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Royal College of Ophthalmologists' National Clinical science Royal College of Ophthalmologists’ National Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313817 on 29 May 2019. Downloaded from Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees John D Ferris, 1 Paul H Donachie,2 Robert L Johnston,1 Beth Barnes,2 Martina Olaitan,2 John M Sparrow3 1Ophthalmology, ABSTRact Cataract surgery requires good stereoacuity and Gloucestershire Hospitals NHS Objective To investigate the impact of EyeSi surgical spatial awareness, combined with excellent hand– Foundation Trust, Cheltenham, UK simulators on posterior capsule rupture (PCR) rates of eye coordination and the ability to use all four limbs 2The Royal College of cataract surgery performed by first and second year simultaneously, as foot pedals are used to control Ophthalmologists’ National trainee surgeons. the operating microscope and the vacuum and/or Ophthalmology Database, Design A Royal College of Ophthalmologists’ National the ultrasonic energy of the phacoemulsification London, UK Ophthalmology Database audit study of first and handpiece. Even small incorrect movements, or 3Ophthalmology, Bristol Eye Hospital, Bristol, UK second year surgeons’ PCR rates over seven consecutive applying too much ultrasonic energy or vacuum, National Health Service (NHS) years. Participating can cause injury before the supervising surgeon can Correspondence to centres were contacted to ascertain the date when their intervene. John D Ferris, Ophthalmology, surgeons had access to an EyeSi machine and whether The most frequently recorded intraoperative Gloucestershire Hospitals NHS this was on-site or off-site. Operations were classified as complication of cataract surgery is posterior capsule Foundation Trust, Cheltenham before, after or no access to EyeSi. rupture (PCR) with or without vitreous loss and this GL53 7AN, UK; john. ferris2@ nhs. net Setting The study took place in 29 NHS Ophthalmology is widely regarded as the benchmark complication Units in a secondary care setting. to judge surgical quality.2 3 This work was presented as Results Two-hundred and sixty five first and second Following PCR, there is a significantly increased a poster at the Royal College year trainee surgeons performed 17 831 cataract risk of retinal detachment (×42), endophthalmitis of Ophthalmologists Annual 1 Congress in May 2018. operations. 6919 (38.8%) operations were performed (×8) and of visual loss (×5.6). Although there are before access to an EyeSi, 8648 (48.5%) after access many ocular and systemic comorbidities which are Received 3 January 2019 to an EyeSi and 2264 (12.7%) operations by surgeons associated with an increased risk of PCR, one of Revised 1 May 2019 with no access to an EyeSi. Overall, there was a 38% the most significant risk factors is the experience of Accepted 3 May 2019 reduction in the first and second year surgeon’s the surgeon, where first and second year trainees http://bjo.bmj.com/ unadjusted PCR rates from 4.2% in 2009 to 2.6% in have an adjusted OR of 3.73 for PCR occurring 2015 for surgeons with access to an EyeSi, and a 3% compared with a consultant surgeon.2 reduction from 2.9% to 2.8% for surgeons without Historically, cataract surgery training has followed access to an EyeSi. The overall first and second year an experiential model, of acquiring skills in the unadjusted PCR rates for before, after and no access operating theatre, which is frequently unstructured. to EyeSi were 3.5%, 2.6% and 3.8%, respectively. The Patient safety concerns alongside the demands of decrease in the with-access to an EyeSi group PCR rate increased efficiency have been the main factors in on 5 June 2019 by guest. Protected copyright. was similar for surgeons with access to an EyeSi ’on site’ developing alternative methods of training. or ’off site’. Wet-lab training using animal models or synthetic Conclusions First and second year trainee surgeons’ eyes designed specifically for phacoemulsification unadjusted PCR rates have decreased since 2009 which surgery enable trainees to rehearse some of the has significant benefits for patients undergoing cataract steps of cataract surgery, but they have been criti- surgery. This 38% reduction in complication rates aligns cised for lacking any form of objective assessment. with the introduction of EyeSi simulator training. In ophthalmology, the most commonly used © Author(s) (or their virtual reality (VR) simulator is the EyeSi surgical employer(s)) 2019. No simulator (VR Magic) which was first introduced commercial re-use. See rights into UK training programmes in 2010. This consists and permissions. Published by BMJ. INTRODUCTION of a mannequin head, instruments, foot pedals and Cataract surgery using phacoemulsification is the a virtual–reality interface, which is seen through the To cite: Ferris JD, most frequently performed surgical procedure in operating microscope (figure 1). The cataract inter- Donachie PH, Johnston RL, Western countries. Advances in operative tech- face includes modules for all of the major steps of et al. Br J Ophthalmol Epub ahead of print: [please nology over the last 20 years have improved cata- phacoemulsification surgery in addition to abstract include Day Month Year]. ract surgery outcomes, with 95% of patients who modules, which train basic skills. doi:10.1136/ have no ocular co-pathology achieving a visual The EyeSi simulator enables trainee surgeons bjophthalmol-2018-313817 acuity of 6/12 or better.1 to practice every step of the phacoemulsification Ferris JD, et al. Br J Ophthalmol 2019;0:1–6. doi:10.1136/bjophthalmol-2018-313817 1 Clinical science organisation, such as reduced costs, increased productivity or Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313817 on 29 May 2019. Downloaded from improved results. The aim of this report was to investigate the impact of the introduction of EyeSi training on the PCR rates for operations performed by first and second year trainees over seven consec- utive National Health Service (NHS) years. The study utilised cataract surgery data from the Royal College of Ophthalmol- ogists’ National Ophthalmology Database (RCOphth NOD) audit. METHODS The RCOphth NOD was established under the auspices of the Royal College of Ophthalmologists in 2010 to collate pseud- onymised data collected as a byproduct of routine clinical care for the purposes of national audit. In 2014, the RCOphth NOD audit was commissioned to perform the National Ophthal- mology Database Audit (NOA) by the Healthcare Quality Improvement Partnership ( www. nodaudit. org. uk). The NOA receives data collected on electronic medical record (EMR) systems and in-house databases from centres performing NHS funded cataract surgery in England and Cymru, including NHS funded operations performed in independent treatment centres. The study time period concerns NOA eligible cataract oper- ations performed between 1 April 2009 and 31 March 2016 which corresponds to seven consecutive NHS years, where the first year includes the operations before the introduction of standard EyeSi training in 2010. Using the RCOphth NOD, 29 centres were identified with the centres first cataract surgery in the study period performed between 2009 and 2012, and where Figure 1 An EyeSi surgical simulator (VR Magic). each centre had at least 50 operations performed by first and second year trainee surgeons. The centres were contacted to determine when they intro- procedure, apart from creating corneal incisions, and the auto- duced EyeSi training and which other hospitals in their region mated assessment categorises performance in five domains: had access to their EyeSi. Of the 29 centres, 23 had either target achievement, efficiency, instrument utilisation, tissue purchased or had access to an EyeSi between 2010 and 2016 damage and microscope usage. and six centres had no access to an EyeSi during this period. The The effectiveness of any training programme can be evalu- supplied date of EyeSi introduction and the date of surgery was ated using Kirkpatrick’s four level model.4 Kirkpatrick’s fourth used to allocate all operations performed by a first or second level evaluates the impact a training programme has had on an year surgeon to either the before, after or no access to EyeSi http://bjo.bmj.com/ groups. Centres with access to an EyeSi were further categorised as access on site or off site. An eligible cataract operation was defined according to the criteria used for eligibility in the National Ophthalmology Data- base Audit. Only operations performed by a first or second year trainee (ST1, ST2 or a Senior House Officer (SHO)) were included. on 5 June 2019 by guest. Protected copyright. All data were recorded on the Medisoft electronic record system (Medisoft Ophthalmology, Medisoft Limited, Leeds, UK, www. medisoft. co. uk) which mandates the recording of intra- operative complications. PCR was defined as posterior capsule rupture with or without vitreous prolapse or zonule rupture with vitreous prolapse. Statistical comparisons used χ2 tests and all analysis was performed using STATA V.14. Patient and public involvement Patients, carers and members of the public were not directly involved with this study. Figure 2 The proportion of operations performed by first and second year surgeons from 29 contributing centres, presented as the proportion RESULTS of operations within each NHS year according to the surgeons access to Over the study period, 265 first and second year surgeons an EyeSi, either before or after the centre had access or in a centre with performed 17 831 operations, 7711 (43.2%) by second year no access. The NHS year runs from 1 April to 31 March. NHS, National surgeons, 6455 (36.2%) by first year surgeons and 3665 (20.6%) Health Service. by SHOs. 2 Ferris JD, et al. Br J Ophthalmol 2019;0:1–6. doi:10.1136/bjophthalmol-2018-313817 Clinical science Br J Ophthalmol: first published as 10.1136/bjophthalmol-2018-313817 on 29 May 2019.
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