Cataracts and glaucoma surgery

Training eye health professionals in cataracts and glaucoma surgery

There is a huge need to perform high volumes of eye surgery throughout the world, and in particular in sub-Saharan Africa, to tackle the backlog of avoidable blindness. There is a great need to train many eye surgeons safely, efficiently, effectively, and to an acceptable level of competence. Currently, surgical training is often conducted using the traditional ‘apprentice model’ on patients. We believe that using this conventional model of training on its own has substantial limitations and drawbacks. It makes surgical training less efficient and less safe especially for novice eye surgeons. Training opportunities for novice eye surgeons are sparse at best in many parts of the world and most importantly, patients must come first. The quality, quantity, and safety of this ‘apprentice model’ training is not necessarily guaranteed. There is increasing appreciation that we need to find ways that train eye surgeons to a safe level before operating on patients.

BCPB supported a project being led by Dr William Dean from the International Centre for Eye Health (ICEH). This project tested the hypothesis that intense modular simulation-based ophthalmic surgical education is superior to conventional training alone for the initial acquisition of competence. Dr Dean set up a Simulation Surgery Training Unit at the University of Cape Town to offer educationally-underpinned and standardised training. 

The project designed two separate intense learning courses for the OLIMPICS trial cataract surgery, and for the GLASS trial glaucoma surgery. These courses were underpinned with educational theory, and piloted ahead of the Simulated Ocular Surgery (SOS) trials. The simulation-based training was conducted at the purpose-built Surgery Training Unit, Community Eye Health Institute (CEHI), University of Cape Town, South Africa. The SICS (small incision cataract surgery), or trabeculectomy (glaucoma surgery), procedure was deconstructed and instruction of individual steps was achieved using Peyton’s four-stage approach to teaching a practical skill. Feedback was given to participants while they engaged in sustained deliberate practice of a particular step

Once all parts of the SICS/trabeculectomy procedure were covered, the full procedure was performed on high-fidelity synthetic simulation eyes, following a round of mental rehearsal. Procedures were performed using latex-free blue gloves to increase reliability and to ensure anonymization of recorded procedures. Zeiss Stemi 305 microscopes (Carl Zeiss Microscopy GmbH, Jena, Germany) were linked to a central router and local area network (LAN). The Zeiss Labscope App (version 2.8.1) on iPads completed the digital classroom, allowing surgeons to record their performance.

Upon completion of a surgery, trainees engaged in reflective learning by watching the performance back on the iPad. This was enhanced by formative assessment and outcome measurement as they graded their performance. All training was conducted by the lead researcher William Dean.

Training Courses Conducted

The project eventually trained forty-nine senior trainees in trabeculectomy (glaucoma surgery), and fifty junior trainees in cataract surgery. These trainee eye doctors came from 23 different countries across Africa

Training the Trainers

Six senior trainer consultant ophthalmologists each spent one week in Cape Town during a training course, and have been fully trained to conduct a simulation surgical training course. This means that there are the skills and knowledge left in Africa to ensure that this work is rolled out to future trainee eye doctors, ensuring more people are trained to a high standard to perform cataracts and glaucoma surgery.

The Cataract surgery results

William Dean trained a group of ophthalmologists in the latest techniques in cataract surgery and compared their surgical skills to a group who received no training. He observed the skills of each doctor at the start (marks out of 40) and again after three months whether or not they had received any training. He also looked at their results a year later.

The group who had been trained by him improved their scores from 10.8 to 33.7 out of 40 – a very significant improvement of 212%.  The control group who had received no training improved slightly from 12.8 to 17.9 out of 40 but these scores had increased by only 44%, which showed quite a difference to the trained group.

He also compared individuals in each group who started out with the same scores – rather than looking at the group as a whole – and confirmed the benefits of training this way too.

But it gets better….

Not only did the skills of the trained group improve but so did their productivity. At follow up after one year, the trained group had performed an average of 22 surgeries compared to only nine in the untrained group. And of equal importance, the group who had undergone training had markedly fewer complications from cataract surgery after one year. This is significant as complications during surgery can cause problems with vision many years later.

The Glaucoma surgery results

This is a different type of surgery which, unlike cataract surgery, does not have the immediate effect of improving vision. It is designed to lower an elevated intraocular pressure to prevent the long term gradual loss of vision.

Student practising surgery on an apple

As in the cataract study, he scored the surgical skills of two groups (training one group, the others receiving no training) and showed a significant improvement in the skills of the group who received training. The scores (out of 40) of those who received training were on average 20 points better than those of the control group who received no training after three months.

This work also produced a number of other benefits including a significant increase in the confidence amongst surgeons to perform this type of surgery. This is important as less confident surgeons are less likely to recommend surgery (which can be more effective than drop therapy) to sufferers.

The figures show that the trained group are now twice as more likely to recommend surgery in suitable cases. Once again, after one year, many more surgeries were performed by the group who had received training compared to the control group who had received no training. The hope is, therefore, that these results will translate in a significant long term reduction in the numbers going blind as a result of glaucoma.

These are the first multi-centre ophthalmic simulation surgery educational-intervention randomised controlled trials ever conducted. This work has showed that intense simulation training does affords a rapid and sustained increase in surgical competence, confidence as a surgeon, and impacts the number of live surgeries performed. In addition, simulation education in cataract surgery affords a striking benefit in terms of patient safety.

Moving forward

Subsequent to the success of the training, William Dean has now developed partnerships and secured funding from Orbis and the Ulverscroft Foundation to set up simulation surgical training units to continue this work in the following places: Mbarara (Uganda), Kigali (Rwanda),Nairobi (Kenya),Moshi and Dar es Salaam (Tanzania),Harare (Zimbabwe) and a centre in Nigeria yet to be determined

These simulation surgical training centres will be set up in partnership with local consultants, with an aim to have sustainable locally-run simulation surgical training available for years to come.

With the simulation programme and the training we have done here, it is fantastic! We get to learn the details of the surgery, we get to be able to perfect it before we operate on patients. I have truly enjoyed my experience, and I think it has been very helpful”

Dr DK – Trainee Ophthalmologist, Uganda

“Thank you for the invaluable course. I came out of the course more confident in my skills. The very calm and relaxed environment was a very huge factor that helped as well.”

Dr AN – Trainee Ophthalmologist, Kenya

“It is really good exposure. I feel all the beginning residents should have this exposure. It can also work for other surgical procedures as well.”

Dr RT – Trainee Ophthalmologist, Zimbabwe