Lecture: Improving & Expanding Surgical Education Systems through Accessible Technology

In many regions of the world, there are not enough faculty or mentors to provide adequate and safe surgical and clinical ophthalmology training. It is clear, that to reduce preventable global blindness, ophthalmologists often require augmented surgical training and development. This live webinar will discuss ways that basic technology can be used to help fill the educational gap in training ophthalmic surgeons.

Lecturer: Dr. Kevin Barber, Ophthalmologist, Central Florida Eye Specialists, USA


[Kevin] Good day, morning, evening wherever you are coming from the world. My name is Kevin Barber. I’m an ophthalmologist in central Florida in the United States on the east coast of the United States. And I work for and run an organization called Advanced Center for Eye Care Global. We are a nonprofit organization that’s committed to reducing preventable blindness primarily in the world of cataracts. And we are partners and work closely with Orbis. So I’m very excited to share with you some ideas and some things that we’ve been experimenting with and working on today. This is an exciting, new frontier in surgical education and very grateful to be here and talk with you about it today. You’ll have to excuse me, I woke up a little under the weather this morning. So my voice is a little raspy but forgive me if I have to stop a couple of times to clear my throat or take a sip of water. I’d also like to acknowledge Britton Etheridge, he’s a medical student in Alabama who helped put this presentation together. Disclosures, I am a consultant for Alcon. I did receive some research funding from Alcon for one of the projects that I’ll present in this study. I’m also a consultant for Beyeonics. The goals for today is, I’d like to offer some inspiration and a change of perspective on methods for surgical education. One of the greatest things about the human experience is that we always get to reinvent ourselves and reinvent how we do things. And I think the COVID experience has forced us to do that. I want us to take this opportunity to rethink how we could do a better job of surgical education. I want us to also be challenged in our thinking on how we contribute to the pressing problem of global blindness by using accessible technology for surgical education. And I would like to propose some paradigm shifts or some different ways of thinking on how we can improve surgical education, specifically in regions of the world where there’s not sufficient educational resources. When I first started in global ophthalmology, I spent many years, most of my career, traveling doing eye projects really around the world. And I guess you could almost call it medical tourism. But I went to many different parts of the world to do cataract surgery. And after maybe five years ago I would say, I decided that I really wanted to get more focused. And I had some mentors say hey, instead of just going all over, why don’t you really narrow down and get focused if you want to help make a contribution. And so I did that. I actually went to Central America for several years. Not to always do surgery, but really just to learn and observe and to ask questions. And really wanting to dig in and understand what the problems were in eye care delivery so that we could come up with some newer strategies or better strategies to help alleviate some of the problems. These are some of the observations I came up with. As you all know, the World Health Organization put out the vision report and it tells us that we just don’t have enough ophthalmic surgeons, especially in low to middle income countries. One of the other things I observed is that surgical training during residencies is often time lacking in these low to middle income countries. And so if the surgeons graduate with inadequate surgical experience, most likely they’re not going to be effective in their careers surgically. I also noticed that a significant percentage of these ophthalmology residents that were graduating in low to middle income countries ultimately would abandon the operating room. And when I would talk to them about that it was usually because they just weren’t trained sufficiently and they didn’t feel they had the skills to bridge into successful surgical careers and so they would just give up and not do it. I also observed that technology does offer some additional surgical training opportunities which might be able to fill this gap. Because although it can be very difficult to create more ophthalmic surgeons because that usually involved lots of politics and government’s involvement, my theory was instead of trying to always create more ophthalmologists, let’s take the ophthalmologists that we’re already training and just make them better. Make them more efficient, make them better surgeons to where they can take care of the needs if they’re not being trained adequately. As I mentioned, many residency graduates would abandon surgery early on in their careers, especially in low to middle income countries. I also observed that there was no fellowship training in many places and there were very few opportunities for additional surgical training after residency. If you didn’t get adequate training during residency, and you didn’t have opportunities after residency, you would essentially be stuck. Mentorship is needed to help these young surgeons bridge the gap from residency to independent practice so that they can care for the visual needs of their local communities. I remember when I finished training, I joined a practice here in the United States and I had senior partners who were willing to come in and help me through my professional development during those first couple of years. Had I not had that, it would have been a more difficult road. This is the area that we’re trying to make a difference. Just a poll question. If additional surgical teaching and training could be easily accomplished during or after residency training, how effective do you think that would be in low to middle income countries addressing their vision care demands? Do you think that would be highly effective, moderately effective, are you neutral about that, or do you think this would not work and would not be effective? I’ll give you 30 seconds to think about that and submit your answers. All right, so 61% of you think that this would be highly effective. 31% moderately effective and 8% neutral and nobody says not effective. That’s very encouraging, thank you for those responses. A new system for augmenting surgical education in low to middle income countries through technology. At ACE, through our COVID experience we developed a system of using technology to help augment surgical education. We start with learning surgeons watching live surgery that’s been done by mentor surgeons. I’ll show you examples of this in just a moment, but this would be the teacher, the mentor surgeon, doing live surgery and streaming it to a learning surgeon. That gives good introduction to OR etiquette. Then we move into a simulation based environment where we have wet labs. And the learning surgeon starts to do simulation cases but those cases can be streamed to a mentor anywhere in the world. This eventually progresses into what we call distance surgical mentorship or DSM. That’s when the learning surgeon is doing live surgery and then streaming that to a mentor that’s not local, that’s not there with him in the same facility. And then this opens up the door for fellowship opportunities and postgraduate streaming mentorship during surgery. And the ultimate goal is to create new eye centers. We all know that that’s what’s needed to provide access to the massive areas of this planet that don’t have access to eye care, as we have to create new eye centers. But we also know that if you don’t have effective, well-trained surgeons, you can’t have effective eye centers. And so we have to start with the training to make sure that we’re adequately training each surgeon going through a training process before these new eye centers can actually be created. As I mentioned before, I got focused in on Central America. I’d like to take the next little bit and talk about Honduras. The country of Honduras is where we focused on that last few years and where we’ve been working through some of these programs. In Honduras, it’s a relatively small country in Central America. There’s only one residency program in the country. They historically have two, or sometimes three residents a year. The population is about 11 million. There’s six part-time faculty members and not all of the specialties are represented so there might not be, for instance, a neuro ophthalmologist or a retina specialist there. And the residency program is housed in a government hospital system and the faculty members are only compensated to be there half time. That’s where part of the problem is. And these faculty members, by the way, are some of the hardest working people I’ve ever seen, they work so hard to try to train these residents. But they only have a short period of time to do that. And so therein lies the problem is that the residents end up having to do a lot of self teaching because there’s just not enough faculty involvement because of the system there. In Honduras there was no fellowship training in the country prior to last year. We estimate there’s about 80 surgeons that are operating in the country. The last RAAB study that was done there estimated 160,000 people that are visually impaired or blind from cataracts. There’s a fairly significant backlog. Obviously nothing huge compared to India or Africa or other parts of the world, but again, this is a relatively small population of 11 million people. Approximately 10% of the population can afford private practice care. The other 90% only have access to care through the government system which, like many government health care systems, can be underfunded or under equipped or they can go to a non-profit. And I think that this is a fairly common representation of many low to middle income countries around the world. When we looked at some recent residency graduates from the residency program, we found that their surgical numbers were probably lower than what we would have hoped. They were graduating with approximately 25-30 MSICS and somewhere in the neighborhood of 60 phacos. In Honduras, like many low to middle income countries, we have found that both doing MSICS and phaco is actually necessary because they need phaco for the paying patients and that helps cost subsidize the whole thing. But they have very dense, very progressed pathology and because of the socioeconomic stratification, MSICS is obviously needed as well. But you can see graduating with only 60 phacos or 25 MSICS you might not be ready to handle operating independently. This whole program started through COVID, so March 2020. I was all packed up, I took all of these donated supplies to do 100 cataract surgeries. I somehow defied the laws of physics and I had it all fit into these four duffle bags. I had my plane ticket and I was ready to go to Honduras to work with these residents, as you can see images here, where I sit next to them at the scope and we do these cases and we try to augment their surgical education. That was March 15th. As you recall, that’s when things started to really happen with COVID and the next day international travel was shut down from Honduras and the United States. So fortunately I did not go where I might have become a naturalized citizen of Honduras because I would have been there probably for a long time. Once I was not able to go, it really forced us at ACE to start rethinking, how can we make a difference, how can we still teach surgical education when we can’t physically be there? We started down this pathway of surgical streaming. Here in the United States we were quarantined. I was only quarantined for about six weeks whereas my partners in Honduras were quarantined for almost six months. I went back to work before they did. When I went back to work, we actually started streaming surgery to them. This is an image of one of our first streaming sessions. Here in the top left, I’m in my operating room in Florida. I’m using an NGENUITY here, made by Alcon, it is a 3D heads up visualization system. So instead of looking through a microscope oculars, I’m wearing 3D glasses and we can see the screen. And I’m streaming this through Zoom to some of the residents and attendings in Honduras. And we started doing this every day that I was operating because the eye team in Honduras was not able to be involved with patient care and so they were sitting at home, and so we set up these Zoom meetings and it became a very powerful and effective teaching tool. Here in the bottom left, this is Dr. Daniel Chang, he would come on with others and be a guest lecturer. So in between the cases he would give lectures. In this case he was doing one on IOL selection. And so again, it just became a very powerful tool for educating. We learned that the streaming process is actually quite easy. If you have an HDMI output coming out of your camera that you mount to your microscope, all you need is this HDMI streamer, this one’s made by Magewell. It’s roughly 300 US dollars. And then you just connect it to a laptop and start a Zoom meeting. It’s a relatively easy thing to do. This experience grew. We had residents start to join in from other countries, from El Salvador, Guatemala, the Dominican Republic, and we would have more and more and more residents and attendings watch as we would mentor surgeons operate. And it became a very effective way. And what we learned, especially with first and second year residents, who may not have a lot of operating room experience, for them to be able to see the operating room virtually, have the opportunity to ask questions, it accelerated their learning curve. When they did return back to the operating room, they had a whole extra knowledge base that they didn’t have before. We began to experiment with creating this virtual OR. We would set up cell phones and use the cameras and we would connect them all to the Zoom meeting so you could see the microscope view, you could see the scrub. So we would have technologists like scrub techs watching to learn how to set up the trays efficiently for sterilization. You can see the surgeon’s hands, you could put these cameras anywhere you wanted. And you could highlight the education that you were trying to communicate whether it’s surgical technique for the case or whether it’s turnover and efficiency of the operation room. There’s really no limit to what you can do with this technology. We also learned that if you have a 3D system like the NGENUITY, you can stream in 3D. The device will stream in a left to right image, and then the viewer or the mentor or the learner, has to have a device that puts the images back together into three dimensions and that could be done either with virtual reality goggles or it can be done with 3D glasses and some software upgrades on a computer. I think there’s a lot of potential with streaming in 3D, it is very nice being able to see that full 3D dimension. So the mentor or the learning surgeon can see exactly what the mentor surgeon sees. However, the couple of limitations are bandwidth, it takes up a lot more internet bandwidth to make this happen and it’s not as cost effective because the learning surgeon has to have usually some virtual reality goggles. I think that this capacity will continue and will increase with time, although it might not be fully practical just yet. This is just a video of one of the streaming sessions where I’m doing a Kahook Goniotomy and I’m instructing or showing some of the surgeons in Honduras. I’ll just play this video for just a moment so you can get a feel for what a live session was like. Joe, if you upload your left folder for me, perfect, there you go. All right. See if we can get a little focus here. How’s the image? [Attendee] Sounds good. I think. [Kevin] All right, there. Now I can see the trabecular meshwork fairly well, are you guys able to see that? [Attendee] Fernando is the expert there. [Kevin] Yes. As you can see, there’s live dialogue going on, there’s conversation going on. And so that’s the big advantage over just watching a video on YouTube is that there can be active questions and answers, there can be lots of non-tangibles like how do you focus the microscope, and how you bring certain things into focus. There’s lots of advantages to doing this live surgical streaming. And so it just gives a whole extra level of education. Some of the advantages that we observed is that it does allow for more frequent mentoring. In the past I would only mentor the residents in Honduras maybe twice a year when I would travel there. But now I was able to mentor them weekly. And so that also stimulated a lot more relationship development, we got to know each other a lot better because we’re meeting weekly. It also creates a very safe learning environment. Sometimes these young surgeons will ask me questions or ask the mentor surgeon questions that they might not feel comfortable asking in their own live OR. Again, it enhances their educational experience. And it does allow for the real time dialogue which was very valuable. After that we moved onto the next step where we created a digital training center or a wet lab, and we started the learning surgeons doing simulation cases and streaming those back to the mentor. This was a project that we did in collaboration with Orbis. Orbis provided funding for the wet lab in Honduras which has now become the training hub for Central America and we’re very grateful for this experience. And it’s had just a wonderful impact. This is the microscope in the wet lab, you can see here on the image to the left. To the right of the surgeon’s oculars is an adapter for a cell phone. What we have found to be the easiest is a cell phone adapter where the resident doing the case could just put his or her cell phone in that and start a Zoom meeting straight from their cell phone. And then the image here on the right is what the mentor would see when they opened up or joined the Zoom meeting. You can see in the bottom right hand, that’s the microscope view where you can see the simulation eye, you can see the surgeon’s hands, you can see the phaco machine. And just like with any Zoom meeting you can pin any one of these images to make them larger so you can see in more detail. Excuse me a second, my mouse is not working. We would also do in-person or live simulation labs and those were also very helpful. We had two stations set up, one for MSICS and one for phaco. Obviously there’s VR simulations or virtual reality trainers, those are becoming much more popular. There’s multiple companies working on this. HelpMeSee has an amazing one for MSICS, VR Magic, the Eyesi, Alcon’s coming out with one. There’s several coming out on the market, they’re all really, really good. We do not have a virtual reality simulator in our lab. But we’re partnering with other institutions that do, where we can do an exchange of the residents. Because I think that as time goes on this is going to be a more necessary way for training. When we compare the streaming simulation to the traditional mentorship, some of the advantages we noticed is that there’s increased exposure to volunteer mentors. The local faculty in a wet lab can be burdened. You work all day in your very busy clinics and operating rooms. And then after clinic, excuse me, after clinic is over, to go spend an hour or two in the wet lab can be difficult. And so that’s where volunteer mentors who are being streamed in can really unload that burden on the local faculty. The learners are exposed to a broader diversity of surgical techniques. I enjoy watching other surgeons mentor residents in the wet lab or in live surgery because I learn so much about different techniques. I’ve never sat in on a mentorship session and not learned something new. We all have some much to teach each other but we, as surgeons, are kind of isolated in our operating rooms where it’s those four walls. This streaming capacity really opens us up to where we can connect and learn from each other. And it’s actually fairly easy to schedule because the wet lab sessions or simulation sessions are done after hours, that’s usually when volunteer mentors are also available. We have found this to be a fairly easy system to set up and to implement. This has actually grown and is now being cultivated into an international training center. The images here on the right are many of the residents and fellows from neighboring countries to Honduras and El Savador and Guatemala. Quarterly we’re now hosting a cataract boot camp over a weekend where the residents and fellows will come and we’ll do lectures that are streamed in by guest lecturers. And then they spend the weekend in the simulation lab doing lots of simulation cases. Some of those cases are being mentored in-person and some of those cases are being mentored through streaming. And again by streaming, it just opens up more mentors who are available to teach. And it’s amazing how this has grown so rapidly. We now have had seven countries send surgeons for training in this wet lab. So truly an international training center is growing from this. And that’s one of the advantages we see with streaming is it just makes the world a little smaller. It starts to connect people from all over the world. If you are in an institution or in an area where you want to develop a simulation lab. Obviously, Orbis is the world’s leader in this. I would encourage you to use their curriculum to use some of the publications they have on this, they’re a great resource for it. It can be done very low cost. So you can get a table mounted microscope, if I can remember correctly, between $2,000-5,000 US is the going rate for some of these table mounted microscopes. And then we just use the cell phone adapter as I mentioned before. And you can see that here in the upper right image. As long as there’s connectivity or data for a cell phone, a resident can put his or her cell phone onto this adapter and begin the streaming process instantly. You can also use a GoPro system, this is another low cost method. These GoPros cost anywhere between $500-800 US depending on which model you get. And then they also use an adapter. And they can either be hardwired to a laptop computer or used in Bluetooth for the streaming process. The nice thing about that is the image quality is really good and you don’t have to rely on the cell phone. But I’m just giving you options. We’ve used both and we still use both the GoPro method and the cell phone method. Now let’s talk about distance surgical mentorship or DSM. DSM is when there’s live surgery being done by the learning surgeon and that’s being streamed to a mentor. I know everybody gets a little knot in their stomach when they first hear this, this is a very novel concept, so let me qualify it and this sounds a little bit scary. But it’s a great tool if done under the proper guise. DSM is only appropriate for learning surgeons who are already operating independently. So this is not for residents. When residents are doing cases, oftentimes the attending surgeon needs to take over the case, we all know that, we’ve all been there. That is not possible with distance surgical mentorship. distance surgical mentorship again, is only for a small niche here. It is for surgeons who graduated from residency and are already capable of operating independently. However, they self-identify as needing more help, more teaching. They’re not quite fully confident in their surgical skills yet so that’s where distance surgical mentorship can have its place. Proper case selection done with the mentor and the learning surgeon, usually the day prior, is critical. Before I mentor one of our fellows or a young surgeon that I’m working with, we’ll review the cases, making sure that they’re appropriate. It’s very helpful if the mentor surgeon has some awareness of what the operating room where the learning surgeon will be. What equipment is available, what instruments are available. And the other thing is having a review of the videos afterwards. And that can become a great teaching tool and I’ll show you some examples of that. I mentioned before we had a research grant from Alcon that we performed. This is an NGENUITY, so we had a 3D NGENUITY system placed in Honduras. This is in Tegucigalpa, Honduras. These are two of the Honduran surgeons performing live surgery. And they’re streaming it. The image here on the right is an image from the Zoom meeting where you can see the mentor here and she’s watching the phaco machine, she can see the microscope view, and she can see the surgeon’s hands. This just gives you a little image of what DSM would look like. We actually published this paper this year and this was just a pilot study or a proof of concept study. We took four Honduran surgeons that were graduates from a residency program, they had performed anywhere between 150 cataracts and 500 cataracts. They’re already operating independently, however they self-identified as wanting or needing more surgical education. We put them in the study and they collectively did 100 cases. And during those 100 cases they were mentored by an expert surgeon not there at their facility. Most were in the United States, however we had some from Mexico and Peru, Chili, from several different places in the world. And we looked at the effect. The two main outcome measures were OSCAR scores and case duration. OSCAR scores, if you’re not familiar, are the most objective way to grade a surgeon’s skill. When we looked at their OSCAR scoring, and we compared their early cases to their late cases, we saw them improve significantly from the mid 60s up into the high 80s. We saw a definitive improvement in their surgical skill going through this mentorship process. Again, with the teaching surgeon or the mentor surgeon never actually being in the operating room with them, only doing this through a streaming process. The other outcome measure we looked at was the case duration. When we compared the early cases to the late cases, we saw a dramatic improvement in their case duration. Some of the cases were as long as an hour with an average being around 40 minutes. But by the end of the process, by the end of those mentored cases, they had improved down to the low 20s. We’re seeing an improvement in efficiency. And that’s an important step because most good and proficient surgeons are also efficient and when you’re in low to middle income countries with such a backlog of cataract surgery that needs to be done, efficiency is very important in the operating room. If you’re not familiar with OSCAR scoring, you can look this up. It’s 20 steps to the surgery and a blinded grader will watch a video and give you a grade between 2-5, so 100 in a perfect score, which doesn’t mean that you’re the world’s best cataract surgeon, it just means that you’re proficient, or minimally proficient in cataract surgery. So that’s how we did this study was using the OSCAR scoring system. And this is one of the DSM cases that were done during the study. Up in the upper left you’ll see Dr. Jorge Ponce. He is performing the surgery and he’s being mentored and I’m just going to play this video and let you just watch and listen for a few moments to get a feel on how it works. Just a little deeper [Jorge] Okay. (speaking in Spanish) [Kevin] Good, nice Okay. Here’s another video, same thing. This is where the Honduran surgeon here is operating and you can see here doing the capsulorhexis. One thing to remember is that during these sessions you can highlight or pin the operating microscope and see it much larger and see it in greater detail. So we found that the detail was sufficient, although you don’t have a 3D view, the mentor was actually able to pick up on lots of cues. For instance you can tell if the anterior chamber was deepening or shallowing or you could tell if the lens was trampolining. And so we didn’t find that the 3D component was absolutely essential, it sure would be nice and I think we’re again moving in that direction as the bandwidth issues are being improved throughout the world. But as you can see the visualization is pretty good. The other thing we measured with latency. The amount of time between what was happening real time to when the mentor could see it or hear it, was less than a half a second. And so that was deemed as safe and we’d never had issues where latency was a problem through this streaming process. The image here on the left, shows that when the teaching surgeon and the mentor surgeon are working together, we have a tablet set up next to the learning surgeon so that they can actually see each other. And on this image on the left, we can see the learning surgeon in Honduras here, and he’s looking at the screen and he can see his mentor surgeon and in this case, it’s Dr. Maria Montero of Orbis. She was one of our generous mentors who donated time. And she’s using hand gestures to demonstrate how to do a particular technique. So they can look back and forth and see each other just as if they were sitting next to each other at the microscope. That was a big advantage. The other thing that we found is here on the right, this is Dr. Russell Swan from Montana, he’s a phenomenal teacher. And what he would do, is he would video record his screen and then he would go back and draw on it and then make comments and send that video through email to the learning surgeon. At the end of the day the learning surgeon would receive these videos where he would draw and say, “Here I wanted you to grab the capsule here and pull it in this direction.” And the learning surgeon would have this video review with the comments and drawings of the mentor surgeon. And it was just a phenomenal way of teaching, there’s so much accelerated learning that happened through that process. I think in certain respects, DSM allows for even better teaching opportunities than live face-to-face teaching at times. You don’t need a 3D NGENUITY system to do this. There are low cost options. You can do this with any smart phone and then you just need a laptop or a tablet is what we recommend. As you see here, there’s a beam splitter with the adapter. This whole system can be purchased for about $2500 US. Relatively low cost for an educational institution where you’re not having to invest in lots of expensive technology. The cell phones, the nice thing about them is they’re easily accessible, everyone has one, they’re low cost. However, it’s very important that a data service is stable and that you have good internet connection. Obviously if the internet connection or data connection is stable, then this system doesn’t work. We brought improved internet into the residency program in Honduras. And set up a better wifi system in the operating room and in the wet lab. So you might have to do that. You can test your wifi but it is important that that is in place. Another application for this is remote locations. This is one of our current fellows and he’s in a remote location about two hours away from the city and he’s doing surgery and he’s streaming it here with the GoPro, you can see it on the laptop computer here. And he can stream that anywhere. If you have young surgeons who are operating in remote locations but you still have internet connection, that can be very helpful because sometimes it’s intimidating to go outside of the training environment or outside of the city into an austere environment and try to operate. We have found that to be a great application for DSM. Some of the lessons we’ve learned. Again, please hear me clearly. DSM, live surgical DSM is only applicable for surgeons who are already operating independently. We would never advocate this being done for training surgeons who are in residency. You do have to establish safety protocols for proper case selection and patient safety. When you’re first starting, do very easy cases, you do cases that you know the learning surgeon can handle. You also want to make sure the learning surgeon has what he or she needs to handle complications. In our study we had three cases where vitrectomy was required. But you know what? Those cases went very well because they had an expert surgeon who’d had a lot more experience doing complicated cases and vitrectomies, talking the learning surgeon through it as opposed to the learning surgeon trying to do it themselves. Again, this doesn’t prevent complications but it helps the learning surgeon learn how to manage these complications. Live DSM has its niche in helping to bridge the gap between residency completion and successful practice. Again, if we’re losing up to a half of ophthalmic surgeons that are being trained in low to middle income countries because they stop operating, if we can take those 50% that we’re losing and help them bridge the gap into becoming successful surgeons, then that can be one of the most successful ways of addressing the preventable blindness problem. We also learned it’s helpful if the mentor has been on site and is familiar with the learning surgeons OR environment. So they’re familiar with the phaco machine, the instruments, and what it’s like. That’s not required but it is helpful. And then mentor to learner streaming and simulation lab streaming are valuable tools to increase surgical education and skill transfer in lower to middle income countries residency training. All right, now if you’re going to teach surgery, you also have to teach pre and postoperative care. Let me preface it, I am not an expert in telemedicine. Orbis has taught the world so much with a lot of their platforms. But I just wanted to say that part of the DSM process is proper case selection. Sometimes that requires images to help with preoperative patient selection and postoperative care. This is an image of the Volk Vistaview. Volk partnered with us and allowed us to use some of these devices and we found them to be very helpful. It’s a small fundus camera that’s about the size of a cell phone. And what’s nice about it is it takes great images but then it can instantly upload them to the cloud. You can upload them onto the Orbis Cybersight if you want an E-consult. You can upload them to the artificial intelligence or the machine learning platforms which are pretty phenomenal. And they really help, as I mentioned, with the pre and postoperative evaluation of surgical patients. I’ll just show you a quick video that shows briefly how these images are taken and applied. [Jorge] Through virtual by Volk I can send a technician, they can give high quality images so that I can review them. Virtual technology by Volk is a cloud-based platform that is synced automatically with Vistaview and as you take the photos of the fundus it is automatically uploaded into the platform. Very easy to review these images. I can be anywhere, I can review the images that the technician takes as soon as they upload it. I can screen my patients virtually anywhere. This device has been very helpful to be able to make me connect with Dr. Barber in a way that we can discuss what the patient’s best interests may be and how to manage them properly. [Kevin] Efficiency is really key because we have such a backlog of people that need care. Both the Vistaview and the- The one thing that I have found is when you’re taking photographs and you’re doing telemedicine, it has to be efficient. If the learning surgeon there on the ground has to take a picture, upload it to one, download it to a computer, upload it to another device, wait to hear back, if that process is too time consuming, they just won’t do it. These surgeons in low and middle income countries work so hard. Very long days, they have such a high need. Any program we implement has to be efficient. I guess what I’m trying to communicate is you need an image system that allows for efficiency. That’s why we liked the Vistaview is that as soon as you take the image, as long as you have internet connectivity, you can upload it and you can get answers back instantly and it makes the system very, very efficient. I would advocate for finding a system that works for you. One of the products of all of this steaming is that it helped us to start the first fellowship in Honduras. As I mentioned, when I did that few years of observation, there was no fellowship training. We started the very first anterior segment fellowship in Honduras two years ago. Our fellow stays in Honduras for 10 months and does the direct patient care. As part of the time is spent in the academic center where they have faculty advising them. And then part of the time is spent in a center where they’re operating independently through streaming. Their cases are being streamed and they have expert mentors coming to them all around and then they also have visiting teams coming to them, doing intensive surgical trips. And we were actually surprised at what this system was able to accomplish. The very first year, the fellow Dr. Ponce, did 600 surgical procedures as the primary surgeon. This live distance surgical mentorship was a big part of that. It really helps increase the volume of surgery that can be accomplished during the training program. And then as we expanded the DSM platform, that allowed us also to expand the capacity for teaching. One fellow went to two. Dr. Ponce graduated and we replaced him with two, Dr. Rocio Banegas and Dr. Luis Rojas. And they are now doing the same thing where they’re doing the fellowship. They have, again, cases mentored directly by Honduran faculty, they have cases mentored directly with visiting surgeons from travel teams, and then they have cases mentored through DSM. And by combining all three of those modalities, it allows for a much higher volume of patient care and of surgical care to give them to maximize the experience during their one year of fellowship. We’re very proud of this program. And again, just showing what some of these streaming capacities can do. It can increase the capacity for education. If you want to create a distance surgical mentorship program, some pearls would be first you have to create a database of dedicated volunteer mentors. That’s just relationship building, that’s reaching out to the surgeons that are in your network and asking them if they would want to be involved. It’s easy to ask a surgeon, “Hey, would you donate one hour a month to teach a resident in the wet lab if you don’t have to travel? If you can just open up your computer.” That’s an easy ask. We have found it relatively easy to create databases of volunteer mentors. You want to start small and grow slowly. Obviously, as I mentioned before, you need stable internet capacity so you need to make sure that that’s in place first. And then you have to have very clear communication in coordinating the teaching surgery sessions between the volunteer and the learning institution. We usually designate one person to be the liaison between the teaching institution and the mentors. In summary, the applications for distance surgical mentorship is you can start off with mentor to learner, where the mentor surgeon streams live surgery to the learning surgeons. Again this seems to be most appropriate for first and second year residents. It can also be appropriate for even attending surgeons if you’re wanting to teach a new technique or a new procedure. The simulation lab is the next step where you can do learner to mentor. When the appropriate safety parameters are in place, live surgical learner to mentor DSM can be very valuable. This can help grow things like fellowship training and post graduate mentorship. Let me stop my screen share here. And that in a nutshell is the DSM project. Let me go to some of the questions and answers here. Some trainees do not perform surgery because they were trained as phaco surgeons and they did not have access to phaco machines after training. They hesitate to MSICS because they’ve been told it’s not a good technique. Yeah, that’s a great point. As I mentioned in Honduras, both techniques are necessary. We’re very deliberate in making sure that the residents and the surgeons are taught and become proficient at both MSICS and phaco. And you bring up an excellent point there, Roy, that access to equipment is also difficult. That’s a pretty big question and another lecture series to itself. But I think the take home message is that surgeons in low and middle income countries and most places really need to become motivated to learn both because both are going to be required. The computerized surgical simulators or the virtual reality simulators again are the new frontier. I think they’re excellent teaching tools. I’ve tried almost all of them and I think that they’re excellent. Some are a little farther ahead than others. I think five years from now we’re going to have five or six VR simulators on the market that are going to be incredible. I think we have to work out the economics of it: how expensive are they going to be, how accessible are they going to be? What I think, I think Orbis is right in that there’s going to be regional training centers and surgeons will have the ability to go to that regional training center and try the VR simulators. I don’t think that they will completely replace model eyes or simulation eyes because there is something valuable in actually holding the real phaco handpiece in your hand and using the real pedal, the same pedal that you’ll use in the operating room. I don’t think that the VR simulators will completely replace wet lab or simulation training with model eyes, but I think they’ll be very complimentary. And surgeons that get exposure to both of those I think will be way far ahead. I think that will really lessen the learning curve. That’s what our experience has been in Honduras and in Central America, is the more time our learning surgeons spend in simulation and that training, once they get to the operating room it just comes so much more naturally. They know how to program their machines, they know the names of the instruments, they know how to hold them, they know so much more detail than if they’re just starting fresh or without any experience at all. Let’s see here. In a case of DSM, do you arrange that for a single or for a group of surgeons? That’s a great question. I think that that’s up to you. Usually a group of surgeons works best so you have a group of learning surgeons in a group of mentor surgeons because the mentor surgeons are only going to have a limited time to volunteer or to give, so you need a group of them. I think, again, you start small. Maybe you start with one or two learning surgeons and you begin to build or develop your database of mentor surgeons. And over time that will grow. But you usually want three to four mentor surgeons, at least, to every one learning surgeon. Just because the mentor surgeons will have a limited amount of time that they can volunteer. For the DSM, do the patients know that they will be used during training? Won’t it be hard to convince the patient if they will know that the surgeon is being taught online? That’s a great question, thank you for that question. That’s part of the consent process. When we did the DSM study, that was being done in a teaching institution in a residency program. The patients already knew they’re in a teaching institution and they will be in a teaching environment where the surgeon will be instructed. And so it was a fairly easy thing to say, “Hey, your surgeon is going to be instructed through video as opposed to live, but that’s okay because your surgeon is licensed to be operating independently.” We do include that again as part of the consent process. To my knowledge, we’ve never had a patient have a problem with that or say they didn’t want it because these patients are coming to a surgeon who’s already operating independently and if the surgeon says, “Hey, while I’m doing your surgery, I’m going to have an expert from another country watching your surgery and providing feedback to me.” And usually the patients are like, “Yeah, that’s pretty cool, I like that.” And it’s also very clear that the mentor surgeon is not taking responsibility for that patient. The medical licensure of the operating surgeon in that country, that’s all still the same process, it’s just the mentor surgeon is being involved for the teaching purposes. How much will it cost for the whole wet lab equipment? Brook, that’s a great question. That can vary greatly. I think if you’re trying to use the smallest amounts, the smallest amount of money, one teaching microscope you could probably pick one up used, a table mounted microscope for $2,000-3,000 US. It also depends on if you’re teaching phaco or if you want to do it just for MSICS or non-phaco things. For phaco you have to buy the phaco machine. And usually once you put a phaco machine in a wet lab or simulation lab, it should not be used in human surgery. You need a dedicated phaco machine. Most of the time we’re looking at donated ones that are older that aren’t being used as commonly in human surgery. Now if you’re just wanting to teach MSICS, you don’t need the phaco machine. That’s great. And then you need basic instruments. Again, you want a dedicated instrument tray for simulation and for the wet lab. You want to designate people to take care of it so that they don’t get broken or stolen. We keep ours locked up so that they don’t walk away. And then for the streaming component, if you wanted to add the streaming component, you just need to make sure that your microscope has the beam splitter and the adapter. A beam splitter is usually about $700 US and the adapter’s about $1800 US. And so by combining those two that is fairly, what are we at? Maybe $5,000-6,000 US for a bare bones but complete MSICS ready simulation lab. I see a lot of questions for DSM for Bangladesh and for Ecuador. And yeah, I think the Middle East. I think DSM, there’s no limitation to it, right? As long as you have internet you can connect any two places in the world. What you need is the basic technology that I just described. And then you need a group of mentors and that might be the hardest part. But if you start to ask and you start to explore your circles of influence, you might be surprised at how easy this is to begin to set up. It does take a little time but it can be done. And you just need to start reaching out and building that database of mentors. Basic techniques in phaco and MSICS? Again, both. You can teach both through DSM and we do. We do MSICS cases and phaco cases and I advocate for both. I think in most places of the world both are appropriate. What other ophthalmic surgeries can you do with DSM other than cataract surgery? Great question. You can do glaucoma surgeries, again, these are very specific. If you have friends that’s a glaucoma surgeon in a country who needs help with putting in a valve. He’s done it, but he or she wants a little more. You can do that. Anything done under the microscope you can do. We’ve also done it with oculoplastics and pediatrics. Instead of using an operating microscope camera, you use a head mounted camera and those are relatively cheap and easy. The teaching surgeon or the learning surgeon wears a headband that has the camera above it or you can also use arms to suspect cameras above the surgical field. And you can do the macro procedures like pediatrics and oculoplastics and that’s worked very well. That’s actually a little easier and a little cheaper to do than microscope based cases. Maybe we’ll do one more question here, I think we’re at the end of our time. Yes, great question, Catherine, I appreciate this question. Do you also routinely train residents for vitrectomy to manage the complications? Yes. We start that in the wet lab. We’ll do specific complication management in the wet lab where we’re using simulation eyes and we’ll break out the vitrectomy and we’ll learn how to use it, how to set it up, the proper techniques for it. And then during a resident’s education they’re going to get that experience as well. We have found with DSM it really is good because as a young, primary surgeon if you have a complication, that’s difficult. Right? That’s a stressful event. Having an expert watching you and talking you through it is a huge advantage and it’s so much better than you trying to suffer through it alone. Yes, complication management is part of the whole education system and it lends itself well to DSM. All right, I think we’ve come to the end of our hour. Thank you guys so much for your time. I hope that this has been helpful and I look forward to growing these ideas with you. Everyone enjoy the rest of your day or evening, whatever the case may be.

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September 9, 2022

Last Updated: December 29, 2022

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