Virtual simulations improve global surgical outcomes

Ophthalmology Times EuropeOphthalmology Times Europe December 2023
Volume 19
Issue 10
Pages: 22 - 23

Orbis advances cataract surgery training in low-resource areas with technology

Cataract extraction is the most frequently performed ocular surgery worldwide and likely the most gratifying, considering the instant restoration of vision. However, the rates of cataract extractions with favorable outcomes in low-resource regions of the world are below that of high-income countries.

Maria Montero, MD, associate director of Clinical Services for Orbis International’s Flying Eye Hospital, described how this problem is being addressed head-on by Orbis at the Women In Ophthalmology Summer Symposium on Marco Island, Florida, United States.

Maria Jose Montero, MD, performs a simulation training. Image courtesy of Orbis/Geoff Oliver Bugbee

Maria Jose Montero, MD, performs a simulation training. Image courtesy of Orbis/Geoff Oliver Bugbee

She explained that a 2017 survey conducted across 20 low- and middle-income countries found that only 36.7% of operable cataracts had been successfully operated with favorable outcomes, highlighting the need for improved effective cataract surgical coverage.

“To address this pressing issue,” she commented, “there is an urgent requirement to increase the number of trained ophthalmologists, thus enhancing the accessibility and quality of treatment.”

She pointed out that certain ophthalmology residency programs have a dearth of sufficient mentors and hands-on surgical training opportunities, and others do not even offer surgical training.

Orbis recognised this educational gap decades ago and brings world-class medical experts together with those in need of training. Orbis trains eye care professionals in both surgical and simulated environments.

Orbis defines simulation as replication of clinical and/or surgical skills in a controlled environment where the modality of teaching does not involve a human patient.

A number of significant benefits are associated with simulation training, Montero pointed out. These include the use of a safe, stable environment, the ability to manage complications, a learning curve free of patient harm, and participant exposure to a diverse range of mentors with various techniques and approaches.

Virtual simulation

Orbis offers simulation training in several capacities including creating traditional simulation centers at partner training hospitals and offering virtual simulation training through Cybersight, Orbis’s telemedicine and e-learning platform.

The virtual simulation training project pairs local residents with an international expert via real-time video conference. The project involves weekly lectures coupled with wet lab assignments on a specific step or steps in the surgical procedure. These assignments are video recorded and uploaded to Cybersight for grading and feedback by the remote professor. This feedback is critical, as it monitors the progress of the resident’s skill development and ensures that they don’t learn incorrect techniques, such as poor instrument manipulation and hold.

This remote simulation training approach has demonstrated improvement in the quality of residents’ surgeries. It also provides simulation training for residents where faculty staff have limited time due to staff shortages.

Montero explained that in order to derive the full benefits of simulation and measure the improvement in knowledge and skills, simulation centers must use a validated and reliable assessment tool.

“Our assessment tool allows measurement of the learner’s progress toward the defined learning objectives and competencies of the simulation training,” she said.

The considerations for the tools are that they must be objective, reliable, and validated as well as easy to use and applicable to learning objectives.

The evaluation tools also outline the reasons for evaluation (ie, to measure the improvement of knowledge and skills and to confirm that the resident has achieved the defined learning objectives) so that participants understand the purpose.

Dr Montero, MD, works aboard the Orbis Flying Eye Hospital. Image courtesy of Orbis/Geoff Oliver Bugbee

Dr Montero, MD, works aboard the Orbis Flying Eye Hospital. Image courtesy of Orbis/Geoff Oliver Bugbee

The available tools include theIowa Wet Lab examination, Objective Evaluation of Skills in Intraocular Surgery, the International Council of Ophthalmology—Ophthalmology Surgical Competency Assessment Rubric and the Orbis assessment tools.


The project titled Virtual Wet Lab Training in Manual Small-Incision Cataract Surgery trained 9 Indian ophthalmology residents in manual small incision cataract surgery (MSICS) through Cybersight.

During the training, weekly live lectures addressed specific steps involved in the MSICS. After each live lecture, the residents recorded 2 assignment videos in the wet lab during which they practiced the surgical step learned on artificial eyes.

The assignment videos then were uploaded to the Cybersight website, where pre- and post-training surgical simulation videos were masked, anonymised, and graded using the Ophthalmic Simulated Surgical Competency Assessment Rubric—Manual Small-Incision Cataract Surgery.

The residents also completed an anonymous post-training survey to register their level of satisfaction with the training.

A second project was the virtual remote training in advanced phacoemulsification skills. During this 4-month programme, 6 learners joined 2-day online simulation workshops, at 2 locations in Santiago, Chile.

The students connected their simulation microscope to an online call and practiced their advanced phacoemulsification techniques on artificial eyes in real time with an Orbis Volunteer Faculty member who was in Mexico or the United States.

On the second day of the workshop, the students and mentors convened for follow-on lectures and discussion sessions concerning the hands-on simulation training from the previous day.

Based on survey results, the 2019 project was one of few opportunities to participate in simulation training before the COVID-19-related shutdowns of 2020.

“At Orbis, we have found simulation is imperative to training skilled, confident surgeons. It is a key component to many of our training projects around the world,” Montero concluded.


1. Lee AG, Greenlee E, Oetting TA, et al. The Iowa Ophthalmology Wet Laboratory curriculum for teaching and assessing cataract surgical competency. Ophthalmology. 2007;114:e21-6; doi: 10.1016/j.ophtha.2006.07.051.

Maria Jose Montero, MD | E:

Dr Montero has no financial interest in this subject matter.

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