Army opthalmology residents receive'visionary' training with virtual reality

A baseball pitcher warms up before taking the mound, a basketball player shoots a few hoops before tip-off, and ophthalmology residents at the Madigan Healthcare System warm up on a simulator before operating on patients' eyes.

As part of Madigan's drive to be on the cutting edge of technology and patient safety improvement, the Ophthalmology Clinic has a virtual reality simulator to ensure that its staff and students are always on top of their game.

The Ophthalmology Clinic is one of the busiest surgical clinics in Madigan's Department of Surgery. The staff conducts about 1,200 operations and sees more than 25,000 patients a year, with the majority of these operations being cataract surgeries. Col. (Dr.) Robert Mazzoli, consultant to the Office of the Surgeon General for Ophthalmology, said that Madigan was the first residency program in the nation to purchase the simulator five years ago. Called EyeSI (eye-see), ophthalmologists can practice their surgical skills on a machine before performing operations on patients. The simulator is designed to be exactly like the equipment the eye surgeon normally uses, and as part of the simulation, displays a three-dimensional helix of red balls floating in a virtual microscope eye. With two instruments, a light source and a surgical pick, the doctor impales the red balls by holding the pick's tip in the center of the sphere for a simulation-determined length of time until the ball turns green.

While that sounds easy, ophthalmic doctors aren't just using their hands when operating, but also both feet, not unlike a drummer. An ophthalmologist holds surgical instruments in each hand, and uses each foot to simultaneously control ohter instruments' functions, such as the microscopes' focus, magnification, and travel, or suction, irrigation and ultrasonic power, to name a few. This requires some retraining of the brain's hard wiring, Mazzoli added. Part of the student's education is to help them develop hand-eye-foot coordination with precise accuracy. That's why residents must spend at least an hour a week using the simulator, and about 30 minutes of warm-up time before scrubbing up to do surgeries. In fact, Mazzoli said even staff surgeons are using the simulator before operating, which increases patient safety during surgery. "We don't want surgeons to be warmed up by the third case, but ready to go for the first one each morning," he said.

The simulator warming-up method has been extremely beneficial to Maj. Bruce Rivers, an ophthalmic resident at Madigan. His first cataract surgery took 90 minutes; but thanks to the simulator, he's down to an average of 15 minutes now. "The simulator lets us work on our skills with no liability involved," Rivers said. "Any time you can practice as close to real-world as possible, without the negatives of being in a real-world situation, I think you are going to have a great result."

The accelerated learning curve associated with EyeSI experienced by Rivers is increasing the residents' surgical decision-making efficiency, Mazzoli said. The simulation scenarios teach a resident how to move their instruments as little and efficient as possible, since surgical cuts in the eye are only a few millimeters in length. If a resident is performing the scenario tasks within the simulator and has too many jerky movements when traveling from one ball to the next, it can cost him or her points. "In ophthalmology, efficiency in the thought process and maneuvers is paramount, as there can be no wasted effort in surgical performance," Mazzoli said. "And efficiency is the most difficult thing you can teach a novice surgeon."