Kerala Journal of Ophthalmology

: 2022  |  Volume : 34  |  Issue : 2  |  Page : 89--91

Ophthalmic simulation: The need of the times

Smita Narayanan 
 Smita Narayanan, Professor, Regional Institute of Ophthalmology, Thiruvananthapuram, Kerala, India

Correspondence Address:
Dr. Smita Narayanan
Regional Institute of Ophthalmology, Thiruvananthapuram - 695 035, Kerala

How to cite this article:
Narayanan S. Ophthalmic simulation: The need of the times.Kerala J Ophthalmol 2022;34:89-91

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Narayanan S. Ophthalmic simulation: The need of the times. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Sep 29 ];34:89-91
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The coronavirus disease (COVID) pandemic was a hugely disruptive event to medical training. The postgraduate workforce was the backbone of the fight against COVID, at least in India. Thus, whatever training was available to the residents stopped. This brought the need for medical training programs to consider simulation as an alternative method to develop procedural skills into focus. Aviation, police, and the military have been using simulation for a long time.[1] Closer home, simulation training in orthopedics, nursing, anesthesiology, and medical education is widespread and gaining ground.[2] Ophthalmology can benefit from simulation training experiences in these fields.

The important thing in simulations is creativity. Dr. Virender Singh Sangwan, Director of Innovations at Dr. Shroff 's Charity Eye Hospital, India, feels that we lay too much emphasis on theory i.e learning science behind surgery instead of the surgical skills, which are mutually exclusive events. Surgical skills are like any motor skills, which have to be improved with practice. The theoretical background is important to be a good doctor but not very important to be a skilled surgeon. He feels that we have the best inputs as medical graduates and yet we churn out average or below average surgeons. This can only be the problem with the system of training.[3]

Only a very small percentage of Indian medical colleges, i.e., nearly 20% advise students to watch, assist, and do wet lab surgeries. Most of the medical schools in India do not have access or will to implement assisted surgeries, perform objective assessments, and provide certification. A dedicated operating room for training is available only in a few centers.

Dr. Sangwan has also suggested a few pointers to train future surgeons. These include assessment of surgical temperament by the online tool (s) in the medical school itself. To those inclined to be surgeons, online virtual reality/artificial intelligence (VR/AI)-based skill-building training and gamification of surgical training are offered.[4] The skills in the mind can be developed much before a structured curriculum is brought out. Mental training, like those given to sportsmen by coaching and visualization, is also advocated. The training includes a wet lab for surgical training in medical school, surgery-based short fellowships, sandwich fellowships with extensive use of technology, simulation, online tools, and surgical YouTube.

 Aviation and Simulation

What does aviation have to teach us about delivering high-quality simulation training? Here qualitative and quantitative data are collected to determine the best course direction for the pilots. They provide scenario-based training, resilience to provide the correct response to startling or surprising situations, development of cognitive reasoning, and the use of training tools from simple to sophisticated.[5] Even practicing pilots use simulation training to update their skills.

Simulation allows for accelerated learning, especially by repetitious skill building which improves the learning curve so that operations on real patients become safer. It helps in refreshing existing skills and the management of complex scenarios or new techniques or management of rare complications and adverse events. This is done in a risk-free environment thereby improving patient safety.[6] This is because simulation uses a controlled environment for training.

 What is Wrong with the Current Training Methods

There is a huge need for trained ophthalmic professionals in the world.[7] The training of the next generation of ophthalmology professionals as local health providers can be done safely, effectively, and efficiently by simulation. Before I talk about simulation, let me highlight some of the problems of current medical training practice.

The curriculum is too long and students and teachers concentrate on one or a maximum of two surgeries. There is also a lack of opportunity to practice regularly, especially in case of uncommon events/procedures and/or complications.[8] Independent studies have reported that 30–50% of the residents in the US and UK cannot operate independently. In India and other developing countries, 70% or more cannot do so.

The current training system involves the perpetuation of the Halsteadian principle of the “see one, do one, teach one” method.[9] Each training session is very stressful for the trainer, trainee, and the others watching. Therefore, the whole environment is high risk and stressful. Since we train on real patients, we must assume the inherent risks. There is also a lack of training in team interaction and crisis management.

Lack of rigorous evaluation, readjustment, and correction of problems by assessing and quantifying skills is also a problem as there is too much subjectivity. Individual likes and dislikes create bias making the training dictatorial at times. Thus, there is limited knowledge of the impact of medical training on patient safety and therefore the number of patients experiencing complications is very high.

Disruptive events happen in medical education. Besides coronavirus disease 2019 (COVID-19), there can be man-made and natural disasters, chronic low patient volume, staff shortage, etc. Obviously, the present training model cannot be scaled up. At the same time, it must be remembered that simulation is not a replacement for live surgical education. Prof. R. Kneebone describes simulation as providing an environment meant to take a novice surgeon to a specified level of competence before performing live surgery.[10]

 The Potential of Simulation in Ophthalmic Education

Simulation allows for learning skills in basic techniques thereby improving muscle memory. Most of the simulation-based surgical training concentrates on turning out a novice into an advanced beginner and then into a competent surgeon. Gaining proficiency and expertise can happen only in a live surgical environment.

It is not a mere wet lab center. It is a center with skill area, models for learning, feedback, sustained learning, curriculum integration, outcome measurement, simulation fidelity meaning it should feel as close to a real experience as possible, skill acquisition and maintenance, transfer to practice, team training, instructor training, and much more.

For those who are returning to surgical practice after a period of absence, e.g., after maternity leave or injury or illness or to quote again, the global pandemic, it is a boon. It can also be used for practicing the management of rare complications, maintenance of skills, and team training.

The potential for quantitatively tracking one's progress as it is a data-centric program is of immense benefit.

In many institutions, the mean number of cataract surgeries performed by trainee residents in their second and third years is zero. Trainees in the UK have a mean annual trabeculectomy rate of 0.5.[11] It has been found that there is a 40% reduction in posterior capsular rupture (PCR) after a five-day simulation training program.[12]

The evidence from randomized controlled trials in simulation learning showed that motivation and increase in confidence occurred 20 times more and tripled competence in the intervention group as compared to the control group. The GLAucoma Simulated Surgery Trial (GLASS) trial for trabeculectomy skill learning and Ophthalmic Learning and Improvement Initiative in Cataract Surgery (OLIMPICS) for small-incision cataract surgery learning show that simulation makes a real difference. We need to gather more evidence, ensure advocacy, and engage with all stakeholders to disseminate the benefits of simulated learning.[13],[14]

Simulation should be integrated into the clinical training portfolio. Steps of simulation-based surgical education include deconstructing the surgical technique, providing explicit instructions, feedback, sustained deliberate practice, and reflective learning. The outcome assessment is done using microscopes linked to a digital classroom and by recording on iPads and marking against Ophthalmic Surgical Competence Assessment Rubrics (OSSCAR).[15],[16]

 The Orbis Simulation Center

One of the pioneers and biggest users of simulation-supported learning is Orbis International's simulation center. Its completely open-source manual serves as a practical implementation guide for training hospitals and teaching institutions, on establishing a simulation center, designing simulation training, and ensuring ongoing management of the program. The manual provides ophthalmic departments with the resources they need to implement high-quality simulation training for ophthalmologists, ophthalmologists-in-training, ophthalmic nurses, and anesthesiologists. They began with upskilling their own team, purchasing mobile wet lab kits, and then building permanent simulation training centers that can be integrated into a residency curriculum at an institutional level.[17]

The virtual reality simulator in the center enables the user to practice multiple times. It is cost-effective and now it is no longer cost-prohibitive with portable off-the-shelf components. A combination of repeated skill-building giving muscle memory and systems that allow tracking of movements improves the learning experience.[18],[19],[20],[21] A skilled teacher is also able to supervise, teach, and enrich the whole process remotely.

They also have the Orbis International Flying Eye Hospital simulation center where training can be provided in basic and advanced cataract surgery, surgical and medical retina, indirect ophthalmoscopy, pediatric strabismus, trauma, minor operations, etc. It also enables to provide training to a greater number of health care professionals.


Simulation training is the way to go for in medical education, especially for surgical specialties like ophthalmology. This alone can ensure a stress-free experience for the trainer and trainee.


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