Lecture: Remotely Supervised Simulated Ocular Surgery

This live webinar will focus on how to set up systems for remotely supervising EYESi and model eye simulated surgery, and how these can be used to provide high quality virtual surgical training. Trainees and trainers can be based in digital dry-labs or at home, and teaching can be on a one-to-one basis, or as part of a hybrid surgical workshop.

Lecturer: Dr. John Ferris, Ophthalmologist, United Kingdom


[John] Welcome, everyone, and thank you very much for joining us for this Cybersight webinar on remotely supervised simulated ocular surgery. My name’s John Ferris, consultant ophthalmologist in the UK. I’ve had the privilege and honor of taking part in two trips with Orbis to Peru and to Chile in the capacity as a surgical trainer. And what I want to do over the next 45 minutes is just illustrate some of the ways where face-to-face training isn’t available or to complement face-to-face training, remotely supervised simulated ocular surgery is a way of providing high-quality training for trainees who may not even be in the same country as their trainer.

Financial disclosures. I’d like to disclose that I’ve designed and funded the Simulated Ocular Surgery website and the Simulation Gallery. And some of the model eyes, heads, and the Zeiss microscopes, which you will see in the videos today, are sold on this website.

COVID positives. It’s very hard to think, really, of COVID positives at the moment as omicron variant sweeps across the globe. But from a medical educational point of view there have been some positives and one of these is the explosion of educational webinars. And Cybersight and Orbis have been at the very forefront of this phenomenon. But across all sorts of organizations, the Royal College of Ophthalmologists, the American Academy, other ophthalmic associations, industry-based educational webinars, there’s been a fantastic array of great, free education available since COVID. And I don’t suspect this would have happened without the impetus given by the pandemic.

Remote teaching in your own region with Zoom and Teams mean that trainees who aren’t able to make it to a local training day can still join in with the training. Virtual consultations may be part of many of people’s practices who are watching today, it’s certainly part of my daily life now. But also the possibility of having remotely supervised surgical training and that’s obviously what we’re going to focus on over the next 40 minutes.

Just to give an example of how a local training day can morph into something much bigger. This time last year I was organizing a pediatric ophthalmology teaching day for our local Severn trainees. Severn is a region in the UK and we have 20 trainees and I was putting together a program that would run all day and I was going to use some of my ex-fellows and colleagues from the States and India. And when I spoke to David Granite, who many of you might know is one of the founders of the World Society of Pediatric Ophthalmology and Strabismus, he said, “John, great program but let’s make it a global event.” Of course, for no extra effort from the speakers’ point of view putting together the talks, we were able to provide eight hours of education which was watched by 3,000 people live streamed on YouTube and then Facebook and is now there in perpetuity on YouTube. And I think the World Society will be one of the many organizations who have really embraced this technology to provide great educational content.

Why should we be interested in remote surgical training? The main reason, probably, convenience for trainee and trainer. One of the obstacles to surgical training, in general, is getting the trainee and the trainer in the same place at the same time. There are pressures on all of our times, especially as we’re trying to catch up with long waiting lists following surgery which was put on hold during the pandemic. And constraints and geography make it, sometimes, difficult for the trainee and trainer to be together in a dry lab or wet lab situation. Remote surgical training and some of the techniques you’ll see in the next few slides will give you ideas of how you can get together remotely and efficiently with your trainer. So convenience and time efficiency.

It’s certainly greener, a lower carbon footprint. Much as we love going to meetings and traveling to see friends and colleagues, actually, with the emphasis now on lowering one’s carbon footprint, remote surgical training is a great way of doing that. You can also access expertise from all over the world. Here in the UK, we’re blessed with having great access to fantastic trainers on our doorstep. But not every country and not every trainee has access to trainers close to them. And remote surgical training will be a way of bringing this expertise to them for the first time.

And economies of scale with hybrid courses. At the end of the talk today I’ll talk how we can run courses in one location and have satellite centers running in different parts of the same country or in different countries all together, to make the most of the expertise that’s available for that course.

I’d just like to start off by looking at Eyesi training. Most of you will know the Eyesi is a fantastic virtual reality system for introducing people to the skills required for phacoemulsification surgery. The paper that we wrote 18 months ago proved that trainees who’d undergone training on the Eyesi had a 38% reduction in the PC rupture rate compared to the trainees in the UK who had not undergone the Eyesi training. But many UK trainees and trainees, I suspect, in other countries, spend time in the Eyesi but without being adequately supervised. They can pick up bad habits and still pass the assessments that the Eyesi poses to them. Certainly, for at least some of your Eyesi training, you should be supervised by, not necessarily a consultant, maybe a more senior trainee, even someone who’s one or two years ahead of you in the training program who’s been through the Eyesi training, to make sure you’re doing things properly.

And the video I’m about to show, Alexander Raviolo, top left here was our Italian glaucoma fellow and Rebecca Jones was one of our first year trainees. And he is supervising her Eyesi training. And not only is he seeing on his screen what’s happening down the microscope view, there’s also a camera on her hands, so he can see what her hands are doing during the surgery, which is equally as important. I’m just going to play their clip now.

[Sunil] Thanks for watching our video demonstrating remote supervision for simulated capsulorhexis surgery. My name is Sunil Mamtora and I’m joined by Rebecca Jones and Alexander Raviolo. I really hope you enjoy our video.

[Alexander] Rebecca, let’s practice on capsulorhexis today.

[Rebecca] Okay.

[Alexander] Okay. Are your hands comfortable? Do you like operating on 12 o’clock because I actually prefer… Yeah, maybe you may want to switch to 11 o’clock or so. It’s easier to come from the side. Yeah, very good.

[Rebecca] Yeah, it feels more comfortable.

[Alexander] Okay, great. Grasp that in the left now, the margin. Yeah.

[Rebecca] It’s torn out slightly on this one.

[Alexander] Yeah, you might want to grasp your rhexis. Pull back slowly. Yes, exactly. I’m not sure you may want to put the, yes, keep going. Okay. Maybe a little bit too much, but it’s okay. One useful tip can be to use some viscoelastic to fill your rhexis margin but you’re doing very well.

[Rebecca] Thank you.

[Alexander] Slowly with a circular manner. And you might want to grasp the rhexis many times to have more control. Yeah.

[Rebecca] Close to the flap?

[Alexander] Yes, close to the flap, exactly. Let me see your hands now. Position is very good.

[Rebecca] It feels a lot more comfortable.

[Alexander] Yeah. All right. Another grasp close to the margin. That’s a very good job, Rebecca. The last bit is the most difficult one so pay attention there. Fantastic. Fantastic job!

[John] You can see from that video clip, Alexander is able to not only get the surgeon’s view, but also the view of what Rebecca’s doing with her hands or hand position, her posture. And these are just really important things to get right when you’re starting your surgical training. And we find this is a fantastic way of trainees getting real time, high-quality feedback on their Eyesi practice. And if I just go back one slide, that QR code, if you want to take a screen grab or a shot of that QR code, will take you to their YouTube video, which at the end of the clinical bits shows you how to connect us your Eyesi to a Zoom call with all the wiring that that’s required. I wasn’t going to play that today but that QR code will take you to the YouTube video of that.

The next video is looking at ways of where you can have remote supervision in theater or in a wet lab or dry lab. And the first clip we’re going to look at is how we use an attachment called the MicroREC. There’s no audio in the first bit of the video and it’s been speeded up as Sunil Mamtora demonstrates how to attach the MicroREC to a Lumira microscope in our theaters in Cheltenham.

The MicroREC can be attached to any operating microscope’s side arm or to any slit lamp. You take off the side arm, plug in the attachment, and this is all beautifully 3D printed adapters. Then your iPhone or other mobile phone casing. And of course with the high-quality mobile phone and iPhone 12 or 13, you’re getting fantastic resolution of not only simulated, but also if you’re using this for recording live surgery or getting feedback on your live surgery. You can just see in a moment when we go to the larger screen, how the image from the phone can be cast onto a monitor, AppleTV, onto the monitor so your scrub team can see what’s happening and your supervisor can see what’s happening. I think the MicroREC’s a really nice way of supervising people undergoing simulated surgery in an operating theater when it’s not being used for live surgery.

If you want to connect your.

[Rebecca] You can use your video output.

[John] Your laptop to Lumira and then be supervised remotely. Rebecca’s just going to talk how we use the video output from this Leica microscope to the laptop and Sunil’s then going to be supervised by Will Dean in another part of the hospital doing some capsulorhexis training.

[Rebecca] You can use video output from the Leica microscope via HDMI to USB to any laptop. And then use that in any video calling app such as Zoom or Microsoft Teams. As we can see, this quality is excellent and we can see Sunil doing a beautiful three step incision.

[John] This is the video output going to a HDMI video capture card and then into your laptop.

[Will] Okay, you can see that really nicely here. Very good. Good and then keep taking your hand to orbit, and then once you’re about there found your, yeah, that’s perfect, and then start regripping and leading it exactly where you want it to go on that plane on the right circumference. That’s very good. Always worth regripping before you come to the 12 o’clock position.

[Sunil] Yeah, that’s (mumbles).

[Will] Yeah, yeah.

You can move your wrist there so that the forceps are actually coming in from the other side. Yes, more like that, exactly, yep. Very good. And then regrip. Make sure you don’t bring it in straight away there, enlarge it a little bit more towards the 6 o’clock position, keep enlarging it, keep going down. Even more, yeah, yeah, okay. No, that’s brilliant. Very nice that you came in at that little angle here. But you could have even enlarged it a little bit more at the 6 o’clock position at the bottom there. Otherwise, that’s really nice. Very nice.

[Sunil] 8 o’clock?

[Will] Yeah, to the side yeah.

[Sunil] I’ll put the forceps down and see what?

I don’t know.

[Will] Is it?

[Sunil] I can’t see. I think it’s gone out.

[Will] I don’t think it’s all the way out there. It’s probably closer to the center there.

[Sunil] Oh, this is a big bubble of viscoelastic.

[Will] I think that’s more the viscoelastic, I think it’s just gone out towards the 3 o’clock position and down ever so slightly. Around about there, down a little bit, there, that’s it, that’s it. That’s it. Very good, so remember just to fold it over and then regrip where it’s tearing. Yep

[John] Again, you can see how Will was able to see the edge of the capsulorhexis, point Sunil in the right direction and go on. If you do have access to an operating theater that’s not being used, maybe at the end of an afternoon list or in the evenings or the weekends, you can set up this form of remote supervision with your trainer. Perhaps being at home or elsewhere in the hospital. It’s a really nice and easy way, and cheap way, of setting up remote supervision without having to have access to a wet lab or a dry lab.

Just going to spend time talking about digital surgical classrooms using the Zeiss Stemi microscopes. The Zeiss Stemi microscope were designed for use in educational establishments, schools, universities, and industry. But they actually work brilliantly for Eyesi as you’ll see from the coming clips.

This was the first Zeiss digital dry lab and it was run in Cheltenham with Alex Short, myself and Paul Tomlins, we had about eight or nine trainees, all had their own microscope. The one here has a camera on top and that camera from the trainer’s microscope is connected with an HDMI cable to a large plasma screen. And you’ll see in a moment how Alex is demonstrating a surgical maneuver. The trainees will be watching it. Paul Tomlins is actually the one chap operating, Alex is just pointing to how he should be creating that incision. Behind Alex here, you can see a complex corneal laceration. And he’s just describing how to place corneal sutures through this complex laceration. Again you can see the resolution from these axial cam cameras on the Zeiss Stemi microscope, even when blown up onto this very large screen at very high resolution.

Alex then demonstrates the technique and they can practice it. The beauty of the Zeiss Stemi microscopes is that the lab scope app, downloadable free to your tablet or your mobile device, allows you to monitor trainees and to watch their surgery without you being right beside them. Because often having a trainer looking down at the side arm of a microscope, being right beside you, can be slightly nerve wracking. You can be sitting in the corner of the room watching their training, recording their surgery and then you can watch it back and give them some feedback.

Nitin Anand in the blue shirt, myself, are watching one of the trainees doing a trabeculectomy. That’s a releasable suture and we’re just going to record a little bit of that and then we can flip to different screens. And you can watch up to eight people operate at the same time. It’s a really nice, flexible system for setting up dry labs, which require nothing other than a room, a desk, and some power points for your microscopes.

The bottom right image here shows a screenshot from the iPad, there are eight Stemi microscopes linked up to lap scope and you can just click on any one of these, watch it, record it. And also trainees can take the microscopes home. If you have them in your institution to practice, they can record their surgery, ping it to their supervisor to look at or show it to them in person the next day to see how they’re improving. Really lovely little bits of kit.

This is the Royal College’s surgical workshop in London. And the picture on the left is the picture of the Stemi microscopes and on the right hand side of that image is the dry lab, the wet lab. So we’ve got a combination of these two. And these two images are taken with the cameras in the Stemi mic’s grip. A penetrating keratoplasty done by one of our fifth year trainees at the time. And here is a scleral fixed intraocular lens. You get some really nice, quality images.

The Simulated Ocular Surgery Trials published over the last 18 months by Will Dean and his team, the OLIMPICS Trial and the GLASS TRIAL. I hope you’ve all heard of these groundbreaking, randomized controlled trials which proved that for small incision cataract surgery, in the case of the OLIMPICS trial, and for trabeculectomy surgery in the GLASS trial, that simulated surgery improved the surgical scores of the trainees threefold compared to conventional training. And reduced the complications significantly and improved the confidence of the trainees significantly. Please look these up. The reason for showing you the slide, apart from reminding about the trials, is that the set up we’ll use were the Stemi microscoped dry labs.

Here’s some nice images. Bottom right is his main training center in Cape Town. Top right, I think this picture was taken in Nairobi with Will there in person, and a nice shot on the left of a trainee undertaking some practice on a model eye with her instruments in front of her. Highly portable little bits of kit.

But you do not have to have anybody in person with you doing your Stemi microscope-based training. This is a picture from Rebecca’s kitchen, here in Cheltenham. Again, she has a camera on her hands, she’s got the camera on the microscope linked up to Zoom. You’re going to see in a moment how I was able to supervise her corneal suturing practice and Sunil Mamtora’s suturing practice from my home one Saturday morning.

This is the plasma screen at home in our television room. You can see I’ve got my Saturday morning toast and a cup of coffee there, I’ve got my iPad and I can see what’s happening. On the two shots on the left is their microscope views and then on the right the pictures of their hands. And the next clip shows Sunil doing a butterfly suture to close a corneal laceration.

A bit like this, like you’re doing. There’s the start within the incision itself, within there. Start, you’re picking up there. Exactly. Come towards you, make the pass on the left hand side of the wound, it doesn’t really matter the left or the right, it doesn’t matter.

[Rebecca] Straight on the inside.

[John] Yep.

Pick it up so you’re ready to go, this is the important bit. Hold it there, hold it there, twist your wrist round, don’t take it out yet. Twist your, let go of the needle, let go, pronate your wrist, turn your wrist round so you’re ready to pick up that needle and go with the next pass. What’s what I’d teach you, Rebecca, with the strabismus surgery, otherwise you’re going to have to mount the needle again, balance it. So grab it now.

[Rebecca] Got it.

[John] Good. Perfect, I can see your wrist doing the right thing. Now you’re ready to go with the next pass. Cool? And then go to the right hand side of the distal end of the laceration a bit furthest away from you.

Again, the point here is I can see that Sunil, as most trainees do, was just going to take the needle out and then he would have to put it down, remind to pick it up and if you’re doing that with a corneal craft or with a large corneal laceration, it adds minutes. 10, 15, 20 minutes to your operation if you’re constantly having to remount the needle. So I was able to teach them to practice turning his wrist round, grabbing the needle and then he’s ready to go with the next pass. Again, you couldn’t do that without having the camera feed from his hands.

This is really an illustration of how you can access the expertise from all around the world. Many of you will know of Uday Devgan in L.A., the Cataract Coach, and his amazing website CataractCoach.com. If you have not visited this website, please go there, have a look. New videos are posted every day by Uday and by guest surgeons. And he very kindly took part in a remote capsulorhexis workshop for our trainees. And this is a short video clip of that experience.

(bright electronic music)

[Uday] CataractCoach.com. Remote capsulorhexis training. It’s the world’s first remote digital dry lab. I recently had the opportunity, through the courtesy of Professor John Ferris, to participate in the world’s first remote learning digital dry lab. I was here in Los Angeles, and there are doctors-in-training in the UK who are using a surgical microscope in their own home. And using the internet connection to broadcast to me their creation of a capsulorhexis in a model eye. And I could guide them remotely and we had a fantastic time. We had a handful of young doctors, all did great and really improved their skills, and I think this is something very important. This is the way you can do things in the future. You could have a coach like me helping you and coaching you from many thousands of miles away. And I want to show you the video, check this out, and we’ll talk more at the end.

[Rebecca] Remotely supervised capsulorhexis simulation session with Uday Devgan, the Cataract Coach. Using Zoom video conferencing, we ran the simulation session with four trainee surgeons at home, in various locations in the UK. Uday was able to join us from L.A. to give us live feedback and tips for our capsulorhexis techniques. We used model eyes from Phillips Studio. We used a Stemi 305 microscope with an axial cam as the camera feed for the Zoom call. The supervising surgeon could simultaneously see the microscope feed and discuss methods for improving practice.

Being able to pin different video feeds, means the trainer can watch multiple surgeries at once, or just one individual feed. Now watch for some clips of our supervision session.

[Uday] And now look at your tip of your forcep and trace the circle. Way better. That looks perfect now! And now you’re going to do the same thing now, regrab. And now obviously your base is towards the right and your tips are at the left. Perfect! Yeah, fantastic.

Now here at the end, keep tracing it, don’t pull centrally. Keep tracing it like you’re doing a loop, the rest has to go around one more time. Then you’ll finish it and you won’t be able to see the widow’s peak, there, now it’s perfect. If you have a spot that’s irregular, just encompass it or encircle it with the new rhexis that you want to do. I usually do a counterclockwise rhexis, but there’s some cases where I just go clockwise. It really doesn’t make a difference.

[John] You can see there how Uday gave fantastic feedback and great tips. I certainly learned a lot in the one-hour session just watching him talking to the trainees. And really proof of concept that you can have somebody from the other side of the world providing fantastic high-quality training for trainees who weren’t even in the hospital, they were at home with their Stemi microscope set up.

Now I’d like to talk about hybrid skills courses. I mentioned this right in one of the initial slides, how we can actually increase the reach of a course being run in one institution with trainees and trainers able to participate fully in the course but not actually being in that training center. And this is another fantastic video put together by Rebecca and Sunil.

[Rebecca] The recent cataract surgery complications course was the first of the college courses to run both virtually and in-person. The virtual participants were able to watch the talks, engage with the speakers in the comfort of their own home via Zoom. Screen sharing, and they were able to watch the lectures and videos in real time along with the in-person participants.

With a Stemi microscope and axial cam connected to Zoom, the virtual participants could also join in with the practical side of the course, performing Malyugin ring, capsular hooks, and capsular tension ring insertion and removal using a model eye. There was even a remote supervisor, Mr. Larry Benjamin, who was also at home, who watched and gave advice and guidance to the virtual participants. He could watch both participants simultaneously and each trainee could also watch the others’ progress. Here are some clips taken from the remotely supervised Zoom call.

[Larry] If your deficiency was, let’s say, 3 o’clock on the left hand side there.

[John] I’m just going to pause this, this is a capsular tension ring being inserted into an advanced cataract Phillips Studio eye where we’ve created a zonular dialysis. So the bag’s a little floppy. Larry Benjamin is giving instructions on how to introduce the capsular tension ring in a minimally traumatic way. Here we go.

[Larry] Then you would go in as you’re doing it because then it pushes against the deficiency as you put it in. Alternatively you can just flip it upside down and do it the other way if the deficiency’s to the right. Again, if you try and engage that you might find it’s too big to go through. Oh, you’re in. Good, well done. Gently guide it around with the injector. Is it under the capsule?

That’s good.

Be careful at this point.

[John] Just in case you’re wondering what this suture was around the capsular tension ring, that’s purely so that we can then remove the capsular tension ring, remount it and then perform the whole procedure again. And here we have Malyugin ring insertion being demonstrated.

[Larry] Be careful at this point, that’s it. That often happens, that top scroll going over the edge of the injector. You probably can’t get it out like that, but if you want to be obsessive, then just manipulate that into the cartridge with the hook. That’s it. It should probably come out of the wound at that size anyway. You can tuck it in, it’s better.

Cool, well done. Brilliant. That’s the essence of it. Just slow, gentle manipulations and it eventually does what you ask of it and that’s brilliant, well done. That’s nice.

You want to try taking them out now?

[Student] (unclear murmuring)

[Larry] Again, it depends. I think if you can leave it as it is for the moment and do one, then the bag is under tension and won’t move while you take them out. It’s probably, you could do them one at a time. It depends on what you’re using them for. If you want the bag to move then that’s different to if you don’t. And now I think you just pull as they’ll unfold, yep. That’s good. Once you’ve got it, you just got to be careful you’ve unhooked it from the capsule first because, obviously, you’ll pull on the edge otherwise.

[John] During the course Rebecca and Sunil, who were at home, could watch the first five, 10 minutes of lecture preceding each of these things. The capsular tension ring, Malyugin ring, they would then watch a demonstration performed at the college and then go into the breakout rooms. And in the college, we had a ratio of one trainee per four trainers. They had a ratio of two to one with Larry Benjamin providing fantastic tuition from his home as they practiced all of these techniques from their home. Even quite complex anterior segment surgery can be not only simulated but supervised remotely.

And the college will be running a trabeculectomy workshop in February and we’re going to have three satellite centers in Scotland, the east of England, and southwest of the UK with trainees joining in there with their supervisors. And it’s basically doubled the capacity of the course that we could have run if we were limited to the trainee numbers in London. But there’s no reason why courses like this couldn’t have 20 satellite centers, each of them benefitting from the experience of the trainers in the central hub.

Multiple locations. The awesome thing that you can have is a little iPod auditory feeds from a consultant who’s giving you supervision. And mentoring schemes with this setup is certainly possible in countries with limited training. These are all ways in which this type of simulation training could evolve.

But it’s not just all about anterior segment surgery and cataract surgery. I’m a strabismus surgeon, so I wouldn’t want to conclude a webinar without talking about strabismus surgery simulation. In fact, a previous Cybersight webinar we did live demonstration with these model eyes. But it’s even lower tech, you’ve got your selfie setup here with a ring light, a mount for your phone, and that’s illuminating the model eyes. Again, your phone is linked to a Zoom call. You can either use this set up to record your surgery and then show it to your supervising consultant. Or, as we did with the World Society of Pediatric Ophthalmology and Strabismus, we set up a virtual strabismus surgery training session. And we had five trainers: one in Canada, one in the US, one in Hyderabad, one in Lisbon, one in the UK. And we had trainees from all over the globe who were able to join us. They’d made their own model eyes according to the instructions we sent them. They had devised their own set up with the Eyesi, with the illumination ring, and their phones. These trainees were selected because none of them had done any strabismus surgery before. We wanted to just teach them the very basics of needle handling, instrument handling, how to make a safe scleral pass, how to secure a muscle. And each trainer had two trainees and a breakout room. We had an hour training together and then we came back together to talk about what we’d learned.

My next video clip is just some edited highlights of the two trainees who were with me. Hetty was in Johannesburg and Derek was in the UK.

Again, that’s too vertical, Derek, if you do that in real life, you’re going to go through the sclera. If you watch my needle again, and I’ll just try and boom. Try to make this dual screen because, just try and show you the difference in angulation. Whole different model eye here at an angle. You’re approaching it like this. You’re relying on you just going at the right depth. Just push down vertically. So on the sclera just push down, go in a straight line, and then roll your finger and thumb and you’ll get the right depth. At no point am I going like this, it’s flat, pushing it down, and then rolling it.

Here is Derek who had done no previous strabismus surgery, making two safe scleral passes at the end of our session. Bearing in mind his first pass of the needle was pointing directly down into the globe, he’s now making it in lovely, long, safe scleral pass backhand, and now he’s doing a forehand pass. Again, achieving safe entry of the needle into the sclera and making a nice long pass with no danger of that needle tip passing through the sclera into the globe. He’s got complete control of the needle all the way along the pass, a big improvement.

And then I’m just going to move on to Derek now securing a rectus muscle for a medial rectus recession. Continue suture placement in a rectus muscle at the end of our wet lab. And the only instruction I gave him during this was just when I told him to pull his suture through so that it was halfway along the continuous suture. He has no other instruction during the course of this suturing exercise.

He’s placed two nice sutures through the middle third of the muscle. Being hypercritical here, he hasn’t quite come out partial thickness, but a nice, safe pass. He’s regrasping the needle really nicely now, ready for his next pass. Full thickness, pass through the edge of the muscle. He’s now just holding the suture slightly long but realizes this because he can’t wrap around the needle. He shortens his grip without any instruction from me, wraps it underneath once, twice, to create a locking knot, pulls it through and secures it at the edge of the muscle.

You can just see from this clip, how’s he’s confidently handling the needle, he’s regrabbing it before making the next pass, he’s getting the hang of creating a locking knot at the end of the muscle, and this is literally after 40 minutes practice from a chap who’ve never placed a suture through the sclera before. And it just shows you how this low tech model and a phone and decent illumination, link to Zoom, means we can provide high-quality surgical training for strabismus surgery, not only basic but advanced strabismus techniques as well. It was a really successful workshop.

In conclusion, the simulation gallery which is linked to the Simulated Ocular Surgery website, has many of the videos you’ve seen. Here’s Uday Devgan’s video on the homepage. When you click on the cataract surgery section or ocular trauma or glaucoma, it will take you to videos that trainees and trainers have posted of high and low tech ways of simulating many, many different types of ocular surgery. I would encourage you to watch some of these videos. If you have some interesting ways of simulating surgery, please ping us a video, you can send a video submission, and if it’s of the appropriate quality, we will put it on the website.

If you follow us on Instagram, Rebecca and Sunil have been instrumental in setting up the Simulated Ocular Surgery Instagram page. I think there’s 1,700 followers at the minute. Any time a new video is posted, you’ll get a notification and you can watch it in full on the website.

What I’ve tried to show today is how simple technologies can be used to, in Will Dean’s words, democratize surgical training. We’re democratizing surgical training by making it feasible for trainees, no matter where they are in the world, to access to high-quality training. Hopefully I’ve shown you that also it makes it easier for trainees and trainers to hook up together. So you don’t have to be in the same physical space, you just have the same 30 minutes free so you can do some high-quality training.

And we’ve shown you don’t need to be in an expensive wet lab or dry lab. You just need some basic kit, Stemi microscopes and other microscopes work well, also linked to a mobile device, and using Zoom or Teams you can have high-quality supervision. We’re hopeful that even when we’re able to travel freely following the pandemic, that this will be not a replacement of face-to-face training, but an adjunct to face-to-face training both locally and internationally. I hope you found the talk helpful.

I’d like to finish by saying a huge thank you to Rebecca Jones and Sunil Mamtora who have been the driving force behind a lot of what you’ve seen today and really proves the point that it’s the trainees around the world who will be driving this, not necessarily the trainers. To Uday Devgan who gave up his time so generously for that workshop, to the team at WSPOS who have really taken this to a new level.

And, of course, thank you to Orbis for the invitation. And just in case people weren’t aware of this amazing manual put together by Amelia Geary and her team, I thoroughly recommend you go on the Cybersight website and download this manual. It contains everything you need to know about how to set up simulation training where you are.

And I’m just going to conclude now. Looking at some of the Q&As that have come in. One of them was asking me would I like to comment about the training at the Mass Eye and Ear on something that I’m not familiar with.

Next question, hello, can you share a video demonstrating wet lab trabeculectomy surgery in Phillips Studio Eyes? Yes, Ashweedy, if you go onto the Simulated Ocular Surgery website there’s a whole section on trabeculectomy training and then there’s a link to the simulation gallery with lots of Will Dean’s fantastic videos of starting off using not model eyes, but apples and other materials to practice your scleral flap creation, to practice releasable sutures and then on to the model eyes. But they’re all on the simulation gallery.

If anybody has any other questions, please feel free to add them to the Q&As on the link on your Zoom call. We’re hopeful that the hybrid courses run by the Royal College of Ophthalmologists is something we’d like to extend to work with other ophthalmological societies or other training centers so we can increase the capacity of these teaching days. One of the things that myself and many other trainers will emphasize is the importance of sustained, deliberate practice. And you can only practice if you’ve got the facilities available to carry out meaningful practice. And the Stemi microscope set up for intraocular surgery and the phone set up I showed for strabismus surgery means that we do now have a way of practicing, in a really high-fidelity way, many of the maneuvers required for even complex anterior segment surgery.

Christina has said, “Can you comment again on the preferred for microscope video set up?” You can have a video in theater, so if you’ve got a theater microscope which you can link by an HDMI cable to your laptop, depending on the operating microscope. I think most operating microscopes you can probably link up to a laptop. The Stemi microscopes, there’s the basic Stemi 305 without a camera, which can be linked with the Labscope app to your phone or to any tablet. The trinocular microscope has got a camera on top and that can then be linked with an HDMI cable to a big screen. If you’re teaching to a group it’s nice to have that. You got a high-resolution image for people to follow. And again there are videos on the gallery showing you different microscope setups. There are other little portable microscopes available which can be attached to cameras, but I don’t have experience of those particular systems.

Mohammad Abdul, doctor at Model Lab, he said please tell us a little bit about Ahmed valves and trabeculectomy. Again, if you go onto the simulation gallery there are videos, I think three videos, comparing live and simulated surgery for valve surgeries and not just trabeculectomy. We’ve got a specific eye that’s been designed by Phillips Studios for practicing Ahmed’s valves and other types of tube surgery as well.

Colin Goldberg, Zoom and online training… He said training videos should also be uploaded to YouTube and the same goes for live patients in the operating room theater and doctor’s office as an adjunct to onsite training. I think you have to be a little bit careful when you’re recording live surgery on patients with patients’ permission to share those videos even though they cannot be identified from the surgery. You would have to seek their consent before doing that.

The MicroREC setup is certainly a nice way for consultants to step out of the operating theater and still watch their trainee as they’re becoming more senior and more experienced. You could maybe be in the coffee room next door watching and listening with an iPod in one ear to do the surgeon informing the surgery and watching what they’re doing. And then, if required, you’re literally just around the corner to just come in and help if there are any difficulties. That’s one way to use that technology. Sunil and Rebecca have used the MicroREC on the slit lamp to conduct global grand rounds where we had five or six patients coming through being examined on the slit lamp and the resolution is good enough to see cells in the anterior chamber, guttata. And it’s a great way to do clinical teaching with this type of remote technology.

An anonymous attendee says, “What tools I would need to set up a virtual wet lab, especially in a low resource country?” Again, if you go to the Cybersight manual, the Orbis manual, they’ll have all the various tools that you could use, what equipment you need: the sutures, materials, the different types of model eyes, the Bioniko eyes, the Kitaro eyes, the Phillips Studio eyes, other types of material as well. And you can work out the costings from that depending on what you want to simulate. The microscopes themselves are relatively inexpensive and they’re pretty robust. Again, the prices of those are on the Simulated Ocular Surgery website. Please have a look at the Cybersight manual because it’s got pretty much everything you would need to know about setting up surgical training where you are.

Another doctor, “Could you send us a link with all the information.” Again, if you just go onto SimulatedOcularSurgery.com and click on the simulation gallery tab you’ll get all those videos. And then if you want to follow us on Instagram any new videos you will be given an alert about that.

I think that’s pretty much all the questions we seem to have gone through and we’re almost out of time. If people do have any other queries following this, if you want to contact Cybersight I’ll be very happy to then get back to you and help you with any questions that you might not have had a chance to answer.

Thank you, again, to the Cybersight team for the invitation. Thank you for your time today and I wish you all a very good afternoon, thank you.

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December 17, 2021

Last Updated: October 31, 2022

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