Lecture: Novel Applications & Innovations in the Surgical Training Space

Good morning, everybody. Or good afternoon, or good evening depending on where geographically you’re located. Thank you for joining us today. My name is Marshall Dial. I am the VP of simulation and education for Haag-Streit simulation residing in Toronto, Canada. Joining us today is Dr. John Ferris from the UK. Pediatric ophthalmologist and off-the-charts great cataract surgeon as well as Dr. Ivo Ferreira from Mexico City and cofounder of Oftalmo University. Today’s subject is How we can use technology and mentorship and adult learning science to address a gap that many young ophthalmologists have which is their comfort level and proficiency in managing PC ruptures and the presence of vitreous during the cataract case. We’re going to take you through a series of slides and also use virtual reality technology. What we hope to do is first create a baseline understanding of where we are in education for teaching anterior vitrectomy and whether or not we can do better. On this subject, Dr. Ferris has done amazing work with his colleagues to drill down into the status quo for rates of complications and how technology has impacted learning in young ophthalmologists learning cataract surgery. >> Marshall, thank you very much, great pleasure to be taking part in another Cybersight webinar. Just looking at this first slide, the PCR risk stratification comes from the electronic patient records that we use in the UK to document almost 80 percent of all cataract operations done in the UK. The odds ratio is the multiple of what the standard PCR risk is. If you for example had a first year trainee operating on a brunescent cataract that had some pseudo-exfoliation, the risk above the average, the PCR are those three figures multiplied together. It comes to about 27 percent chance of a PCR. One of the things we’re going to be following today is preventing PCR. One of the most effective ways of doing that as a trainee is case selection. And these from the more than a million cases on the electronic patient record collected by the royal college of ophthalmologist on their national database are the highest individual risk factors for PCR. And many of these you will recognize. Next slide, please, Marshall. >> So when we look at the rates of PCR, this is the first ever national ophthalmology database paper that showed for independent surgeons, there is a 1.4 percent risk of PCR. Senior trainees 2 and a half and junior trainees a 5 percent chance of PCR. This was published back in 2006. It’s an annual audit that we do and those figures have fallen to 1.1 percent for independent surgeons and across all trainees to just over 2 percent. So still double the risk but significantly less than it was in 2006. And in the main, this is due to the mandation of EyeSi virtual reality cataract surgery training before undertaking live surgery. So this was a study, again, taken from the national ophthalmology database data set where we looked at six years of surgery for first and second year trainees. 265 surgeons in 28 centers over 17 and a half thousand cases. We find that in those trainees who had undergone EyeSi training in their hospital or a neighboring hospital, it shows a 38 percent reduction in PCR rate. So at the box on the bottom left of the slide you can see that before EyeSi practice, the average PCR rate for this group is 33.5 percent and it fell to 2.6. That’s a 38 percent reduction. In the trainees who had no access to EyeSi, the PCR rate stayed the same. We performed 400,000phacos in the UK a year, this results in 400 fewer PC ruptures across the country. This is the first evidence that simulation practice reduces the risk of complications. The evidence is out there that this technology works. The other interesting study that was done in the UK recently was looking at senior trainees. In the UK the training program is 7 years. And 350phacos is the min numb our trainees need to do to become a consultant. The vast majority have done over 600, 700 cases. These are experienced trainees who have done 6 or 700 cases and they consider asked how confidence they are doing a sole low anterior vitrectomy. You can see that over a third of the patients of the trainees felt they were not in a position to carry out this surgery independently. They were just about to enter independent practice. And I stress, these were very experienced cataract surgeons. Rather perversely the fact that our training has become so good that PC rupture rates were so low, they haven’t had the opportunity to manage a PCR. This is why the simulation techniques we’re going to talk about today are so important. And not just for trainees but also senior surgeons to keep up their skills in managing PCR. Next. >> With that — let’s go to our first survey. So we’d like to ask the audience how would you feel you were trained during your residency for management of anterior vitrectomy? This is I know for residents and young ophthalmologists that I deal with a very sensitive subject. It’s also a complex scenario involving your teacher and a patient. So we’d love to get your feedback on your experience such as it was during your training. All right: Very interesting. 35 percent of the audience was well trained with significant live surgery. I don’t know how you feel, John, that to me is quite high. That’s wonderful. >> That’s pretty high. That’s pretty much what it was in the UK. A third of our trainees felt they were well trained. That still left two-thirds who felt that they were anxious about managing themselves. >> Then we look on the bottom of the survey results, little over half the audience was mostly observing and had limited hands-on time or had essentially not undertaken during their training the opportunity to manage. Clearly there are some gaps in the conventional way we prepare young ophthalmologists to under take cataract surgery and feel they are prepared for managing a PCR. So that is great. >> It looks as if we have Ivo ready for a live demonstration. >> How are you guys? >> Good. Glad we have you. At this point we’re going to now have the opportunity to look at a paradigm shift in how we can fill that gap and create a meaningful supplemental training experience, the use of virtual reality and mentorship to address this gap. Dr. Ferreira will you show us how to use a simulation to teach a rare event so that young ophthalmologists feel comfortable doing anterior vitrectomy. >> Sure, thank you for the introduction. It’s a real pleasure to be here with the great John Ferris and all the Cybersight and Orbis family. You said in the beginning, this is a simulated environment. This is a place where all the laws change and we’re going to do something extremely interesting in a controlled environment with metrics and we’re going to create a channel of communication between the mentor and the trainer, how, on how to especially pass skills to the person who is in training. So right now you’re going to see on the big screen a simulated scenario with a posterior capsular break and vitreous that is already stained. So this is going to be great in order for people to understand what is going on and look at this. Also, I am completely obsessed with the hand position. I’m going to do something different here. Simulation allows this. I’m going to do something that I call the most intuitive thing to do for the people who are starting. But there is three or four important mistakes that I’m going to do. I’m going to do things wrong. I think that’s one of the most powerful things about virtual simulation. As you can see here, of course, I’m watching in 3D. This is virtual reality. This is tissue that has been modeled in order to interact. I’m going to enter, I also can choose my parameters that I’m going to show afterwards. Now you’re going to see something that I believe is most intuitive. I see vitreous in the top and I go for it. I’m doing a bimanual vitrectomy. I see vitreous on the top and the first thing I do is go for the vitreous. I take my time. This is another mistake I see a lot. The way I move, this is vitreous, this is a new structure. So what people do is they move a lot in the anterior chamber, something that is not correct. Because vitreous is a whole structure and you create traction. And I keep going. Sometimes it’s not easy to see vitreous but sometimes you see that shadow and I keep going. And maybe I get a little bit close to the posterior break. I take my time, but I keep going, I keep going, I keep going. And you know, what I think that I did almost everything and I have removed the vitreous, you know, maybe I just finish. Okay. That’s something that is intuitive and many people say, okay, maybe this is the correct way to do it. And I’m going to try to show in this camera, okay, my metrics. This is one of the most important powerful things about simulation. So I got a zero but the question is why. The question is what happened. If you really see here the target achievement, let me share with you so you can see everything that is going on in this metric. Look at this. Look at the power of those metrics. The machine is telling me there was six seconds when you paused irrigation. So something happened in the anterior chamber that wasn’t correct. Then it says, well, you left some vitreous in the anterior chamber, it wasn’t that much. But especially you pulled vitreous towards the anterior chamber. Many interesting things. I’m going to leave it like that and we’re going to keep going and then we’re going to try to do it again in the correct way. Marshall. >> So thank you for framing the initial experience as we move forward, everybody, what we’re going to see, we’re going to start to deconstruct through virtual reality all the nuances of how you actually approach a PCR and manage vitreous is a more appropriate fashion. Ivo, talk to us about the three components that are possible to effectively train through the use of simulation. >> Yes. That’s one of the most important things when we are training people. I think every time you face any step in cataract surgery, especially in vitrectomy, we talk about three skills that you should artificially be thinking about. You always need the model skills, in this case with my hands. In my hands I need to move correctly. I need to be very careful with the vitreous. But then, you know, in the 70s, Franz Spencer was talking about the problem solving capabilities of a surgeon. This is called cognitive skills. And we’re always trying to push our students in how to make the best decisions and algorithms on how to do that. And especially in this part, we’re going to talk a lot about this with John, is about the mind set skills. I see so many surgeons they can do a cataract surgery in 7 or 8 minutes and suddenly you have a posterior capsular break and they freeze. And you see that as a failure. What happens when you’re failing and need to keep going? The mind set skills, especially in this, especially in this surgical step, they’re extremely important. Next one, please, Marshall. And for each of them, we have assigned a specific workshop in order how to make it. There is a way how you learn skills when you’re a micro surgeon, you remove different groups of muscles. You need to have the correct biomechanics of your hands. And then we have algorithms in how you make decisions being a surgeon. And of course, one of the most important ones is how to be in a peak performance state during the entire surgery. Those skills, I’m sure they’re one of the most important skills when talking about anterior vitrectomy. Next one, please. This is something I need to give a lot of credit to Marshall. This is something so powerful and it’s an analogy with another activity that it’s something we need to talk about and think about it. Here we have, you know, another person with 38 years old who says, you know what, I’m bored during the pandemic and next month I want to do surf in this kind of waves. These kind of waves can be fun but also can be very, you know, very challenging and very dangerous. So what he does is he says, the first thing, I need a coach. Great. You want to be good at something, get a coach. But then after he gets the coach, he, the coach says this and it’s so important and actually I think it’s very important for today, he says I’m going to teach you every single scenario in which you can fail and then what you’re going to do when you fail. So you’re ready if something happens, you’re ready to mitigate the risk, right, Marshall. This is something we love. This is a very important concept. >> I think you’re 100% right and I think we’re going to drill into that right now. >> One of the most important things in my opinion and emphasized by Ivo there, is the cognitive skills and the psychological skills. The motor skills are something that can be practiced but they only make up 20 percent of what’s important when dealing with any form of complicated cataract surgery. And over the next few slides and videos, hopefully we’ll show ways of approaching this type of complication. And it will happen to all of us no matter how brilliant a surgeon you are, you will have PC ruptures to deal with. And to give you just a little framework of how to get yourself and your team into the right place to deal with it effectively. If dealt with effectively, there is no reason that patients shouldn’t have an excellent visual outcome. Next slide, please. So what is the goal of anterior vitrectomy. The ultimate goal is to remove all of the vitreous from the anterior chamber. Avoid damaging the anterior segment structures. As Ivo was emphasizing, avoid placing any traction on the vitreous. If you start pulling on the vitreous, you will cause a retinal break and retinal detachment. You want to preserve the chamber stability. And we’ll see in some of the slides, the instant reaction that many people have when they notice the PCR is to remove the instruments from the eye. Immediately decompress the anterior chamber and propagate the tear. Once you remove the vitreous, then you can learn how to place a three-piece IOL safely in the sulcus to get a nice stable outcome. Those are the ultimate aims in the eye’s point of view. The other aim, probably more important, is the patient who will be awake and listening to what is going on does not have a frightening experience. Experiences of wonderfully calm, and the option is taking a little longer than anticipated because of the rehearsed way the entire team are managing this. Even if you do a wonderful anterior vitrectomy, if the patient is aware of anxious voices and shouting and confusion going on around them, they will be extremely worried that something terrible has happened even if the complication is being managed well. That’s something I want people to be very much mindful of as we go through the next slides. So how to do a correct anterior vitrectomy. The best way to handle the PCR is avoid it happening in the first place. If you assess the patient properly beforehand and you’re mindful of the risks for PCR that we showed in the first slide, you will already have prepped the theater team this could be a potentially complicated on the list. An elderly patient, deep set eye. They know there is increased risk of PCR and they will be mindful of that should it happen. Practice and preparation we’ll see in the coming videos how we can practice managing PCR as well as the EyeSi simulation, some model eye simulation. And how we can use that to help prepare the entire team in theater not just the surgeon. So we can practice not only the motor but the cognitive and psychological skills requires. We’re going to look at some of the points at which a PCR can happen. Hydrodissection. If you have, are too vigorous with the hydrodissection, especially in the presence of a posterior polar cataract, you can rupture the phaco. If you have multiple VEG F injections, one of those injections could have touched the capsule leaving a weakness. So gentle but thorough hydro dissection and the placement of posterior cataract, hydro-dilation rather than hydrodissection. This is one step where a PCR can occur but it’s far and away the rarest point. So if you’re sculpting, the probe can go through the base of the nucleus and you get this horrible red glow. You can see a snap of the pupil as it comes down and expands again, that’s a sure fire sign you have gone through the posterior capsule. Maybe aggressive phaco settings, not paying attention to the morphology of the lens as a junior surgeon you can have an early PCR which is harder to deal with than the one that happens later on in the surgery. Last quadrant removal. With the phaco machines, this is something that happens less frequently than it did when I was training 25 years ago when the posterior capsule was frequently bouncing up towards you. So all the modern phaco machines are less likely to happen. What trainees should avoid is chasing the last segment. Trying to pick it up from the periphery when they’re not in the right position because PC rupture can certainly happen if you start to chase sections of the last quadrant of the lens. There’s the temptation for people to have the second instrument inside the eye when removing the last quadrant in the incorrect hope that it might keep the posterior capsule back. It’s much better in my opinion to remove the second instrument. So you have a nice tight anterior chamber and the fluidics of the machine can be relied upon to let that segment of nucleus come up to the phaco probe. There is often leakage of aqueous and fluid out of the anterior chamber and you’re more likely to get PC rupture. Sub incisional cortex, you think I got rid of the nucleus, you are relaxed and careless. Irrigation, aspiration of the cortex can lead to rupture of the posterior capsule and this is really something which should almost never occur because almost always it’s due to surgical technique. And finally, and probably least commonly is when incorrect IOL implantation technique. You have to be pretty aggressive implanting an IOL to tear the PC but it certainly can happen. >> Okay, Ivo, maybe show us the appropriate phaco settings and let’s — sorry — let’s talk a little about the phaco settings that are appropriate for conducting anterior vitrectomy and then we’ll jump into another virtual surgery and help the audience understand the importance of low flow, low vacuum and high cut rate. >> Of course. I think it’s extremely important, and again, one of the things we learn in simulated environment is to learn how to think instead of learn how to copy a technique or parameters from another colleague. So in this case you’re seeing a specific machine but what I want to transmit to you is the logic behind this. And I think it makes a lot of sense in this case that you’re always going to need to have a high cut rate. Why? Because of the principal of you don’t want to traction vitreous and vitreous you first should cut it and then aspirate is extremely important. Because vitreous behaves that way. The second thing is about irrigation, aspiration and vacuum. What you want in anterior vitrectomy is you want to go smoothly and control the situation. So you don’t have the mind set of being fast but pre-sis. Precision is everything here. What I strongly recommend in anterior vitrectomy is a low — if you have a gravity machine or if you have an active fluidics machine that is called Centorian, you have an IOP and the anterior chamber is going to be low. I recommend low vacuum settings. A 15 or 20 aspiration rate. Sorry it’s in Spanish. We do surgery in Spanish, sorry. And about vacuum, you want low vacuum in order to traction vitreous. There is something interesting here and I would love to ask John in this case, because I have seen many, many surgeons especially in the U.S. who say something interesting. Just to keep the conversation and think about it. There are many surgeons that say, okay, vitreous, vitreous is what? 98, 99 percent water. And people who will lower the — say they don’t want to hydrate vitreous. How can you hydrate something that is already 99 percent water. You know what these guys do, they put a high bottle when doing anterior vitrectomy and they say they do that because they want to push everything back. I don’t know what you do, John, in my case, I still use low bottles but there is always other mind sets around. >> Yes. So certainly, in the UK the teaching and my personal practice is to have low bottle height, low pressure. It’s not so much hydrating the vitreous. One of the points you make in the slide is to have the irrigation well away from the point of the PCR but low bottle height you have more control. And low vacuums and low flow rates but with high cut rate. The ability to go from aspiration cut to just aspiration when you’re removing vitreous and cortex and been able to flick with your food pedal seamlessly from one to the other. >> Perfect. So again, we talk about parameters. High cut, low bottle. Low vacuum and low aspiration rate. Why? You want to control the situation. Next one, please. >> Okay. Now I think this is the perfect opportunity for us to apply this theoretical discussion in real world terms. Our next virtual surgery is actually going to be Dr. Ferreira doing a typical cataract case. Doing irrigation and aspiration and everything is good and getting ready to put the lens in and then suddenly have a PCR. And all the psychological and cognitive and psyco motor skills and decision-making elements are going to come into play. I think we’re going to do L5. >> That’s correct. Guess what? As always I have a surprise. Because I really want people, you know, sometimes they see me that I have experience with the machine and they will say, you know, okay, he makes sense. He knows the machine. But we’re going to put one of our great students to do it and I’m going to comment. Why? Again, I think it’s extremely important for people to understand that simulation is the way that in my humble experience, simulation became the gold standard to train so many things, specifically this one when we have complications. Again, we’re going to have one of our students to come and I’m going to try to comment and John, of course, you are — this is the other power of simulation, you’re going to be a virtual mentor for 7,000 kilometers. She is going to be in a great situation. So we have Allie here. We’re going to do, let me talk to you — >> Good morning. >> — about this scenario. We have again a scenario in which she is going to do INA as you’re going to see here. There you go. There is still cortex in the anterior capsular bag, the bag is not broken. So now, I think it’s extremely important for you to understand that she has many things to show or to use. She has a lot of tools. She has irrigation, aspiration, she can choose a vitrector. She has viscoelastic. She is going to be doing a decision making on steroids here. You can start, she is going to do the INA bimanual. She has an aspirator in the — (speaking Spanish) okay. Very good. You’re going to see she started with irrigation and now she is going to do the INA. Perfect and suddenly something bad is going to happen. No matter what she does, something bad, oh, that happened and I hope you can see. I see it perfectly through the screen. She has a big posterior capsular break. This is the moment, this is the key moment where everybody freezes and everybody brings everything out of the eye. And that could be a big problem in this case. Why? You don’t want to lose the pressure on the anterior chamber. She did something great. So she put viscoelastic in the anterior chamber. That single maneuver is extremely important. Why? Because she is keeping the positive pressure in the anterior chamber. One thing she can do, she was able to put — to visualize vitreous a little bit better. But guess what, in the operating room, I challenge anybody who has — ready in that specific moment. It’s not easy to have triamcinolone ready because you’re doing phaco and have high confidence. >> Obviously, you knew that the PC rupture was going to happen and you’re pretty relaxed. But one of the dangers, there is a human reaction to deny that it happened. To wish that it hasn’t happened. But what you must and Brian little and Larry Benchman talk about the danger of denial. Recognize the signs and rather than panic and remove the instruments, do exactly the correct thing. Keep the infusion going and tamponade the anterior chamber and then you can pause and stop. And get your team ready to carry out the next bit of the procedure. And that’s, as you were saying, the most important thing. Yes, this happened but I’m relaxed. I know exactly what to do and so does my team and then carry on. >> Great. Now she did a second thing, again, you can see in the machine the settings, okay. So we have, let me show you the settings perfectly. There is a 45 cm of height of the bottle. A vacuum of 175 and high cut rate of 3,000. Again, anterior vitrectomy is about the parameters but about how you behave. So she did something, I don’t know if you were able to see, she did something which I always recommend and it’s extremely important for me. That is what? She went below the rupture, below the level of the posterior capsule and that is exactly because of one of the most important principles after anterior vitrectomies, she is not pulling vitreous from the posterior to the anterior chamber. There is another discussion to come. Probably there is many American surgeons in the audience and we know there are many American surgeons that will even choose to access an anterior vitrectomy through pars plana. John, tell me your thoughts on this. >> Five years ago when I was teaching in the U.S., this was mentioned to me, nobody in the UK would do an anterior vitrectomy by a par planar approach. It seems a well-recognized way to do it. But in the UK, everybody that I know would do it through this bimanual anterior approach. It’s a controlled approach and certainly the one that I would prefer but equally valid doing through the pars planar if you’re a trained vitreous retinal surgeon and are used to that approach. >> Excellent. Now, there is another important thing that Allie needs to do. She took care of vitreous. My, what I’m teaching here, my mantra is always for people not to forget to say if you see vitreous, you go for vitreous. So even if you have a piece of lens or cortex, if you see vitreous, you go for vitreous. Why, if you enter the anterior chamber with another objective, you’re going to create a couple of important problems. Because you’re going for INA or the lens and then your traction in vitreous a lot and vitreous is sticking to the hand piece and to the aspiration. So it’s very important. Now that she deal with vitreous and you see the posterior capsular break, it’s amazing, it’s completely closed. Now she is going for the cortex. There is something important here is that sometimes you can go actually with the vitrector for cortex. That is what we’re showing in the parameters. Sometimes you just put the cutting, you can put it off and then you can go for, with the aspiration for cortex. John, what are your thoughts on that? >> Absolutely. I will use the vitrector settings to either have cut IA or just irrigation, aspiration. At this point using the vitrector on aspiration mode. And if I see vitreous comes forward, I put trans-sin loan in and with the foot pedal kick right and cut the IA and remove the vitreous and kick again and go back to aspiration. In a fraction of a second you can flip between those two modalities and safely remove the residual cortex without damaging the capsular access and at the same sometime removing any bits of vitreous that might come forward into the anterior chamber. I think it’s a neat way of doing it. >> Great. >> I believe the EyeSi can be set up now. The foot pedal can be configured to do that. >> Exactly. We can put the cutting off and do the aspiration. Look at this, just to end, she, before she left irrigation she put viscoelastic. This is something so important for me and there are so many people that can forget about that. I think it’s extremely important to do. In this case, let’s do it. The only thing that happened, she did everything great. Okay. So the metrics went to zero because we were waiting for you in the comment and we stopped. We transitioned from, when she was doing vitrectomy to IMA. The machine said you paused the irrigation and she removed 100 points but that is only because we were waiting. She did everything great. Look, she didn’t leave any vitreous in the anterior chamber. She even removed the vitreous from the directly below the capsule where the break was. And she almost didn’t pull any vitreous from the back to the front. So again, imagine this, Allie here is training with two mentors, one is with her and the other one is 7,000 kilometers away. She has metrics on what she did. She is doing a test this she can repeat, what, five, ten, 20, 100 times. And she has subjective metrics with that. There is no other way how to train this. I don’t know if you have any last comments for this simulation activity, John. >> I think you summarized it beautifully. I think the other comment I would make is when you’re removing the instruments from the eye, say you’re going from cut to IA, just have the cutter on until you have taken the instrument out of the eye and that minimizes the chance of having any strands of vitreous there. I’m not sure again with the modern iterations of the EyeSi whether we can effectively inject miochole at the end to shrink the pupil and see if there are any little bits of strand comes up to the wound. But that is another thing that would be great to simulate and practice before having put the lens in place. But it’s a wonderful — it’s a great demonstration and well done by the student. I noticed the book there, Ego is the enemy. Very important. Good. We’re going to our survey next, Marshall. >> I believe that’s the case, yes. Let’s continue. All right. We’re going to have our second survey. Which is the moment in which you are most at risk of having a posterior capsular rupture in your experience? Let me do a comment since people are answering. We have been with an approach lately about seeing cataract surgery as a process. Like let’s be engineers and let’s see, in which part of the process there is big risk. Even engineers do risk management activities. So I think it’s extremely important for you to see where problems can happen so you’re more aware of them. And I really like the answer. Actually, no, please, John. >> I think quadrant removal I would agree is the one where there’s the highest risk. And that can of course be when sculpting you can go through the rhexis and if you’re chasing bits of fragments of nucleus around the bag rather than let them come to you. You’re trying to peel away epi nucleus. Employing incorrect chopper techniques where the chopper catches the bag. And operating on dense cataracts and you’re going through the back of the capsule. But it was interesting to see IA being as low as it is. And that’s what it should be. It shouldn’t really happen with irrigation aspiration once the nucleus is removed. Quadrant removal is certainly the time where I see it most commonly with our trainees in the UK at the moment. >> I agree with — sorry, please. >> No, Ivo, go ahead. >> No, no, I will say that I agree 100% with quadrant removal. But in the second spot from my experience and what I see around the world, I would say IMA is higher than that. Especially for a confidence level. Many people, the nucleus is out, everything is fine and they start rushing the surgery, especially in the sub incisional part. I see many posterior capsular breaks that we can avoid as the second place that a posterior capsular break can happen. Sorry, Marshall. >> This is probably one of my favorite parts of the whole discussion and something I think the folks in the UK are way ahead of the curve on. That is looking beyond the surgeon experience to the larger OR dynamic of the team. John, do you want to share with us some of the really position o progressive parts. >> This is a concept popularized by my David in Glasgow and he calls it the fire drill for PCR. If you watch a formula one team when the car comes into the pit and they change four tires in 8 seconds, there are 20 people around the car. Every single person on the team knows exactly what to do and what their role is, how they have to do it to get a smooth execution of that pit stop. That’s what your theater team should be. Everybody in that room needs to know exactly what they should do. And have a checklist before the operation. They should be informed of which cases there is more likely to be a complicated procedure or not. How can you practice this? Can you have immersive theater team simulation with unscripted complications. We’ll see that in the next slide. One of David’s tips for this is have the bag with everything you’re going to need to manage the PCR. You the trans-SIM loan and the miochole and nylon sutures are ready for securing the wound. You have the anterior vitrector. You don’t have to say can you find these things. It’s all in one place and everything knows exactly what they should do. The other thing that we stressed to our UK trainees is that all ophthalmologists should know how to set up their phaco machine for an anterior vitrectomy and not just rely on the scrub nurse. You may one day operate with a scrub nurse who is not very experienced and you need to be able to do it yourself. In our courses, it’s interesting to see how many people know how to set up the machine themselves. So we’ll show the next video of the fire drill in action. And we tend to do this as the end of a routine operation, once every three or four months. Here we are in the theater. Paul is one of our cornea surgeons and there is a model eye. And there’s been a PC rupture and he is saying to Heidi, a senior scrub nurse to calmly get up the phaco machine. At this time you do what we did in the simulation. Start thinking about what you’re going to say to the patient. You’re going to say we’re just going to take a little longer to finish your operation. There will be extra maneuvers: I hope you’re comfortable. Make sure they’re not in pain or discomfort and talk them through the whole thing. And Larry Benton one of my mentors, use your dinner party voice. Rather they saying get the vitrectomy — say calmly, please set up the machine. Calm voice, like it’s a matter of routine that reassures the patient and the staff around you that you’re in control, the team is in control. That’s what we mean by fire drill training. Here is the model IV used. It’s a cataract eye which had the posterior capsule ruptured. It’s filled weeing white. Paul is staining the egg white with a substitute and carrying at an anterior vitrectomy. So the people had practice setting up the machine and talking like you’re talking to a patient. I would highly recommend everybody who is involved in the theater team to instigate this form of fire drill training. On the surgery website there are ways to detail this type of simulation. >> On that note, now we’re going to actually look at some of the available resources that you can tap into. John just mentioned this amazing gallery that is available online and maybe you can share that with us a little bit, John. >> So link to the simulated ocular surgery website. People send in videos of surgical simulation. And all the techniques that Ivo has been showing on the EyeSi, teach you a lot of the manual dexterity and cognitive skills but to put it in practice in the theater with your microscope and your vitrector is the next step to that. With the simulation that we’ve seen on the EyeSi, the trainee there knew what was going to happen. You can doctor these model eyes. So somebody can be doing a phaco without realizing we ruptured the posterior capsule where a blade or damaged the zonule. They don’t know whether it’s going to be a bird strike or the landing gear not working like for a pilot. People in the theater, the surgeon does not know what complication is going to happen. And that’s a real test of whether you’re ready to deal with these type of scenarios. This is a video here showing, Marshall, go to the next one if you like. Keep playing this. It shows you with the egg white vitreous, the triamcinolone substitute and the video has the recipe you can use. When the sodium salt and egg white mixture react with the calcium, you see how it becomes this tenacious liquid just like vitreous. So the skills you practice on the EyeSi, you can practice with your Victrector to clear the vitreous away and make sure there is none left. And inject more egg white. You can practice for half an hour, as long as you like in removing the vitreous using the cutter on your own machine. It’s the next stage from the virtual reality to practice in theater with your team. It’s highly realistic. These eyes can be used time and time again to do the same form of simulation. Thanks, next slide. This video is from the Cybersight website. Shows you what happens when you’re carelessly removing the last pieces of the cortex here. Play the video. >> Hang on one second. >> Watch carefully what happens. That star thing, the PC rupture, a hole. They recognized the complication but what do they do? What shouldn’t they do? What they shouldn’t do is remove the instruments from the eye. Should do what we saw in the simulation earlier is keep the irrigation going, tamponade that. You can see how that small PC tear suddenly becomes a larger one with more vitreous prolapse. Recognizing the sign. Ideally refluxing and kicking left with the foot pedal to stop the PC tear. But if it does happen, get some viscoelastic in there, anterior chamber decompressing, control the tear. And then have the conversation with the scrub team about setting up for the anterior vitrectomy. A nice example of whatnot to do. >> That brings us to our third and final survey question for our audience. What is your confidence level managing prolapsed vitreous if you encounter a PCR? >> Again, you know in this kind of question, I like to put a little bit of philosophy in it. Right. What confidence means, because you can be confident but maybe you don’t have the correct knowledge to make decisions. I think we should always think about what it means to be confident in this kind of case. I head a great student a couple of months ago, she would say, hey, I can be to confident and everything but give me correct algorithm, you know, which decisions to make in every possible scenario and my confidence is going to boost in that moment. I think this is one of the exact moments to do that. let’s see what people picked. Okay. >> Since the beginning we have a very interesting, let’s be honest, we have a very interesting audience here. There is a lot of people and many people said they have been training on anterior vitrectomy. There are many people who didn’t have formal training. But here even if they have correct training, you know, there is lack of confidence in many of them. That is good. That’s the most important thing. Start with being humble and identifying that we all have a lot to learn. John? >> Yes, absolutely, I agree. Again those figures show the need for this type of training to access not only the virtual reality stimulation but the model eye is highly effective as well. And just going through your own mind and almost rehearsing what you’re going to say to the patient, say to the team. Could you have done that. That’s another thing you practice and there is not that pressure to communicate with the scrub team, with the nurse and think about what you should be doing. But it’s okay to pause once things are stabilized and then a deep breath and think, right, now we’re ready to go again. It’s not a rush, it’s not a race. It can all be managed slowly and calmly. And every single anterior vitrectomy just like every cataract is surgery but in particular every anterior vitrectomy is different. As long as you have the basic principals that we outlined today engrained in your brain, you will end up with a good result and a good visual result and a happy patient. >> Can’t agree with you more, John. >> I think for the interest of time, Marshall, this figure can be seen on the Cybersight website. It doesn’t add touch to what we’ve been talking about. We can just go to the, maybe the last slide for the simulation. >> Let’s do that. >> Or just the ten commandments. >> I think this is actually a perfect set up for the last live virtual surgery. Because it really speaks to the paradigm of it’s a high risk situation but one that does not happen frequently. How do we as professionals prepare ourselves adequately for something that happens so infrequently. And I think this whole dialogue has been about finding non-patient encounter-based mechanisms by which we can assure ourselves that we have surgical readiness. With that, do you want to take us to the last live virtual surgery? >> Yes, sure. Let me comment a little bit about what John said. Again, look how they’re planning for something that can be so stressful, so complicated. This is a complicated scenario. And they are proactively simulating what’s going to happen. And they have one of the best healthcare systems in the world. And let’s be honest, in many other parts of the entire planet, you see ophthalmologists with clinics so you don’t have all that staff that is well trained and there is a lot of communication. So I think what you just said, John, with also David and this about the fire drill, this is something that everybody should do around the world. Because sometimes they’re doing surgery in different scenarios with people who are not very well trained. And yes, we’re going to simulate the task itself but this is a team, right. This is a team activity. You need to also train the people who are going to be giving you, you know, all the instruments you need and helping you with new stuff that they’re maybe not very used to use. Like the anterior vitrector. With this, I would like to have another student. I want her to go back to level No. 7 so we can see very fast how she is going to perform what I did completely incorrectly in the beginning, she can do it right. I think again, this is extremely important. You said it Marshall, this is not going to happen frequently. We have an amazing student. She is in her learning curve as we speak as she came to train with us for two weeks. My question to you is are you competent if you did 200, 300, 400 cataract cases but you’re not competent doing anterior vitrectomy. This is exactly what is happening to her right now. >> Absolutely. This is where the virtual reality simulator, if you have access to the EyeSi is so invaluable. >> Okay. So remember guys, level No. 7: You have a posterior capsular break. The vitreous is stained. And now she needs to make decisions based on the most important anterior vitrectomy principals which is always have positive pressure on the anterior chamber. Don’t bring vitreous from the posterior chamber to the anterior chamber. And don’t traction vitreous. So you see her movements are very slow and very controlled. She went directly to a lower level with the vitrector. You can see in this exact moment, you’re going to see vitreous that is going down. You know what I mean? It’s going low. It’s not going through the main incision. So vitreous is slowly, because she is taking her time, right, going to the posterior chamber. You can see the vitreous that is not stained right in the bottom and that’s a good thing. She has the correct parameters. She is making sure that she has positive pressure in the anterior chamber. And now, she is taking the time, this is a completely new mind set. This is not cataract surgery if it takes 20 minutes, 30 minutes, 40 minutes, you need to take those 40 minutes. And I think one of the most important things, John, is that sometimes you see this as failure but if you really take your time and do things right and do a three-piece IOL in the sulcus, these patients do so good in the postop. >> Absolutely. They do perfectly well. >> She did a mistake. She is going to be penalized. She decompressed the capsule. This is training, this is real life. She is going to have a bad score now. She was coming great. But in the end, she did decompress the capsule. The anterior chamber. >> Very nice up to that point. Very nice up to that point. >> Okay. So she did everything good, again, this is the way, how you learn. She did everything good. She didn’t leave any vitreous in the anterior chamber. She didn’t leave vitreous below the capsule. She didn’t put vitreous but she decompressed the anterior chamber in the end. What happens? Exactly what you were showing in the video, right, John. Even the hole sometimes gets bigger because the vitreous comes into the anterior chamber. >> Very good. >> I don’t know, Marshall, if you want us to do another. Again, you guys saw two levels and we can have, we have 7 levels. We have many levels in which vitreous are sticking to many substances. There are so many different things. I love that slide. That slide I think is going to summarize everything we have been talking about. >> Just to summarize before we go onto questions, it’s that mental transition to different surgeries. Know the signs where there’s been a PC rupture. Don’t deny it. You’re wishing it hasn’t happened. It has happened. Don’t deny it. Don’t remove the instruments from the eye. Tamponade the eye and make decisions. Knowing about your cutter, is that set up. Seal the anterior chamber. Anterior is my preferred approach and parse planar if you’re trained to do that. Anterior techniques with no traction and starting at the level of the PCR and working up anteriorly. And completing the vitrectomy. Final slide. Triamcinolone is your friend. Judicious and copious use of triamcinolone to visualize the anterior chamber up to the wound. Once you removed the vitreous in the cortex, the decision is, is it safe to implant a sulcus lens. If so, what strength of lens are you going to choose compared to the strength of the lens you’re going to use in the bag. That’s another webinar. And how to implant the lens safely. Shrinking down the pupil and making sure there are no strands of vitreous. Communicating calmly and empathetically with your patient. Speaking to the patient immediately after the operation. Speaking to them before they go home and their relatives. Meticulous follow up. Check the pressure the next day. And the following week, you do not want to lose these patients in a big hospital system. By looking after them so well, they are often your most grateful patients. Not only should they have a good visual result if you followed all of these steps but they have been looked after extremely well. That is so important. Patients who like their doctors, who feel they’ve been well looked after and haven’t had a frightening experience, maybe pleasant but a longer experience in the theater are much less likely to sue their surgeon and be happy with the outcome. So communication is absolutely key. I cannot stress that enough as well as the other surgical and cognitive skills that we have spoken about. Thank you, Marshall. >> Okay, that’s a wonderful summarization of all the key take aways from today. There are a few questions, gentleman, that we’ll try to get through. We’re a little over time. The first is when you have a PC tear in the vitreous is lost accordingly, but put the lens, no chance to put a lens in the sulcus. Sorry, I’m having trouble understanding the question. Maybe — >> There are scenarios, Marshall, where if you’re not sure, you think is there enough support there. Say there is an anterior capsule tear and you’re not confident there is enough support. Clean the vitreous up and explain that we didn’t put a lens in for this surgery. But let the eye settle down and then — especially if your patient is becoming uncomfortable, the local anesthesia is wearing off. The operation has gone on for 30 minutes or more. There is no shame in that. It can be the best option and you can decide in clinic if there is support for a sulcus lens or maybe a sutured lens. That is disappointing to the patient but I have certainly done that in the past and ended up with a good visual result. But it come down to communication and decision making. If you think it’s hazardous to put a lens in, I suggest you leave the patient until you’re confident on what lens you can use. >> I agree 100%. And I especially like that you are teaching people how to think. You need to evaluate every single case. I think in cataract surgery, we more, are more aware of what is going to happen and it’s easy to make decisions but in anterior Vicar everything changes. You need to evaluate every single case and make the best decision for that patient. >> Okay. The next question gentleman, how do you handle the lens pieces when a PCR occurs during sculpt or a quadrant removal. >> That is an entire webinar. But again, yes, because the decision making process, again, is so complex, you’re going to base in very important principles and is vitreous present or not present. Or is the piece of the lens hard or soft. How is that — the characteristics of the rupture. Is it a big tear. There are so many variables that we can be here two or three hours talking about the different scenarios, right John? >> Absolutely right. And whether it’s a small hole or whether the bag is gone and you’re trying to prevent pieces of the nucleus floating into the vitreous. But if it’s obvious the lens is going to tip and fall into the vitreous, do not go chasing it with your phaco probe. Just let it fall. Because you can’t retrieve it. You think on the anterior segment, you’re going to have to let it go and swallow your pride and get the VR team in there to help you out. Do not think you know what I think I can get this. It’s only gone into the vitreous a little bit. Do not ever chase a piece of the nucleus with the phaco probe, you will make things ten times worse. With a big PC rupture and you can’t safely float the remaining nuclear fragment up to the anterior chamber, you have to cut your losses and involve the VR team and they will do a nice job and remove the piece of the lens and then you can help with the IOL selection. But don’t go chasing bits of nucleus behind the posterior capsule or what is left of it. >> A degree of pragmatism is always a healthy thing. Last question, this is I think a subject Ivo and I talk about a lot in terms of equity and access to resources and one reason I’m so grateful to be part of this activity with Orbis. Any suggestions for simulation ideas in low-income countries with little or no access to an Eyesi simulator. >> You have done the phaco, it can only be done once but you have a PC, you have the capsule there, you can rupture it and fill it with the egg white solution. As long as you wash it, it can be used multiple times to practice this technique with the egg and sodium salt solution and the made up triamcinolone solution. It’s safe, no matter what the theater nurses say, it’s safe to take these and the egg white solution into the theater and use it with instruments you operate on with patients. And that’s a cheap way of replicating at least some of the motor skills. Of course you don’t get the detailed feedback with the Eyesi. But you will get used to having the instruments and the vitreous and having the foot pedal. There is a cheap and alternative way of doing things. >> With that, I think we’re a wrap. Dr. Ferris and Dr. Ferreira, thank you for your time and sharing your wisdom. Dr. Ferreira, the resources that you have and your passion and knowledge are amazing. We’re all grateful to Orbis and the folks at Cybersight for creating this platform. Thank you everybody for your participation. If you were unable to attend, Cybersight will have this tomorrow online. And people are more than welcome to access this at that time. Thank you all and have a good day or a good evening. >> Thank you very much. >> Gentleman, thanks. >> Thank you, very much, bye bye.