Topic outline

  • Simulation and Wetlab

    a) Early in training

    Think:

    • Do I know my anatomy?

    • What instruments will I be using, how do I use them and what are they called?

    • Can I practise this in a simulated environment (see resources)?

    • Can I be assessed in a simulated environment/wet-lab setting?

    • Many skills, such as suturing, can be assessed in a simulated environment

    Activity:

    • Go on the College Microsurgical Skills Course 

    • Ask a theatre sister/deputy to show you the instruments, and to let you be scrub nurse

    • Watch experienced surgeons and ask questions

    • Practise, practise, practise

    Resources:

    b) later in training:

    Think:

    • (As you progress) What are my weak points, how can I improve?

    • What useful techniques have I seen used that are not assessed under other SS learning outcome requirements?

    Guidance note:

    • You should be assessed in different skills as you progress through training

    • As cataract surgery is regularly assessed seperately it should not be used for this learning outcome

    • Several Surgical Skills (e.g. biopsy, surface protection, cantholysis) are only compulsorily assessed twice between ST4 and ST7; consider having further assessment of them under this heading to show progression of skills

    • You should consider what other procedures you may wish to learn which are not actually compulsory, eg tarsorrhaphy

    • For this learning outcome you do NOT have to perform a complete procedure - so look out for surgical procedures of which you have the opportunity to perform only a (significant) part, where you utilise different skills from those you have had assessed previously

    Activity:

    • Watch experienced surgeons to identify different skills and techniques

    • Discuss with your trainer additional surgical skills they can assess such as different suturing techniques for different ocular and adnexal tissues to show understanding of different sutures and knots

    • Ask to perform steps in a longer procedure that would be a transferable skills, where you might be unlikely to perform the entire procedure

    • Use the operating microscope

      Think:

      • How does the microscope work (optics and mechanics)?

      • Which buttons do what?

      • How should I get comfortable at the microscope?

      • What checks do I need to make before I start operating?

      • What do I do if the bulb goes out or something else seems to go wrong during an operation??

      Activity:

      • Go on the College Microsurgical Skills Course (compulsory)

      • Ask an experienced surgeon to show you the controls and to help you get comfortable

      • Watch experienced surgeons and ask questions

      • Practise under supervision, and on your own, both in and out of hours

      • Learn how to perform simple maintenance tasks on the particular microscope(s) you use - especially bulb replacement (and know where the spares are kept!)

      Resources:

      • Manufacturer's manual (?web based?)

      • Videos, books, websites

      • TEXTBOOK OF OPHTHALMOLOGY VOL. 1 Edited by Sunita Agarwal, Athiya Agarwal, Lucio Buratto, David J. Apple, Jorge L. Ali Published by Jaypee Brothers Publishers. Copyright.

      • Safety Of The Clean Air Strorage Hood For Ophthalmic Instruments In The Operating Room

      • Herman DC. Am J Ophthalmol. 1995 Mar;119(3):350-4. PMID: 7872397 [PubMed - indexed for MEDLINE]

      • Ophthalmic Microsurgical Training: Are We Approaching A Crisis Point

      • Ormonde SE. Clin Experiment Ophthalmol. 2005 Oct;33(5):453-4. PMID: 16181267, [PubMed - indexed for MEDLINE]

      • Use the operating microscope

        Think:

        • How does the microscope work (optics and mechanics)?

        • Which buttons do what?

        • How should I get comfortable at the microscope?

        • What checks do I need to make before I start operating?

        • What do I do if the bulb goes out or something else seems to go wrong during an operation??

        Activity:

        • Go on the College Microsurgical Skills Course (compulsory)

        • Ask an experienced surgeon to show you the controls and to help you get comfortable

        • Watch experienced surgeons and ask questions

        • Practise under supervision, and on your own, both in and out of hours

        • Learn how to perform simple maintenance tasks on the particular microscope(s) you use - especially bulb replacement (and know where the spares are kept!)

        Resources:

        • Manufacturer's manual (?web based?)

        • Videos, books, websites

        • Aseptic surgical technique

          Think:

          • By what routes could the operative field become contaminated?

          • What can I touch safely when scrubbed?

          • What is "no-touch technique?

          • What do I do in the event of a needle stick injury to myself or one of the team?

          Activity:

          • Ask theatre sister/deputy to check your scrubbing, gowning & gloving technique

          • Ask to be a scrub nurse for a list - or even for a week

          • Watch experienced surgeons and nurses and ask questions

          • Practise and ask for constructive criticism

          • Always be alert for you or a colleague inadvertently or deliberately breaking sterility and don't be afraid to speak up about it

          Resources

          • BASIC PRINCIPLES OF OPHTHALMIC SURGERY , Thomas A. Oetting- 2011: This updated edition introduces the resident to key concepts and elements in the realm of ophthalmic surgery.
          • https://books.google.co.zm/books?isbn=1615252312
          • OPHTHALMIC SURGICAL PROCEDURES, PS. Hersh, BM Zagelbaum, SL Cremers. Thieme, 2ndEdition. 2011. Pg. 175-179 & 346 - 348.


          • Cataract surgery

            a) Early in training

            Think:

            • Exactly what am I trying to achieve by each manoeuvre?

            • What am I trying to avoid?

            • How can I learn this with minimal risk to the patient, and minimal stress to the patient, the trainer and me?

            Activity:

            • Go on the College Microsurgical Skills Course (compulsory)

            • Ask for supervised simulated experience then practise over and over again (simulation can be with a virtual reality simulator if available, but should also include work in the wet-lab and/or in theatre out-of-hours with plastic practice eyes)

            • Discuss with your trainer how (s)he will organise your training (modular, "reverse-chaining", etc) and how you will be given protected operating time

            • Agree what signal the trainer will give to tell you (s)he must take over

            • Record every operation on video/digital recording, to review regularly yourself and frequently with your trainer

            • Note that although no specific number of cataract operations is actually required of trainees, the College advises a minimum number of 50 complete procedures during the first 2 years of training to help ensure adequate progress. 

            • Throughout your training, you MUST perform a continuous ongoing audit of any of your cataract surgery cases in which significant complications occur. This must be recorded using the on-line RCOphth electronic logbook, and an updated synopsis must appear in your e-portfolio for each ARCP. The synopsis must include details of the final outcome of these cases, including the final visual acuity and (where available) refraction, and details of any further complications which arise.

            Resources:

            • Books, videos, meetings, wet lab/out-of/hours theatre, surgical simulator

            • TEXTBOOK: ILLUSTRATIVE GUIDE TO CATARACT SURGERY: A STEP-BY-STEP Agarwal - 2011 - ‎No preview

            • TEXTBOOK: MANUAL SMALL INCISION CATARACT SURGERY Garg, ‎Luther L. Fry, ‎Francisco J. Gutierrez-carmona- 2008 - ‎Preview- ‎More editions

            • TEXTBOOK: THE WILLS EYE MANUAL:OFFICE AND EMERGENCY ROOM DIAGNOSIS AND TREATMENT OF EYE DISEASEKunimoto DY, Rapuano CJ, Friedberg MA, Maker M, Kanitkar KD.  4th ed. Appendix 7. Technique for Sub-Tenons and subconjunctival injections. Lippincott Williams and Wilkins; 2004

            b) Later in training

            Think:

            • How can I refine my skills to be safe and effective in all cataract cases, even complex ones?

            • How can I learn this with minimal risk to the patient, and minimal stress to the patient, the trainer and me?

            • How can I be sure that my surgery is good enough?

            Activity:

            • Go on an advanced phaco course

            • Ask your trainer to show you how to approach difficult cases and then to take you through them

            • Continue to use video/digital recording and the simulator/wet-lab

            • Continue to seek feedback from your trainers, both formal and informal

            • Note that although no specific number of cataract operations is required of trainees, the College advises a minimum number of 350 complete procedures during the 7 years of training to help ensure satisfactory progress to fully independent practice. These procedures should include the full variety of complex cases; in this context complex cases must include high myopes, cases with previous anterior or posterior segment surgery, cases with previous iritis, unusually hard or soft cataracts, white cataracts, cases with pseudoexfoliation syndrome, subluxated lenses and post-trauma cases. 

            • Throughout your training, you MUST perform a continuous ongoing audit of any of your cataract surgery cases in which significant complications occur. This must be recorded using the on-line RCOphth electronic logbook, and an updated synopsis must appear in your e-portfolio for each ARCP. The synopsis must include details of the final outcome of these cases, including the final visual acuity and (where available) refraction, and details of any further complications which arise.

            • In addition, by the end of training your e-portfolio MUST contain an audit of at least 50 consecutive cataract surgery cases performed during or after ST4. This must include information on risk factors (see www.nature.com/eye/journal/v26/n6/fig_tab/eye201251t1.html) and complications (seewww.nature.com/eye/journal/v23/n1/fig_tab/6703015t7.html), along with outcome data which must include final visual acuities and should (where available) also include the refractive outcome.

            • Surgical measures to lower IOP

              Think:

              • When is surgery appropriate?

              • What am I trying to achieve?

              • What am I trying to avoid?

              • How can I learn this with minimal risk to the patient, and minimal stress to the patient, the trainer and me?

              Activity:

              • Go on the College Microsurgical Skills Course (compulsory)

              • Ask for supervised simulated experience then practice ofver and over again (simulation can be with virtual reality systems when available, but should also include wet-lab or out-of-hours in-theatre work

              • Discuss with your trainer which procedures are appropriate for you to learn, and how your training will be achieved. This could include the needling of blebs. 

              • Record every operation, to review regularly yourself and frequently with your trainer

              • Ideally actual surgical procedures should be assessed, but if this is not feasible then additional laser procedures, especially cyclodiode laser, can be counted

              Resources:

              • Perform surgical repair of ocular and adnexal tissues after trauma

                Think:

                • How can I maximise my exposure to ocular trauma management?

                • What can I do to practice in a simulated situation?

                • In what elective procedures can I develop transferable skills for trauma repair?

                • What are the generic principles of surgical repair?

                Activity:

                • Take full advantage of training opportunities to learn suturing in elective, simulated and trauma situations; ask trainers/senior trainees to supervise you in these contexts

                • Watch trainers and ask questions

                • Ensure you are readily available for on-call duties

                Resources:

                • Undertake the surgical management of lid problems

                  Think:

                  • What anatomy do I need to know?

                  • What can go wrong with eyelids which is amenable to surgical correction?

                  • What complications are possible, and why?

                  • Who can I watch performing lid surgery?

                  • Are my basic tissue-handling/suturing skills good? - what can I do to improve them?

                  • How should I plan my progression through simple to more-complex lid surgery?

                  • How should I explain the options and procedures to the patient?

                  • Are there any situations where cryotherapy could be useful? If, in conjunction with my trainer, I consider cryotherapy to be useful how would I arrange cryotherapy if working in a unit that does not offer this procedure?

                  Activity:

                  • Read up lid anatomy and patho-anatomy

                  • Ask to attend clinics dealing with structural lid problems

                  • Watch more senior surgeons and ask them to explain what they are doing, and why

                  • Practise suturing in the wet-lab, or using spare sutures with apples, grapes, etc

                  • Ask to be taken through lid procedures (simple at first) and practise them under supervision

                  • Assess your patients carefully pre and post-op and audit the results

                  • Your surgical logbook should include a range of procedures and your training should concentrate on helping you develop transferable skills. It is expected that the procedures would include correction of simple entropion and ectropion, pentagon excision for lid margin lesions, upper lid blepharoplasty, chalazions and ideally, tarsorraphy.

                  Resources:

                  • Undertake surgical measures for the protection of the ocular surface

                    Think:
                    • When is lid protection necessary?

                    • Does it need to be temporary or permanent?

                    • When is a surgical approach (eg amniotic membrane, Frost suture with bolster, tarsorraphy) likely to be better than a conservative approach (eg ointments/lubricants, protective cover, bandage contact lens, botulinum toxin)?

                    • How can I learn the different techniques?

                    • Who can best teach me?

                    Activity:

                    • Ask to attend clinics/ward visits dealing with corneal exposure

                    • Look up the techniques available, surgical and otherwise

                    • Watch experienced surgeons performing these procedures

                    • Ask to be taken through the procedures where feasible

                    • Assessment can be in simulation (wet lab) if necessary

                    Resources:

                    • Perform lateral canthotomy and cantholysis

                      Think:

                      • When is cathotomy/cantholysis required?

                      • What may be the alternatives?

                      • How can I get involved with patients needing these procedures?

                      • Can I manage this patient myself, or do I need help?

                      Activity:

                      • Actively try to get involved with patients needing these procedures

                      • Watch experienced surgeons/ask to be taken through the procedures

                      • Get involved in the follow-up of these patients

                      Resources:

                      • Perform a biopsy of eyelids and the ocular surface

                        Think:

                        • What tissues may I need to biopsy?

                        • Is incisional or total biopsy indicated?

                        • What are the risks, and can I explain them well enough to the patient?

                        • Can I apply skills I have learned elsewhere, or do I need to learn new skills?

                        • Can I do it myself alone, or with supervision, or do I need to refer the patient to an expert?

                        • How can I be sure I can cope (eg in emergency with endophthalmitis needing vitreous biopsy?)

                        • When will the result be available, and who will ensure that it is acted upon expeditiously?

                        • What are the protocols for ensuring correct labelling?

                        Activity:

                        • Attend clinics dealing with lid and external eye tumours

                        • Practice skills in "wet-lab" or other simulated situation

                        • Ask to attend lid surgery lists, observe biopsy and ask to be taken through appropriate procedures

                        • Take advantage of on-call opportunities to perform vitreous biopsy under supervision

                        • Ask to attend VR lists and to be allowed to set up for pars plana vitrectomy and perform the core vitrectomy yourself under supervision

                        • Liaise closely with your local laboratories regarding specific requirements for sample preparation, documentation and transportation, particularly in regard to specimens being transported by non-NHS personnel such as taxi drivers

                        • Ensure that you will receive the result promptly, or at least ensure that someone knows you have delegated this to them

                        • Ensure you know the significance of the result, and discuss this with colleagues/trainers if necessary.

                        Resources:

                        • Perform surgery on the extraocular muscles

                          Think:

                          • How do I decide whether this patient needs muscle surgery at all, and if so which muscle and which operation?

                          • What are the pros and cons of surgery and how should I explain these to the patient/parent?

                          • How can I learn muscle surgery with the least possible risk to the patient and minimal stress to my trainer and myself?

                          Activity:

                          • Take an active role in orthoptic clinics seeing child and adult patients

                          • Read up on muscle surgery

                          • Discuss cases with, and then watch, experienced surgeons and then ask to be taken through simple, then more complex procedures

                          • Follow up your patients

                          Resources:

                          • Remove the eye when indicated

                            Think:

                            • When should removal of an eye be considered?

                            • What are the alternatives?

                            • How should I approach the subject with the patient, and how much time should I give them to consider the alternatives? (And is it really as urgent as I think it might be?)

                            • What alternative techniques are there, and do I need to balance pros and cons (eg good cosmesis with implants against risks of extrusion and possible future delay in detection of secondary tumour)

                            • How can I learn the techniques with minimal risk to the patient and minimal stress to the trainer and myself?

                            • Can I provide adequate counselling, or does my patient need expert help?

                            • What special considerations apply to the removal of a donor eye from a cadaver?

                            Activity:

                            • Get involved in trauma cases

                            • Attend clinics dealing with ocular tumours

                            • Read up about the options and discuss with experts

                            • Observe expert surgeons and ask to be taken through procedures. You must observe and then perform at least one enucleation and one evisceration; if the opportunity to perform these does not arise in your clinical practice you should be assessed (using OSATS) in the retrieval situation (for enucleation) and the wet-lab (for evisceration)

                            • Follow up your patients when feasible

                            • Find out what support services are available and how to access them

                            • Read the RCOphth Standards document on Retrieval of Ocular Tissue for Transplantation, Research and Training

                            Resources:



                            • Apply appropriate laser for the management of the lens capsule

                              Think:

                              • What are the indications for laser to the lens capsule?

                              • How does the laser work and what safety precautions are required?

                              • Does my Trust require a formal laser induction process?

                              • What is the balance of risks and benefits, and how should I explain these to the patient?

                              • Are there any underlying conditions which would alter the risk/benefit ratio?

                              • What complications could ensue, what follow-up is necessary, what warnings should the patient be given, and will I be able to handle complications myself or will I need help?

                              • How can I learn the techniques with minimal risk to the patient and minimal stress to my trainer and myself?

                              Activity:

                              • Read up on the subject

                              • Check up on Trust procedures

                              • Read the laser manufacturer's manual

                              • Listen to experts talking to patients about the procedure

                              • Watch experts performing laser, then ask to be taken through it with easy and then with more tricky cases

                              • Follow up your patients and consider an audit

                              • Talk to patients before and after laser

                              Resources:

                              • Apply appropriate laser for the management of raised intraocular pressure

                                Think:
                                • What sort of laser procedures are possible for IOP, and what are their indications?

                                • How does the laser work and what safety precautions are required?

                                • Does my Trust require a formal laser initiation procedure?

                                • What is the balance of risks and benefits, and how should I explain these to the patient?

                                • Are there any underlying conditions which would alter the risk/benefit ratio?

                                • What complications could ensue, what follow-up is necessary, what warnings should the patient be given, and will I be able to handle complications myself or will I need help?

                                • What pre and post operative treatment is indicated for my patient?

                                • How can I learn the techniques with minimal risk to the patient and minimal stress to my trainer and myself?

                                Activity:

                                • Read up on the subject

                                • Check up on Trust procedures

                                • Read the laser manufacturer's manual

                                • Listen to experts talking to patients about the procedure

                                • Watch experts performing laser, then ask to be taken through it with easy and then with more tricky cases

                                • Follow up your patients and consider an audit

                                • Endeavour to perform a variety of laser procedures

                                • Talk to patients before and after laser

                                Resources:

                                • Apply appropriate laser for the management of retinal problems

                                  Think:

                                  • What are the indications for laser treatment to the retina, and what tests may be helpful in deciding about treatment?

                                  • What sort of lasers are available, and on what basis should one choose between them? How do the lasers work and what safety precautions are required?

                                  • Does my Trust require a formal laser initiation procedure?

                                  • What techniques of laser application are available (delivery systems and treatment strategies)?

                                  • What are the pros and cons of treatment, and how can I best communicate these to the patient?

                                  • What complications could ensue, what follow-up is necessary, what warnings should the patient be given, and will I be able to handle complications myself or will I need help?

                                  • How can I learn the techniques with minimal risk to the patient and minimal stress to my trainer and myself?

                                  Activity:

                                  • Read up on the subject

                                  • Check up on Trust procedures

                                  • Read the laser manufacturer's manual

                                  • Learn about the various imaging techniques which help with clinical decision-making

                                  • Listen to experts talking to patients about the procedure

                                  • Watch experts performing laser, then ask to be taken through it with easy and then with more tricky cases

                                  • Follow up your patients and consider an audit

                                  • Talk to patients before and after laser

                                  Resources:

                                  • Topic 17