Ophthalmic Simulation-based Surgery Digital Class Lab at University of Abuja Teaching Hospital (UATH): The setting-up, GLASS training and participants’ feedback

Abstract

Introduction: Of about 250,000 ophthalmologists worldwide, there are 2,700 in Sub-Saharan Africa (SSA), a ratio of 1.8
ophthalmologists per million population1,2. In addition to the low numbers, ophthalmic surgical proficiency is a challenge. Treatable by surgery, cataract is the most common cause of blindness affecting 12.6 million of the 36-million blind people worldwide. It is the main cause of vision lossin Nigeria1. Small-incisioncataract-surgery (SICS) is a widely accepted, appropriate, affordable procedure and delivers high-quality vision outcomes3. Similarly, for advanced glaucoma, surgical treatment is a main option. However, there are concerns of safety, quality, and efficiency of surgical training for cataract and glaucoma surgery. Therefore, training ophthalmologists to perform these operations safely and efficiently is of major ophthalmic public health significance3. The simulation-based surgery training was recently
introduced for enhancement and refinement of skill acquisition with remarkable results. We report our experience at University of Abuja Teaching Hospital (UATH).

Methods: Sim-Lab set-up: The SimLAB is located in a 6X4ft room.The facilities include: (a) furniture -5 tables and chairs, cabinet with partitions/spaces, and white board; (b) digital class lab comprising 4 stemi 305 microscopes, LAN Network linking the 65" LGTV and 4 iPads using Zeiss LabScope application, and internet for interaction with international/external faculty; (c) surgical items - glaucoma and cataract surgical instruments, Phillips simulated eyes for Manual SICS and
trabeculectomy, and capsulorhexis eye models.

GLAucoma Simulation-based Surgery(GLASS) Training: The advanced glaucoma surgery course was a blended course with two weeks online facilitated meetings to discuss surgical videos specific for the course. This was followed by a 5-day face-to-face GLASS component which comprised:
1. Performing full trabeculectomy on Trab-Sim eyes using the Zeiss Stemi 305 microscopes (Figure 1); recording the procedure on iPad, and then watching the recording and selfassessing (reflective learning); using a
scoring system - the ophthalmic simulated surgical competency assessment rubric (SimOSSCAR) for trabeculectomy.
2. Practicing releasable sutures on foam and sclera flap on apples. The course participants had live surgery demonstration by the trainers with step-by-step commentary/teaching. Trainees performed at least one trabeculectomy, from start to finish.Post-operative evaluation of trabeculectomy patients included discussions on surgical complications and management of complications. One of the participants went further to operate on two patients upon return to base hospital with the assistance of one of the trainers who was physically present to guide. Feedback was obtained from the participants.

Results: There were 19 respondents of which 74% (14/19) reported they gained greatly; 79% said the course was beneficial/very beneficial. All participants (19/19) appreciated the benefits of shared learning and the experience of a sim-LAB course. Report on one of the participant’s two surgical cases performed upon return to base hospital, post-GLASS training showed achievement of target IOP in both cases from 29mmHg to 7.5mmHg by week 2 and from 37mmHg to 13.1mmHg by week 4 respectively.

Discussion: The simulation-based surgery laboratory offers easy skill acquisition when guided by experts. It demystifies the surgery and the supposedly difficult steps: Capsulorrhexis in SICS, releasable sutures and construction of inner block
in trabeculectomy. Simulation-based surgery training is highly desired by trainers and trainees as it improves surgical
proficiency and confidence as well as patient safety. Shared learning and networking experiences are added benefits for centralised surgical course and our facilities need to be enhanced for such training.