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Comparing performance of junior and senior ophthalmology residents on an intraocular surgical simulator
CORRESPONDENCE A macular smile A pleasant 95-year-old female was seen for her yearly follow-up of her dry age-related macular degeneration. Despite having only counting fingers vision in both eyes, she maintains a positive attitude. Indirect ophthalmoscopic examination of her left fundus revealed a striking finding that matched her demeanor. The combination of atrophy and clumping of retinal pigment epithelium in her macula adopted the appearance of a smiling face (Fig. 1). Michel J. Belliveau, Sherif El-Defrawy Department of Ophthalmology, Queen’s University, Kingston, Ont. Correspondence to: Michel Belliveau, MD: [email protected] Sherif El-Defrawy, MD: [email protected] Can J Ophthalmol 2011;46:87
doi:10.3129/i10-098
Comparing performance of junior and senior ophthalmology residents on an intraocular surgical simulator Eyesi (VRmagic, Mannheim, Germany) is a virtual simulator for teaching intraocular surgical skills.1 Construct validity using Eyesi has been demonstrated when comparing less experienced trainees (i.e., ophthalmology residents) to experienced ophthalmic surgeons when performing anterior segment tasks.1 The purpose of our study was to establish similar construct validity using Eyesi when comparing junior ophthalmology residents to senior residents using similar anterior segment tasks as part of a training course with a proficiency target. This retrospective study was conducted at the University of Alberta using the Eyesi surgical simulator, software version 2.3. Immediately after purchasing Eyesi, a customized training course consisting of 6 anterior segment modules (4 forceps and 2 antitremor modules) was created. A score of 595 out of 600 (maximum total combined score for all 6 modules) was arbitrarily set as the goal for individual residents in the program. Residents were given free access to the simulator over a 14-month period (September 2007 to November 2008) to achieve this goal. Ten of the 11 residents in the program chose to participate. The residents had no previous experience using a surgical simulator. Residents were split into 2 groups: junior (training years 1 and 2; n 5 5) and senior (training years 3–5; n 5 5). This split was chosen because operating time increases dramatically starting in year 3 of our program and this split allowed for a realistic comparison based on surgical experience.
Fig. 1—Fundus image as seen by indirect ophthalmoscopy.
Statistical analysis was performed using SigmaPlot 11 (Systat Software Inc, San Jose, Calif.). Time to reach a score of 595 was compared using Student’s unpaired t test. Results are given as means ¡ standard deviation (SD). The junior group (263 ¡ 100 minutes) took significantly longer to achieve a score of 595 than the senior group (115 ¡ 61 minutes) (p 5 0.022). The scores of residents at all training levels improved as they spent more time on the simulator and this occurred in a logarithmic fashion (Fig. 1). The senior group was able to achieve higher scores at the outset and progressed towards the target score more quickly than the junior group. Eyesi demonstrates construct validity when comparing groups of junior and senior residents performing anterior
Fig. 1—Scores after each surgical simulation session plotted against cumulative time for individual users in each resident group with associated logistic regression. CAN J OPHTHALMOL—VOL. 46, NO. 1, FEBRUARY 2011
87
Correspondence segment tasks with a proficiency target. By comparing junior and senior residents and not experienced surgeons and residents, we were able to demonstrate how surgical simulation can be used to discriminate between less dramatic differences in presumed surgical experience. The question that still needs to be addressed is whether ophthalmic surgical simulation improves surgical performance in the operating room setting. Nawaaz Nathoo,* ManCho Ng,* Cory L. Ramstead,{ Michael C. Johnson{ *Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; {the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver,
Differential effects of triamcinolone and bevacizumab in central retinal vein occlusion The ideal treatment approach to central retinal vein occlusion (CRVO) remains controversial. Recently, the SCORE study1 documented that intravitreal triamcinolone (IVTA) may be a viable option in the treatment of CRVO. Small studies2–4 are available that comment on the use of bevacizumab (Avastin, Genentech, San Francisco, Calif.) in eyes with CRVO, some cases reported short-lived improvement in the cystoid macular edema (CME) with relatively frequent injections. Given the complex pathophysiology of CRVO and its sequelae, a combined therapeutic approach may be the most beneficial. The following case report describes combination therapy with intravitreal bevacizumab and IVTA in an eye with a non-ischemic CRVO. The differential effects of the 2 treatments documented highlight the multifactorial pathophysiology of CRVO and its sequelae. The visual acuity (VA) of a 58-year-old patient decreased to 20/200 OD due to a CRVO (Fig. 1A) with intraretinal hemorrhage in 4 quadrants, optic disc edema, and retinal venous tortuosity. Fluorescein angiography demonstrated a nonischemic CRVO. Optical coherence tomography showed the CME (Fig. 2A). An intravitreal injection of 1.25 mg of bevacizumab was given and repeated twice at 6-week intervals. Significant resolution of the intraretinal hemorrhage, optic disc edema, and some of the venous tortuosity (Figs. 1A, B) was observed with VA improving to 20/64. Though improved, the CME persisted (Figs. 2B–D). One subsequent 4 mg dose of IVTA (Kenalog, Bristol-Myers Squibb, New York, N.Y.) led to the prompt and complete resolution of the CME (Fig. 2E) with further improvement of the VA to 20/20. Three months later, the intraretinal hemorrhage, optic disc edema, and venous tortuosity recurred (Fig. 1C). The CME also recurred with a drop in VA to 20/200 (Fig. 2F).
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CAN J OPHTHALMOL—VOL. 46, NO. 1, FEBRUARY 2011
B.C.; and {the Department of Ophthalmology, University of Alberta, Edmonton, Alta. Correspondence to: Michael C. Johnson, MD: [email protected] REFERENCES 1. Mahr MA, Hodge DO. Construct validity of anterior segment anti-tremor and forceps surgical simulator training modules: attending versus resident surgeon performance. J Cataract Refract Surg. 2008; 34:980–5. Can J Ophthalmol 2011;46:87 Can J Ophthalmol 2011;46:87–8
doi:10.3129/i10-065
A series of 3 intravitreal bevacizumab injections was given again at 6-week intervals with significant improvement in the intraretinal hemorrhage, optic disc edema, and venous tortuosity; however, again, the CME did not resolve (Figs. 1D and 2G). A second injection of IVTA was given resulting in the prompt resolution of the CME and improvement of the VA to 20/30 (Fig. 2H).
Fig. 1—Fundus photographs depict the changes in the ophthalmoscopic features of CRVO with the different interventions over time. (A) Pretreatment photograph demonstrates the extensive intraretinal hemorrhage, optic disc edema, and retinal venous tortuosity. The VA was 20/200. (B) Six weeks after the third intravitreal injection of bevacizumab (1.25 mg dose per injection given at 6-week intervals), there was marked improvement in the intraretinal hemorrhage, optic disc edema, and venous tortuosity. VA improved to 20/64 but was limited by persistent CME. (C) Twelve weeks after a single treatment with IVTA and 5 months after the last intravitreal bevacizumab injection, the intraretinal hemorrhage, optic disc edema, and venous tortuosity began to return. The CME also returned. (D) Four weeks after the second round of treatment with bevacizumab (given at 6-week intervals; 3 injections in total), the intraretinal hemorrhage, optic disc edema, and venous tortuosity again improved. (CRVO, central retinal vein occlusion; VA, visual acuity; CME, cystoid macular edema; IVTA, intravitreal triamcinolone.)
doi:10.3129/i10-098
Comparing performance of junior and senior ophthalmology residents on an intraocular surgical simulator Eyesi (VRmagic, Mannheim, Germany) is a virtual simulator for teaching intraocular surgical skills.1 Construct validity using Eyesi has been demonstrated when comparing less experienced trainees (i.e., ophthalmology residents) to experienced ophthalmic surgeons when performing anterior segment tasks.1 The purpose of our study was to establish similar construct validity using Eyesi when comparing junior ophthalmology residents to senior residents using similar anterior segment tasks as part of a training course with a proficiency target. This retrospective study was conducted at the University of Alberta using the Eyesi surgical simulator, software version 2.3. Immediately after purchasing Eyesi, a customized training course consisting of 6 anterior segment modules (4 forceps and 2 antitremor modules) was created. A score of 595 out of 600 (maximum total combined score for all 6 modules) was arbitrarily set as the goal for individual residents in the program. Residents were given free access to the simulator over a 14-month period (September 2007 to November 2008) to achieve this goal. Ten of the 11 residents in the program chose to participate. The residents had no previous experience using a surgical simulator. Residents were split into 2 groups: junior (training years 1 and 2; n 5 5) and senior (training years 3–5; n 5 5). This split was chosen because operating time increases dramatically starting in year 3 of our program and this split allowed for a realistic comparison based on surgical experience.
Fig. 1—Fundus image as seen by indirect ophthalmoscopy.
Statistical analysis was performed using SigmaPlot 11 (Systat Software Inc, San Jose, Calif.). Time to reach a score of 595 was compared using Student’s unpaired t test. Results are given as means ¡ standard deviation (SD). The junior group (263 ¡ 100 minutes) took significantly longer to achieve a score of 595 than the senior group (115 ¡ 61 minutes) (p 5 0.022). The scores of residents at all training levels improved as they spent more time on the simulator and this occurred in a logarithmic fashion (Fig. 1). The senior group was able to achieve higher scores at the outset and progressed towards the target score more quickly than the junior group. Eyesi demonstrates construct validity when comparing groups of junior and senior residents performing anterior
Fig. 1—Scores after each surgical simulation session plotted against cumulative time for individual users in each resident group with associated logistic regression. CAN J OPHTHALMOL—VOL. 46, NO. 1, FEBRUARY 2011
87
Correspondence segment tasks with a proficiency target. By comparing junior and senior residents and not experienced surgeons and residents, we were able to demonstrate how surgical simulation can be used to discriminate between less dramatic differences in presumed surgical experience. The question that still needs to be addressed is whether ophthalmic surgical simulation improves surgical performance in the operating room setting. Nawaaz Nathoo,* ManCho Ng,* Cory L. Ramstead,{ Michael C. Johnson{ *Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; {the Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver,
Differential effects of triamcinolone and bevacizumab in central retinal vein occlusion The ideal treatment approach to central retinal vein occlusion (CRVO) remains controversial. Recently, the SCORE study1 documented that intravitreal triamcinolone (IVTA) may be a viable option in the treatment of CRVO. Small studies2–4 are available that comment on the use of bevacizumab (Avastin, Genentech, San Francisco, Calif.) in eyes with CRVO, some cases reported short-lived improvement in the cystoid macular edema (CME) with relatively frequent injections. Given the complex pathophysiology of CRVO and its sequelae, a combined therapeutic approach may be the most beneficial. The following case report describes combination therapy with intravitreal bevacizumab and IVTA in an eye with a non-ischemic CRVO. The differential effects of the 2 treatments documented highlight the multifactorial pathophysiology of CRVO and its sequelae. The visual acuity (VA) of a 58-year-old patient decreased to 20/200 OD due to a CRVO (Fig. 1A) with intraretinal hemorrhage in 4 quadrants, optic disc edema, and retinal venous tortuosity. Fluorescein angiography demonstrated a nonischemic CRVO. Optical coherence tomography showed the CME (Fig. 2A). An intravitreal injection of 1.25 mg of bevacizumab was given and repeated twice at 6-week intervals. Significant resolution of the intraretinal hemorrhage, optic disc edema, and some of the venous tortuosity (Figs. 1A, B) was observed with VA improving to 20/64. Though improved, the CME persisted (Figs. 2B–D). One subsequent 4 mg dose of IVTA (Kenalog, Bristol-Myers Squibb, New York, N.Y.) led to the prompt and complete resolution of the CME (Fig. 2E) with further improvement of the VA to 20/20. Three months later, the intraretinal hemorrhage, optic disc edema, and venous tortuosity recurred (Fig. 1C). The CME also recurred with a drop in VA to 20/200 (Fig. 2F).
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CAN J OPHTHALMOL—VOL. 46, NO. 1, FEBRUARY 2011
B.C.; and {the Department of Ophthalmology, University of Alberta, Edmonton, Alta. Correspondence to: Michael C. Johnson, MD: [email protected] REFERENCES 1. Mahr MA, Hodge DO. Construct validity of anterior segment anti-tremor and forceps surgical simulator training modules: attending versus resident surgeon performance. J Cataract Refract Surg. 2008; 34:980–5. Can J Ophthalmol 2011;46:87 Can J Ophthalmol 2011;46:87–8
doi:10.3129/i10-065
A series of 3 intravitreal bevacizumab injections was given again at 6-week intervals with significant improvement in the intraretinal hemorrhage, optic disc edema, and venous tortuosity; however, again, the CME did not resolve (Figs. 1D and 2G). A second injection of IVTA was given resulting in the prompt resolution of the CME and improvement of the VA to 20/30 (Fig. 2H).
Fig. 1—Fundus photographs depict the changes in the ophthalmoscopic features of CRVO with the different interventions over time. (A) Pretreatment photograph demonstrates the extensive intraretinal hemorrhage, optic disc edema, and retinal venous tortuosity. The VA was 20/200. (B) Six weeks after the third intravitreal injection of bevacizumab (1.25 mg dose per injection given at 6-week intervals), there was marked improvement in the intraretinal hemorrhage, optic disc edema, and venous tortuosity. VA improved to 20/64 but was limited by persistent CME. (C) Twelve weeks after a single treatment with IVTA and 5 months after the last intravitreal bevacizumab injection, the intraretinal hemorrhage, optic disc edema, and venous tortuosity began to return. The CME also returned. (D) Four weeks after the second round of treatment with bevacizumab (given at 6-week intervals; 3 injections in total), the intraretinal hemorrhage, optic disc edema, and venous tortuosity again improved. (CRVO, central retinal vein occlusion; VA, visual acuity; CME, cystoid macular edema; IVTA, intravitreal triamcinolone.)