Not just for eating: Grapes and potatoes help surgery trainees hone skills
The pandemic has impacted ophthalmic surgical training. Exercises have been developed to provide key skills that can be practised simply at home and require no special equipment.
Ophthalmic surgical training has been gravely affected worldwide by the COVID-19 pandemic.1 In an international survey, up to 53.1% of ophthalmology residents and 34.4% of fellows admitted being unable to perform cataract surgery during the pandemic and, similarly, 56% of the former and 51.1% of the latter cited a lack of simulation-training facilities in their hospitals.2
Microsurgical simulation typically relies on specialist equipment with an operating or portable microscope or utilises virtual-reality simulators such as the EyeSi.3 These simulation options are thus not only location-specific but also time- and resource-intensive and associated with high costs.
Given these challenges, we have devised a smartphone-based, practical, low-cost, easily reproducible and realistic intraocular microsurgical simulation modality that can be used at home. The focus of the simulation exercise is four skills that are core to cataract surgery: corneal incisions, capsulorhexis, wound suturing and general manual dexterity microsurgical skills.
A range of exercises—including the necessary equipment and set-up—were developed by the authors for each of the core skills. These were based on similar techniques described in another cataract simulation study whereby everyday basic materials were utilised to mimic the various steps of cataract surgery and then subjectively validated with high levels of concurrence through a questionnaire study amongst ophthalmologists of all grades in the UK.4
For each skill, a smartphone (iPhone X with iOS 13.5.1, Apple) was balanced on a pile of books (height: 10.5 cm) such that the smartphone camera was overhanging the books and looking down at a work surface (Figure 1). The camera was used in video mode with × 2 zoom; phone torch illuminations were used if required.
Easily available items
The equipment necessary includes easily available everyday materials such as grapes, superglue, potatoes, drinking straws, poppy seeds and orange peel.5 The practice can be recorded and discussed with a trainer for feedback.
The rationale and aim behind the exercises are to provide a low-fidelity means of practising manual dexterity for ophthalmic surgery when access to well-equipped surgical simulation suites is limited. For example, performing corneal incisions on grapes (Figure 2) is useful practice for cataract surgery incisions and access to the anterior chamber.
Figure 2A. Incision marking on the skin of the grape to left and marking in the stroma of the grape to the right.
Corneal Incisions. Equipment needed: grapes, 15-degree blade, black marker pen.
Left: profile view showing the skin of the grape; right: surgeon's coaxialview from the smartphone, focusing on the stroma of the grape.
Figure 2B. Making the keratome incision.
Corneal Incisions. Equipment needed: grapes, 15-degree blade, black marker pen.
Left: profile view showing the skin of the grape; right: surgeon's coaxialview from the smartphone, focusing on the stroma of the grape.
Figure 2C. Making the incision with a 15-degree blade.
Corneal Incisions. Equipment needed: grapes, 15-degree blade, black marker pen.
Left: profile view showing the skin of the grape; right: surgeon's coaxialview from the smartphone, focusing on the stroma of the grape.
Capsulorhexis on potato skins (Figure 3) directly correlates with the capsulorhexis step of cataract surgery. As for the manual dexterity exercises (Figures 4 and 5), they emulate instrument manipulation in a confined space, whilst orange peel (Figure 6) provides a durable yet pliable surface for suturing practice.
Figure 3A. Secure the potato slice to a flat work surface and mark a 7–10 mm diameter circle.
Capsulorhexis on potato skin. Equipment needed: thin slice of boiled potato ~2 cm wide; small piece of cardboard work surface; ruler; marker pen; lozenge packets; small blade; putty-like pressure-sensitive adhesive (such as Blu Tack, Bostik); cystotome on a 1-mL syringe; capsulorhexis forceps.
Figure 3B. Using a blade, prepare a lozenge packet with incision ports: a main incision port, 5 mm wide and the full depth of the packet, and a 5 × 2 mm paracentesis port. Secure the lozenge packet over the potato using putty-like adhesive.
Capsulorhexis on potato skin. Equipment needed: thin slice of boiled potato ~2 cm wide; small piece of cardboard work surface; ruler; marker pen; lozenge packets; small blade; putty-like pressure-sensitive adhesive (such as Blu Tack, Bostik); cystotome on a 1-mL syringe; capsulorhexis forceps.
Figure 3C. Using a cystotome, create a 'capsular flap.' Using the forceps, complete the simulated rhexis as guided by the circular markings.
Capsulorhexis on potato skin. Equipment needed: thin slice of boiled potato ~2 cm wide; small piece of cardboard work surface; ruler; marker pen; lozenge packets; small blade; putty-like pressure-sensitive adhesive (such as Blu Tack, Bostik); cystotome on a 1-mL syringe; capsulorhexis forceps.
Figure 4A. Using a small blade, prepare your lozenge packet with a 5 × 10 mm incision port on your non-dominant side (blue arrows). Draw a 2 × 2 cm cross on a work surface. Secure the lozenge packet over the cross – this is your simulated anterior chamber.
Manural dexterity exercise: Dot the cross. Equipment needed: poppy seeds; marker pen; a small piece of cardboard work surface; lozenge packets; small blade; putty-like that adhesive; forceps.
Figure 4B. Place five poppy seeds inside the chamber. Using your non-dominant hand and forceps, place the seeds on the edges of the cross (yellow arrows). Repeat as required.
Manural dexterity exercise: Dot the cross. Equipment needed: poppy seeds; marker pen; a small piece of cardboard work surface; lozenge packets; small blade; putty-like that adhesive; forceps.
Figure 5A. Using a small blade, prepare two incision ports in the lozenge packet, 90–120 degrees apart and measuring 5 mm wide × the full height of lozenge packet (blue arrows). Secure the lozenge packet to a flat work surface, such that the ports are aligned to your regular operating hand positioning. This is your simulated anterior chamber.
Manual dexterity exercise: Loop the hoops. Equipment needed: paper drinking straw; suture; scissors; a small piece of cardboard work surface; lozenge packets; small blade; putty-like adhesive; forceps.
Figure 5B. Using scissors, cut three cross-section ‘hoops’ of drinking straw and place them inside the chamber (red arrows).
Manual dexterity exercise: Loop the hoops. Equipment needed: paper drinking straw; suture; scissors; a small piece of cardboard work surface; lozenge packets; small blade; putty-like adhesive; forceps.
Figure 5C. Using forceps and a suture, thread the hoops onto the thread. Repeat as required with both dominant and non-dominant hands.
Manual dexterity exercise: Loop the hoops. Equipment needed: paper drinking straw; suture; scissors; a small piece of cardboard work surface; lozenge packets; small blade; putty-like adhesive; forceps.
Figure 6A. Cut a 1-cm disc of thin orange peel. This is the simulation corneal “graft.” Retain the remaining peel as the “host” tissue. Flatten the remaining peel and secure to a flat work surface using putty-like adhesive.
Suturing orange peel. Equipment needed: orange peel; marker pen; small blade; putty-like adhesive; suture of choice; needle holders; forceps.
Figure 6B. Using your suture of choice, needle holders and forceps, suture the graft to the host in various clock hour directions.
Suturing orange peel. Equipment needed: orange peel; marker pen; small blade; putty-like adhesive; suture of choice; needle holders; forceps.
Figure 6C. Repeat with non-dominant hand for practice. (All images courtesy of the authors)
Suturing orange peel. Equipment needed: orange peel; marker pen; small blade; putty-like adhesive; suture of choice; needle holders; forceps.
The authors acknowledge and accept that these exercises do not mimic real ophthalmic surgery steps; however, they do require hand-eye coordination and can enhance muscle memory when performed regularly. The ubiquitous role of smartphones in our daily lives allows for frequent access and practice; the set-up is low maintenance and has no requirement for formal approvals/licences, plus the microsurgical simulation set-up can be safely recreated in the home environment.
Therefore, we believe that by simplifying simulation training methods and enabling trainees to practice in the comforts of their own home or at the workplace, our intraocular microsurgery simulation model provides an easy, feasible, realistic, practical option. Assuming most trainees have access to a smartphone and basic disposable surgical instruments, our models do not require any additional expense, thereby minimising cost and resource barriers.
Download Issue: Ophthalmology Times Europe April 2022
