Unite and conquer: Refractive surgery goes on a world tour

During the summer of 2023, the European Society of Cataract and Refractive Surgeons (ESCRS) debuted its Moving Simulator programme. Initiated by immediate past president Oliver Findl, MD, MBA, FEBO, the specialised training is one part of the society’s focus on reaching junior members across Europe. Using charitable funds, ESCRS leadership purchased an Eyesi Surgical Simulator (Haag-Streit Simulation). This Moving Simulator was paired with curriculum developed by Artemis Matsou, MD, MRCP, FEBO, PgDipCRS, from Greece, and Alja Crnej, MD, from Slovenia, both members of the ESCRS educational committee. By partnering with cataract and refractive socieities in several European countries, the ESCRS has been able to send the Moving Simulator to eight countries in its inaugural year of use. The simulator will continue to visit at least six countries per year, and return to its host countries every other year, based on factors including community needs. After completing the 8-hour programme, trainees may download a certificate from the ESCRS and performance results from each of the training modules.

Hands-on experience

Paul Filip Curcă, MD, is a specialist physician of ophthalmology and doctoral student at Carol Davila University of Medicine and Pharmacy in Bucharest, Romania. He used the ESCRS Moving Simulator during its tenure in Romania, while he was still a resident physician at Clinical Hospital for Ophthalmological Emergencies, Bucharest. Dr Curcă described his experience with the Moving Simulator as a unique and valuable opportunity for residents.

“Except for devices seen on the ESCRS Congress expo floor, I personally have not experienced a similar device,” Dr Curcă said. “It was a fantastic educational opportunity, for which I am personally grateful since something similar wasn’t available in the first years of my residency.”

Dr Curcă said that, up until that point, he had only experienced a capsulorhexis simulator during the ESCRS Congress. Many trainees across Europe are in a similar position, he pointed out, and only able to access “technologically excellent” simulators by travelling to major meetings. Loredana Smarandache, MD, expressed a similar sentiment. She participated in the Moving Simulator programme in Romania and now works at University Hospital Ayr, Scotland, United Kingdom.

”When I first used the Moving Simulator, I had some experience with cataract surgery,“ Dr Smarandache said. "While I wasn’t highly experienced, I had performed a moderate number of cataract surgeries, enough to identify my areas of weakness." These trainees had a major opportunity when the Moving Simulator came to Bucharest, attracting young ophthalmologists (YOs) from throughout Romania.

Local support and regional challenges

While the Moving Simulator initiative is made possible by the ESCRS, much of its success has depended on national societies of ophthalmic surgeons. Liudmyla Vasylieva, MD, trained on the Moving Simulator in August of 2023. The simulator was originally intended to arrive in Dr Vasilyeva’s home country, Ukraine. But when that proved impossible, colleagues from other parts of Europe stepped in to make the training possible for Ukrainian ophthalmologists. Volodymyr Melnyk, MD, head of the Ukrainian Society of Ophthalmic Surgeons, recalled how the training came to reach physicians from Ukraine.

“At first, we decided to [host the simulator] in Ukraine, in Kyiv,” Dr Melnyk said. “But there were two barriers. First is that the simulator was located in the United Kingdom, and it was too challenging to transport it into Ukraine. And second is that Ukraine is not part of the European Union. We would have had to pay for the temporary use of the simulator here in Ukraine, and it was quite expensive for us.” Instead, after the simulator left Romania, it headed for Poland, and around 40 Ukrainian trainees travelled to access and use it there. “I had many talks with our Polish colleagues and Polish friends,” Dr Melnyk recalled. “They helped us to use this simulator in Poland so our young Ukrainian ophthalmologists could receive this very, very valuable experience.”

Dr Vasylieva described her training in Ukraine, prior to the introduction of the Moving Simulator programme, as limited by a lack of resources. “The system of training in Ukraine is based largely on animal eyes,” she said. “Wet labs and animal eyes can be used in limited cases, but we cannot perform and practice complicated cataract surgery cases on rabbit or porcine eyes. The simulators are very useful because they create conditions to train your skills not only on basic skills, but also in specific scenarios, like posterior capsular breaks.” Both Dr Melnyk and Dr Vasylieva appreciated that the simulator enabled trainees to perform certain procedures, like phacoemulsification, in combination with other surgeries.

Dr Smarandache expressed a similar set of challenges for YOs training in Romania. "Romania faces significant challenges in providing sufficient hands-on training for surgeons, primarily due to a shortage of experienced mentors and limited access to live surgical cases," she explained. As a result, trainees’ skill sets wind up imbalanced or incomplete, she said. A lack of vitreoretinal surgeons in Romania has resulted in a major training deficit, and mentors who specialise in anterior-segment surgery may feel "uncertain and hesitant" about allowing YOs to operate, she said. "The high cost of advanced surgical technology...hinders medical institutions and professionals from upgrading their skills," Dr Smarandache said. "Simulators like the Moving Simulator are essential for providing affordable, high-quality training."

Atanas Bogoev, MD, FEBO, is a Bulgarian ophthalmology specialist who now works at the University Eye Clinic of Bochum, Germany, as part of a team lead by ESCRS Secretary H. Burkhard Dick, MD, PhD. As both a mentor and a YO, Dr Bogoev has completed the Complete EyeSi course on the simulator twice.

Differing career trajectories can also create challenges, said Dr Bogoev. Often, simulator training is limited to YOs practicing in very specific circumstances. "There are several surgical simulator devices [in Germany], usually located in big university hospitals, which are mostly used for the surgical training of the residents and specialists on site," Dr Bogoev explained. "This makes it difficult for young ophthalmologists in private practice to use the technology."

In many cases, the Moving Simulator gave trainees an opportunity to perform procedures they had witnessed their mentors perform in the surgical suite, but for which they had not received hands-on training. “For me, it was particularly interesting to perform anterior vitrectomy. I’d never performed it before,” Dr Vasylieva said. “It was also challenging to perform capsulorhexis in different complicated cases, with no pressure of failure.”

“I was surprised by the quality of the simulation and the wealth of training scenarios,” said Dr Curcă. He, too, was excited to practice different phacoemulsification styles, such as practicing chopping technique, or running the “divide and conquer” scenario. “This helped me better judge the correct depth for sculpting the initial trench,” Dr Curcă recalled. “For me the initial sculpt is stressful, since starting out, it’s difficult to judge how deep is safe, and how deep is actually necessary to proceed with either dividing, or to commence chop after an initial trench.”

Freedom to fail

One of the major benefits of a surgical simulator is the freedom it gives trainees to experience worst-case scenarios before encountering them in the surgical theatre. Both Dr Curcă and Dr Vasylieva said the simulator was valuable at presenting “unwanted scenarios,” like posterior capsule rupture, in practice rather than in theory. “The gist of the steps for addressing posterior capsule rupture were known to me from the excellent ESCRS Young Ophthalmologist courses,” Dr Curcă explained. But tackling the scenario in a simulation helped him develop a totally new set of skills; for example, correct movement in the anterior chamber to not further extend vitreous prolapse. “To be able to freely practice again and again the same case is invaluable to honing better, more efficient movement,” he said. It also allowed Dr Curcă to experience variation in capsule elasticity, or different behaviour in capsulorhexis, and adjust his surgical technique based on simulated patient differences. “The procedure is repeatable for however long it takes to master, instead of struggling with comprehending and adjusting to patient variations which can be significantly stressful, and all this without risk to the patient,” Dr Curcă said.

Capsulorhexis was a major talking point for Dr Smarandache, too, who was eager to master performing the procedure with a cystotome.
”In the past, I had used the cystotome to create the initial flap but then switched to forceps for the remainder of the procedure," she said. Working on the simulator gave her a chance to develop the skill in a way that was not possible during real surgery. "It took me some time to master controlling the cystotome, but I eventually succeeded," she said.

Dr Smarandache was also excited to learn the stop-and-chop method. "Up until that point, I was only comfortable with soft cataracts, using the divide-and-conquer technique," she said. Stop-and-chop, on the other hand, enabled her to operate on harder, more advanced cataracts. "I would have been reluctant to attempt [the stop-and-chop technique] on a real patient for the first time," Dr Smarandache said.

Many YOs took creative approaches to the training in order to maximise its value. "The best part about the simulator is that you can improve on any level of your surgical training," Dr Bogoev said. He placed a special emphasis on complex surgical situations and handling complications. "I spent the time to practice surgery from a temporal approach and went through the complete ESCRS course with my left (non-dominant) hand. The performance tracking, which I was paying close attention to, allowed me to observe and improve my precision and task times, which translated to a better outcome in the surgical room."

Dr Vasylieva said practicing on the simulator drastically improved her confidence—in more ways than one. “Not only did it increase my confidence in performing some steps of surgeries, but also in watching how my mentors and senior surgeons perform surgeries,” she explained. “Now, I have a better
understanding of what to pay attention to, specific things I should notice in their hand motions,” she said. “It gave me a better understanding of mistakes I had made in my training, and how to correct and improve my technique when I perform these cataract surgery procedures again.”

"Regarding my performance score, I was quite surprised to find it lower than expected," Dr Smarandache said. "The simulator requires the surgeon to perform every step by the book, including the precise way instruments are entered into the anterior chamber and the amount of corneal oedema induced during phacoemulsification. This experience made me realise that while I had been focusing on certain aspects, I was neglecting some fundamental principles of cataract surgery, such as properly inserting and manipulating the instruments." The simulator let Dr Smarandache take note of which aspects of her technique she had been developing "superficially," and emphasised how crucial it is to cement best practices in the surgical routine.

Comparing the surgical simulator to flight simulators used in aircraft pilot training, Dr Melnyk emphasised the value to the simulation programme for educators. “In real life, in real surgery, mistakes are very, very, very difficult to restore,” he said. “Using this simulator gives mentors a better understanding of students’ surgical skills, and [enables them to] see where they are performing procedures without any mistakes. That is how we know when it is time to bring this student to the operating theatre, and give them a chance to do some steps in real surgery.”

The trainings are already demonstrating a positive outcome in the operating room. Dr Bogoev recounted a surgical scenario that put his dexterity and precision to the test. "Shortly after practicing the anterior vitrectomy course, I had a situation where, after removing the viscoelastic on a pseudophakic patient following MIGS, there was a vitreous string that came to the incision and I had to perform an anterior vitrectomy," he recalled." I remained calm and knew the steps and the right approach I had to take, even though the situation was not routine." Upon completing the surgery, Dr Bogoev was struck by a strangely familiar feeling. "The case went well and after reviewing the case video I was fascinated by how similar it looked to the exercise from the simulator," he said.

Future travel plans

Just one year after its initial voyage, the Moving Simulator has provided training for hundreds of YOs in countries where surgical training faces accessibility and resource barriers. The simulator will move on from its current post in Serbia to Bulgaria and Spain before it charts a new course for 2025.

As time goes on, the Moving Simulator initiative has the potential to radically change the careers of YOs throughout Europe, said Dr Melnyk. “Dr Vasylieva, for example, is very lucky, because she is working now in a big ophthalmic clinic where the staff performs all types of ophthalmic surgery, and she is able to take part in surgical procedures as an assistant,” Dr Melnyk said. “Unfortunately, most Ukrainian students and residents don’t have that possibility. They may not have surgical mentors or practices near them. For those young ophthalmologists, this simulator is their best chance to choose this direction for their careers.” Dr Melnyk added that, as a mentor, he sees it as his duty to provide YOs with the opportunity to choose a surgical track, so broadening access to the simulator is a major factor.

"After going through the Moving Simulator training, my day-to-day clinical experience has changed significantly," said Dr Smarandache. "The training made me much more conscious of the finer details that I might have overlooked before. I'm now more mindful of adhering to best practices and ensuring that every step is done 'by the book,' which has improved my overall surgical technique."

Despite low performance scores at the beginning of training, Dr Smarandache also said that her experience using the Moving Simulator made her feel more prepared to learn and master other surgical techniques going forward. "The simulator also boosted my confidence in performing more complex procedures, which I might have been hesitant to attempt before. As a result, I approach surgeries with greater precision and a heightened awareness of the potential complications and how to avoid them," she said. "Overall, the training has led to improved outcomes for my patients and a more disciplined approach to my surgical practice."

Dr Melnyk, Dr Vasylieva and Dr Curcă all advocated for expanding access to the Moving Simulator and to programmes like it.

Dr Curcă said he wished the initiative had been underway earlier in his training. “It would have been incredible if, for example, this simulation was available in the first year, starting out with smaller manoeuvres such as instrument coordination,” he said.

Dr Vasylieva echoed that sentiment. “It would be wonderful to have the ability to practice incisions, corneal main incisions, et cetera,” she said.

And while the training curriculum was comprehensive, Dr Curcă and Dr Vasylieva expressed hope that the simulator will be back in Romania and Ukraine soon, to empower more young trainees. “I joked after this training, it would be great if we had such a simulator in a clinic in Ukraine, in some place where students could constantly come to practice, day in and day out,” Dr Vasylieva said.