residents in ophthalmology in the performance of laser retinopexy around retinal breaks, increase their experience and confidence before having to apply their skills on real patients, and significantly shorten their learning curve. In addition to this model’s realistic nature, additional important advantages include its being simple to fashion and understand, reusable and inexpensive. It is our belief that this simulator may be a valuable instructional tool for training residents in performing adequate laser retinopexy.
54
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
Acknowledgments The authors would like to thank Mrs. Galit Yair-Pur for her assistance in creating the photographs that appear in this article.
Disclosure Statement No grants or funds were received to finance this study. None of the authors has any proprietary interest in this study.
References
1 Hikichi T, Hirokawa H, Kado M, Akiba J, Kakehashi A, Yoshida A, Trempe CL: Comparison of the prevalence of posterior vitreous detachment in whites and Japanese. Ophthalmic Surg 1995;26:39–43. 2 Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S: Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA 2009;302:2243–2249. 3 Davis MD: Natural history of retinal breaks without detachment. Arch Ophthalmol 1974; 92:183–194. 4 Shea M, Davis MD, Kamel I: Retinal breaks without detachment, treated and untreated. Mod Probl Ophthalmol 1974;12:97–102.
Moisseiev/Loewenstein
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/13/2015 2:35:43 PM
a
Simulation of Laser Retinopexy for Ophthalmologists in Training
9 Khan AA, Gupta A, Bennett H: Risk stratifying retinal breaks. Can J Ophthalmol 2013;48: 546–548. 10 Levin M, Naseri A, Stewart JM: Resident-performed prophylactic retinopexy and the risk of retinal detachment. Ophthalmic Surg Lasers Imaging 2009;40:120–126. 11 Ghosh YK, Banerjee S, Tyagi AK: Effectiveness of emergency argon laser retinopexy performed by trainee doctors. Eye 2005;19:52–54. 12 Pollack A, Milstein A, Oliver M, Zalish M: Circumferential argon laser photocoagulation for prevention of retinal detachment. Eye 1994;8:419–422. 13 Moisseiev E, Michaeli A: Simulation of neodymium: YAG posterior capsulotomy for ophthalmologists in training. J Cataract Refract Surg 2014;40:175–178.
14 Dubois P, Rouland JF, Meseure P, Karpf S, Chaillou C: Simulator for laser photocoagulation in ophthalmology. IEEE Trans Biomed Eng 1995;42:688–693. 15 Rouland JF, Dubois P, Chaillou C, Meseuree P, Karpf S, Godin S, Duquenoy F: SOPHOCLE (Ophthalmologic Simulator of Laser PHOtocoagulation): contribution to virtual reality (in French). J Fr Ophtalmol 1995; 18: 536– 541. 16 Peugnet F, Dubois P, Rouland JF: Virtual reality versus conventional training in retinal photocoagulation: a first clinical assessment. Comput Aided Surg 1998;3:20–26.
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
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5 The Eye Disease Case-Control Study Group: Risk factors for idiopathic rhegmatogenous retinal detachment. Am J Epidemiol 1993; 137:749–757. 6 Colyear BH, Pischel DK: Preventive treatment of retinal detachment by means of light coagulation. Trans Pac Coast Otoophthalmol Soc Annu Meet 1960;41:193–215. 7 Preferred Practice Pattern. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. San Francisco, American Academy of Ophthalmology, 2013. 8 Wilkinson CP: Evidence-based analysis of prophylactic treatment of asymptomatic retinal breaks and lattice degeneration. Ophthalmology 2000;107:12–15.
Ophthalmologica
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
Received: July 7, 2014 Accepted: September 1, 2014 Published online: November 26, 2014
Simulation of Laser Retinopexy around Retinal Breaks for Ophthalmologists in Training Elad Moisseiev Anat Loewenstein
Key Words Laser retinopexy · Simulation · Retinal break · Retinal tear
Abstract 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. © 2014 S. Karger AG, Basel
Introduction
Posterior vitreous detachment is an age-related event that occurs at some point during most people’s lives [1, 2]. Although usually benign, posterior vitreous detach© 2014 S. Karger AG, Basel 0030–3755/14/2331–0051$39.50/0 E-Mail [email protected] www.karger.com/oph
ment may cause tractional forces on the retina that result in full-thickness retinal breaks (tears and holes) [2]. It has been shown that 33–46% of untreated retinal tears may progress to retinal detachment, a significant complication that requires surgical intervention and may result in irreversible visual loss [2–5]. Additional predisposing factors for retinal breaks include high myopia, trauma, lattice degeneration, and pseudophakia or aphakia [5]. The fact that photocoagulation therapy prevents retinal breaks from progressing to retinal detachment has been established over 50 years ago [6]. Current recommended management includes prompt laser retinopexy around symptomatic retinal tears. Traumatic retinal tears are also usually treated by laser retinopexy, while retinal holes and asymptomatic retinal tears may be followed without treatment [7, 8]. Prophylactic laser retinopexy around retinal breaks is achieved by surrounding these lesions with rows of contiguous laser burns. This is a common procedure, which requires some experience and expertise. A recent study has shown that only 53.5% of patients treated by laser retinopexy were adequately treated in a single session, and the remainder required repeated laser applications or additional interventions such as cryotherapy or surgery [9]. Laser retinopexy is very often performed in an emergency setting in emergency rooms, by residents in ophthalmology who may still be at an early stage of their training, yet very little information has been reported on Elad Moisseiev, MD Department of Ophthalmology Tel Aviv Medical Center, Weitzman 6 Street Tel Aviv 64239 (Israel) E-Mail elad_moi @ netvision.net.il
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/13/2015 2:35:43 PM
Department of Ophthalmology, Tel Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Fig. 1. The model eye. a Frontal view, showing the 6-mm-wide pupil. b Internal view, showing the painted fundus details. c Side view, showing the flap that has been cut (edges marked in red).
a
this subject. Levin et al. [10] have shown that 15% of laser retinopexy procedures performed by residents were inadequate and required retreatment. Ghosh et al. [11] have reported that 24% of laser retinopexy procedures performed by residents were inadequate and required retreatment. Additionally, 8% of the patients with retinal breaks who were treated by residents had progressed and required surgery within a few weeks of the prophylactic laser treatment, a much higher rate than that reported for experienced ophthalmologists (3.8% in over 5 years of follow-up) [12]. The purpose of this study is to describe a novel method for simulating retinal defects and for instructing residents in performing laser retinopexy around them under semirealistic conditions.
b
a
c
b
Fig. 2. a Two orange-colored paper strips used to simulate retinal
defects. The top strip features a horseshoe flap, the bottom strip features a hole. b Enlarged view of the elevated horseshoe flap.
Methods This report describes a simulation of retinal breaks that can be used by ophthalmologists in training to perform laser retinopexy around them under simulation of realistic conditions. The model includes several components: an adjustable mechanical arm that enables the model to be mounted up on the laser slitlamp, a model eye, and a replaceable simulated retinal break inside it.
Simulation of Retinal Breaks A 5-mm-wide strip of paper is prepared and colored orange using a permanent marker. Using a surgical blade, a simulation of a retinal break is fashioned at the center of the paper strip – either a retinal tear or a retinal hole can be made (fig. 2). The strip of paper is then placed with the simulated retinal break under the flap that had been made in the model eye (fig. 3), and the excess edges of the paper strip are cut away or folded back.
52
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
Fig. 3. The paper strip inserted under the flap that has been cut at the side of the model eye. The simulated retinal break is placed directly under the flap, and excess edges are then cut away or folded back.
Placing the Model An adjustable mechanical arm was fashioned, which holds the model eye with the simulated retinal break inside it (fig. 4). This arm had been previously described and may also be used with a simulator for Nd:YAG posterior capsulotomy that we have developed [13]. The arm can fit any laser instrument, it is attached to the headrest and adjusted so that the model eye is placed exactly where a patient’s eye would be.
Moisseiev/Loewenstein
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/13/2015 2:35:43 PM
Model Eye This simulator is based on a model plastic eye, which is approximately 3 cm in diameter and has a 6-mm-wide pupil (fig. 1a). The inside of this model eye has been painted like a normal fundus, containing an optic disk, orange retina and retinal vessels that extend anteriorly (fig. 1b). The model eye is commercially available and may be used repeatedly for the purpose of this simulator. A 5-mm-wide square flap has been cut at the side of the model eye (fig. 1c).
lar in size and appearance to those encountered in clinical practice and can be surrounded by rows of contiguous laser burns just like in reality (fig. 5). The only differences are that the laser burns appear black and not white as in a real patient and require slightly higher laser energy settings (the burns shown in this article are 300 μm in diameter and have been achieved by using 400 mW with 0.2 s duration). To prove the usefulness of our model, we have used it for the training of 3 first-year residents who have never performed laser retinopexy before. After a brief explanation of the procedure and familiarization with the laser instrument, the three-mirror lens and the simulated retinal break model, the residents practiced locating the breaks and performing laser retinopexy around them. After a single day of training, which included several hours of repeated attempts, all 3 residents could perform an adequate laser retinopexy around the simulated retinal breaks. Fig. 4. The adjustable mechanical arm used places the model in the
Discussion
This model allows conditions simulating near-real laser retinopexy. The same three-mirror lens and laser instrument will be used by a resident trained by this method when treating a real patient in the future, and the experience gained in the simulator will be easily translated into clinical skills. The simulated retinal defects are very simi-
Guidance and evaluation of the residents’ performance is crucial for their training in any procedure. Performing laser retinopexy around retinal breaks is a difficult skill to master, and training in it in the real clinical scenario is limited for several reasons. First, training opportunities are dependent on incoming patients, whose number and frequency cannot be controlled, making it impossible to establish a fixed learning curve for residents. Additionally, some patients may not be suitable for treatment by inexperienced residents, due to retinal breaks that are difficult to find or treat, additional ocular morbidities, low tolerability to the examination with a three-mirror lens, or anxiety. Second, a supervising expert is not always available for the residents when a laser retinopexy needs to be performed. Finally, even under expert supervision, the laser procedure still carries risk for complications. The studies on prophylactic laser retinopexy performed by residents [10, 11] demonstrated a high rate of cases requiring repeated or additional treatment and indicate the need for structured supervised training of residents in performing this procedure. Review of the literature revealed few studies focused on designing simulators for retinal laser photocoagulation, based on virtual reality technology [14–16]. One of these studies has also shown that training residents to perform the procedure using a simulator is as effective as the conventional method and may shorten the duration of training [16].
Simulation of Laser Retinopexy for Ophthalmologists in Training
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
The Procedure Once the model is assembled, it includes a model eye with a simulated retinal break inside it. The mechanical arm may be adjusted to fit the model into any laser instrument. To perform laser retinopexy, a three-mirror lens is held against the model eye, and its internal surface is viewed through the mirrors. The orange color of the paper strip is identical to that of the retina painted inside the eye, and the model eye may be rotated so the retinal break may be placed anywhere along the circumference. This way, the retinal break is first sought after until it is located. When seen through the mirror, the laser beam is activated, and a retinopexy treatment surrounding the break can be planned and performed (fig. 5). The laser creates black burns when applied to the orange paper strip. No burns are achieved if it is out of focus or if it is applied to the plastic model eye.
Results
53
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appropriate location for performing laser on it. A = Adjustable connector that attaches to the headrest of the slitlamp and controls the vertical location of the model; B = adjustable connector that controls the horizontal location of the model; C = a wooden plate holding the model eye, that can be rotated 360° in it. The edges of the paper strip simulating the retinal break may be seen at the 10:30 position.
b
c
d
e
Fig. 5. Sequence of performing a laser retinopexy around a simulated retinal tear. a The tear prior to laser treatment. b A single 300-μm burn made at the posterior edge of the tear. c The tear sur-
rounded by a single row of laser burns. d The tear fully treated and surrounded by three rows of contiguous laser burns. e A different example of a simulated retinal hole surrounded with laser burns.
The presented simulator allows residents to perform laser retinopexy around retinal breaks, using the same threemirror lens and laser apparatus they would later use on real patients, as often and as many times as they should desire. Their performance can be evaluated by senior ophthalmologists at their convenience, and feedback may be provided for each attempt, even days later. Additionally, there is no risk of any complications or patient discomfort when using the simulator. Another significant advantage of this model is its low cost. The only cost is that of the model eye, which may be used repeatedly and is not damaged by the laser, while the simulated retinal breaks are made of small strips of paper (a single A4 sheet may be cut into over 400 such strips, so their cost is negligible). In contrast with the previously described training models [14–16], this simulator is simple to understand, construct and use and does not require advanced technology or computer skills. It offers a better simulation of the laser retinopexy procedure, as it involves use of the actual three-mirror lens and laser apparatus on a model eye, without an artificial complicated user-software interface. This simplicity of this simulator makes it more realistic, much cheaper and virtually impossible to malfunction or require any maintenance. Therefore, it is likely that residents and senior ophthalmologists will find it easy to use and adapt it for the training process. We acknowledge that the model eye has no eyelids and does not require use of a lubricating gel on the three-mirror lens. Also, the laser settings required to achieve burns in the simulator are higher than those used in reality and the laser burns are black. Despite these limitations, our model is the closest approximation available for training in this important procedure. A proper laser burn will not be created unless it is accurately focused, or if the energy settings are too low, just like in reality. Residents may use this simulator to practice their examination skills with a three-mirror lens, learn to find retinal breaks, as well as to plan and apply laser around them. By using it, the learning curve of laser retinopexy by residents may be significantly shortened. We have successfully used this model on 3 novice residents who have never performed
laser retinopexy before, who were all able to perform adequate laser retinopexy around the simulated retinal breaks after a single day of training. This is a much faster rate of training than that possible when training on real patients, which has been reported to be 42 days in one study [16], but may be even much longer in reality. In summary, using this model can improve the training process of residents in ophthalmology in the performance of laser retinopexy around retinal breaks, increase their experience and confidence before having to apply their skills on real patients, and significantly shorten their learning curve. In addition to this model’s realistic nature, additional important advantages include its being simple to fashion and understand, reusable and inexpensive. It is our belief that this simulator may be a valuable instructional tool for training residents in performing adequate laser retinopexy.
54
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
Acknowledgments The authors would like to thank Mrs. Galit Yair-Pur for her assistance in creating the photographs that appear in this article.
Disclosure Statement No grants or funds were received to finance this study. None of the authors has any proprietary interest in this study.
References
1 Hikichi T, Hirokawa H, Kado M, Akiba J, Kakehashi A, Yoshida A, Trempe CL: Comparison of the prevalence of posterior vitreous detachment in whites and Japanese. Ophthalmic Surg 1995;26:39–43. 2 Hollands H, Johnson D, Brox AC, Almeida D, Simel DL, Sharma S: Acute-onset floaters and flashes: is this patient at risk for retinal detachment? JAMA 2009;302:2243–2249. 3 Davis MD: Natural history of retinal breaks without detachment. Arch Ophthalmol 1974; 92:183–194. 4 Shea M, Davis MD, Kamel I: Retinal breaks without detachment, treated and untreated. Mod Probl Ophthalmol 1974;12:97–102.
Moisseiev/Loewenstein
Downloaded by: Universitätsbibliothek Giessen 134.176.129.147 - 5/13/2015 2:35:43 PM
a
Simulation of Laser Retinopexy for Ophthalmologists in Training
9 Khan AA, Gupta A, Bennett H: Risk stratifying retinal breaks. Can J Ophthalmol 2013;48: 546–548. 10 Levin M, Naseri A, Stewart JM: Resident-performed prophylactic retinopexy and the risk of retinal detachment. Ophthalmic Surg Lasers Imaging 2009;40:120–126. 11 Ghosh YK, Banerjee S, Tyagi AK: Effectiveness of emergency argon laser retinopexy performed by trainee doctors. Eye 2005;19:52–54. 12 Pollack A, Milstein A, Oliver M, Zalish M: Circumferential argon laser photocoagulation for prevention of retinal detachment. Eye 1994;8:419–422. 13 Moisseiev E, Michaeli A: Simulation of neodymium: YAG posterior capsulotomy for ophthalmologists in training. J Cataract Refract Surg 2014;40:175–178.
14 Dubois P, Rouland JF, Meseure P, Karpf S, Chaillou C: Simulator for laser photocoagulation in ophthalmology. IEEE Trans Biomed Eng 1995;42:688–693. 15 Rouland JF, Dubois P, Chaillou C, Meseuree P, Karpf S, Godin S, Duquenoy F: SOPHOCLE (Ophthalmologic Simulator of Laser PHOtocoagulation): contribution to virtual reality (in French). J Fr Ophtalmol 1995; 18: 536– 541. 16 Peugnet F, Dubois P, Rouland JF: Virtual reality versus conventional training in retinal photocoagulation: a first clinical assessment. Comput Aided Surg 1998;3:20–26.
Ophthalmologica 2015;233:51–55 DOI: 10.1159/000368248
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