Journal of Clinical Ophthalmology

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Review Article - Journal of Clinical Ophthalmology (2020) Therapeutic Advances in Vision Research

Artificial eye models: An opportunity to increase surgical training exposure in ophthalmology during and beyond the COVID-19 pandemic

Andrew Swift1*, Patrick Gooi2,3

1 University of Calgary, Cumming School of Medicine, Calgary, AB, Canada

2 Cloudbreak Eye Care, Calgary, AB, Canada

3 Section of Ophthalmology, Department of Surgery, University of Calgary, Calgary AB, Canada

Corresponding Author:
Dr. Andrew Swift
University of Calgary Cumming School of Medicine Calgary, AB Canada
E-mail: [email protected]

Accepted date: 10 December, 2020

Citation: Swift A, Gooi P. Artificial eye models: An opportunity to increase surgical training exposure in ophthalmology during and beyond the COVID-19 pandemic. J Clin Ophthalmol 2020;4(S1):16-18.

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Abstract

Purpose: To review 3 recently published articles regarding the face and content validity of 3 artificial eye models used for practicing ab-interno goniotomy, ab-interno canaloplasty, and anterior vitrectomy (SimulEYE® KDB/TrabEx, ABiC iTrack and A-Vit, InsEYEt, Westlake Village, CA)

Participants: A total of 71 surveys were completed by ophthalmologists following a surgical simulation session at the 2019 Canadian Ophthalmological Society annual meeting.

Methods: A 15-question survey to assess the face and content validity of the model was given immediately following the surgical simulation session. Responses to each survey question were recorded on a 5-point Likert scale ranging from (5) strongly agree to (1) strongly disagree.

Results: Respondents rated statements regarding the models with a median response ranging from 5 (Strongly agree) to 3 (Neither agree nor disagree). Mann-Whitney U nonparametric analysis revealed no significant difference in responses between instructor vs. non-instructor or between prior experience vs. no prior experience in each study. The models received the highest combined ratings for their usefulness in training residents, utility in novice skill acquisition prior to in vivo procedures and higher likelihood of success with the procedure than theory and observation alone. The lowest aggregated score for the models was for realism of the models compared to a human cadaveric eye.

Conclusion: Results from these studies suggest the SimulEYE KDB/TrabEx, AbiC iTrack and A-Vit models are a reasonably cost-effective solution for surgical simulation of ab-interno goniotomy, ab-interno canaloplasty, and anterior vitrectomy.

Keywords

Education, Glaucoma, Ophthalmic surgery, Surgical training, Resident training, Artificial eye model.

About the study

The COVID-19 pandemic has caused major disruptions to ophthalmology residency training programs across the world [1-6]. Many ophthalmological societies have adopted guidelines that highlight the need for extra safety measures, including postponing non-urgent medical and surgical care [7]. These guidelines have had a negative impact on surgical training as the volume of surgeries being performed has decreased significantly [2,5]. The long-term impacts on trainee’s core competencies caused by a decrease in clinical and surgical exposures during the pandemic are not yet clear [2]. To mitigate potential gaps in learning, many ophthalmology training programs around the world have recognized the need to adapt and change their teaching methods [8]. There is a critical need for programs to adopt validated and reproducible surgical training models that are high fidelity, low cost, reproducible, accessible, and easy for the trainee to set up and use. Various training models have been used in ophthalmology to simulate surgical techniques, including post-mortem human eyes, post-mortem animal eyes, synthetic eyes, computer simulated eye surgery and foodstuffs such as fruits and vegetables [9-12]. In this article we summarize three recently published papers that each analyzed the face and content validity of an artificial eye model produced by InsEYEt LLC (Westlake Village, CA) designed to practice specific ophthalmologic surgical techniques (Table 1) [13-15].

Model Surgical Technique Designed to Practice Current Cost (USD) Features of the Model
SimulEYE®KDB/TrabEx Ab-interno goniotomy using the Kahook Dual Blade (KDB)*, TrabEx and Trabectome†. 70 •Contains TM which can be visualized using viscoelastic and a gonio prism
•Multiple clock hours of the TM can be treated before the model is consumed
SimulEYE® ABiCiTrack Ab-interno canaloplasty (AbiC) using the Ellex iTrack device‡. 200 •Angle structures can be visualized using a gonioprism and gel
•Pre-placed opening in the pigmented TM for placement of the iTrack catheter
•Allows visualization of the red blinking l ight on the outside of the model
•Model can be reused multiple times
SimulEYE® A-Vit Bimanual anterior vitrectomy via pars plana approach 50 •Model filled with synthetic vitreous
•Single use

Table 1: Eye models analyzed for face and content validity in recent survey studies at the 2019 Canadian Ophthalmological Society (COS) annual meeting.

Discussion

In each study the face and content validity of the models was assessed using a short (15 question) survey (Appendix A). Questions used in the surveys were designed using McDougall’s definition of face and content validity where face validity is the realism of the simulator and content validity is a judgment of the appropriateness of the simulator as a teaching modality [16]. Responses were recorded on a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1). In addition to the 15 questions assessing face and content validity, other questions included whether the respondent was a course instructor or participant and the number of times they had performed the specific procedure on live patients in the past (Table 2).

  Ab-interno goniotomy using KDB Ab-interno canaloplasty Bimanual ant vitrectomy- pars plana approach
Procedure Range Procedures in past year Procedures lifetime Procedures in past year Procedures lifetime Procedures in past year Procedures lifetime
0 7 7 10 9 11 4
1-10 2 2 2 3 25 14
11-20 1 0 0 0 1 6
21-30 0 1 1 0 1 5
31->100 0 0 3 3 0 8
Respondent Count (n) 10 10 16 15 38 37

Table 2: Respondent’s self-reported experience with in vivo procedures prior to using the simulation eye models at the 2019 Canadian Ophthalmological Society annual meeting.

Each survey was completed by ophthalmologists at the 2019 Canadian Ophthalmological Society (COS) annual meeting immediately following a surgical training session. Before each session, a brief instructional presentation, free of any product endorsement, was given by a course instructor followed by 90 minutes of hands-on practice. Each ophthalmologist was given their own model and equipment to practice with. Surveys were filled out by course instructors and participants with no financial or other incentives provided. The surveys for each of the models were analyzed using Mann–Whitney U nonparametric analysis to determine whether prior experience performing the procedure on live patients or being a course instructor had significant influence on responses.

Survey results from each study are combined and summarized in Table 3. Respondents rated all questions for the SimulEYE® KDB/TrabEx and ABic iTrack models with a median score ranging from 5 (strongly agree) to 3 (neither agree nor disagree) and the A-Vit model ranging from 5 to 4 (agree). When responses from all participants are aggregated together, all three models received a favorable median rating between 5 and 4. Furthermore, respondents rated all statements specifically regarding face validity of each model (questions 1-2, 14; Appendix A) with a median response of 4. Statements specifically addressing content validity of the models (questions 4-7, 9-11; Appendix A) all received a median response of either 5 or 4.

  SimulEYE® KDB/TrabEx SimulEYE® ABiC iTrack SimulEYE® A-Vit Aggregated responses for all models
 Survey Question 5-Point Likert total # Responses Median 5-Point Likert total # Responses Median 5-Point Likert total # Responses Median 5-Point Likert total # Responses Median
Q1 53 13 4 75 18 4 165 40 4 293 71 4
Q2 56 13 4 77 18 4 167 40 4 300 71 4
Q3 59 13 5 81 18 5 178 38 5 318 69 5
Q4 60 13 5 85 18 5 182 34 5 327 65 5
Q5 58 13 4 81 18 5 167 40 4 306 71 4
Q6 58 13 4 82 18 5 163 40 4 303 71 4
Q7 58 13 4 83 18 5 169 39 4 310 70 4
Q8 59 13 5 78 18 4 178 40 4 315 71 4
Q8 56 13 4 72 18 4 175 40 4 303 71 4
Q8 42 13 3 53 17 3 143 38 4 238 68 4
Q9 60 13 5 79 17 5 178 40 4 317 70 5
Q10 43 11 4 68 17 4 141 38 4 252 66 4
Q11 45 11 4 72 17 4 145 38 4 262 66 4
Q12 46 11 4 71 17 4 156 38 4 273 66 4
Q13 46 11 4 72 17 4 145 40 4 263 68 4
Q14 48 11 4 75 17 4 161 40 4 284 68 4
Q15 44 11 4 74 17 4 147 40 4 265 68 4

Table 3: Summary of 5-point Likert scale survey responses of each model ranging from strongly agree (5) to strongly disagree (1).

The models received the highest combined ratings for their usefulness in training residents, utility in novice skill acquisition prior to in vivo procedures and higher likelihood of success with the procedure than theory and observation alone. The lowest aggregated score for the models was for realism of the models compared to a human cadaveric eye. This is not surprising since cosmetic details, like conjunctival vessels, are purposely omitted to maximize cost-effectiveness. Using Mann–Whitney U nonparametric analysis each study found that the models demonstrated no significant difference in responses observed between instructors versus non-instructor or between prior experiences versus no prior experience for each of the survey statements.

Limitations of the studies include a relatively small sample size and selection bias as all respondents in each study had selfselected to attend the COS review course. Furthermore, there was no control group or alternate model for comparison used in any of these studies. Another limitation is the low number of questions used in the surveys that related specifically to face and content validity. Survey questions can be strengthened in future studies by adapting a well validated assessment tool for simulation of glaucoma surgery proposed by Dean et al in 2019 [17].

Declarations

Conflict of interest

No conflicting relationship exists for either author

Financial support

None

References

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