The Orbis Symposium on Day 4 of the 42nd Congress of the European Society of Cataract and Refractive Surgery (ESCRS 2024) gathered experts from around the world to tackle the issue of cataract surgery training access in low- and middle-income countries.
The session featured insights from the likes of John Ferris (Orbis International, United Kingdom), Dr. William Dean (Orbis International, United Kingdom), Anna Barba i Giro (Eyes of the World, Spain) and Dr. Oliver Garcia Yanez (Oftalmo University, Mexico).
The hurdles
In low- and middle-income countries, the challenges surrounding cataract surgery training are both urgent and multifaceted. In sub-Saharan Africa, for example, aspiring surgeons face fierce competition, with too many trainees vying for the few cataract surgeries scheduled in both teaching and non-teaching hospitals.
This gap in training echoes in countries like Bolivia, where Giro revealed that over a third of cataract surgeries result in poor outcomes, largely due to complications arising from insufficient training. She reported a staggering 82% of these cases are linked to a lack of qualified ophthalmologists, inadequate resources in training centers, and limited access to high-quality education.
What’s more, the traditional “see one, do one, teach one” model of training, once a cornerstone of surgical education, simply isn’t effective in today’s context. As both Ferris and Dr. Garcia pointed out, this outdated approach fails to meet the demands of modern cataract surgery training.
Digital learning platforms
Cybersight, Orbis’s digital learning platform, is revolutionizing access to high-quality surgical education by connecting trainees with over 100 international mentors, online courses, live surgical demonstrations and even a cutting-edge AI platform for clinical decision-making support. “It’s superb for education, and all courses are translated into 12 languages,” noted Ferris.
Cybersight’s distance learning capabilities have already made a significant impact. In one study, a group of 21 ophthalmic residents participated in a five-week distance cataract wet-lab course delivered via Cybersight. The results were remarkable.1
Over the course of the training, residents’ average competency scores increased by 6.95 points. Additionally, the post-training surgeries performed by the residents yielded impressive visual outcomes: 92% of patients achieved visual acuity of 20/60 or better, meeting the World Health Organization’s standard for quality.1
This demonstrates that structured, distance-based wet lab training in phacoemulsification can significantly enhance surgical skills, helping to bridge the gap in cataract surgery competency in regions where in-person training opportunities are scarce.
Remote surgical mentoring
Remote surgical mentoring not only transcends geographical boundaries but also brings real-time expertise directly into the operating room. In one study, senior ophthalmology residents in Trujillo, Peru, were paired with a seasoned mentor from Vanderbilt Eye Institute in Tennessee. The setup was simple but powerful: live phacoemulsification surgeries were performed in Peru, with the mentor watching in real-time via audio-visual equipment and Zoom conferencing.2
Despite the nearly 4,000 miles separating them, the mentor and surgeon maintained constant voice contact throughout the procedures. With minimal audio and video latency—226 milliseconds for video and 232 milliseconds for audio—the mentor could guide each step of the operation, offering instant feedback and support. The precision of the video feed, with a resolution of 1280 x 720 pixels, ensured that the mentor could clearly observe every detail of the surgery.2
Over four sessions, seven surgeons performed a total of 12 operations under this mentorship model. Remarkably, 10 of these surgeries achieved postoperative vision of better than 6/18, demonstrating the effectiveness of this remote training approach.2
Virtual reality training
Orbis, known for its cutting-edge eye health innovations, has developed a VR tool specifically designed to teach manual small-incision cataract surgery (MSICS). This immersive experience is aimed at students and ophthalmic residents who have little to no experience with MSICS, helping them progress from novices to advanced beginners. “Practicing in virtual reality gives surgeons the muscle memory and confidence they need to perform their duty efficiently,” Ferris asserted.
The Orbis MSICS VR Experience offers a low-cost, portable and scalable educational tool, making it accessible even in regions with limited resources. It forms part of a larger surgical training curriculum, enabling self-directed learning at the trainee’s own pace. With a detailed 28-step process, the tool provides comprehensive insight into MSICS, breaking down each step of the technique, highlighting the expected outcomes, and preparing users for potential complications.
Simulation training
An innovative approach that allows ophthalmology trainees to practice critical procedures in a controlled, risk-free environment, simulation training accelerates their learning curve and improves surgical outcomes.
The OLIMPICS trial recruited 50 first- and second-year ophthalmology trainees from five different training institutions, giving them access to high-quality simulation training specifically focused on small-incision cataract surgery (SICS).3
The results were transformative. Confidence scores among the trainees doubled, empowering them to take on more surgeries with skill and assurance. In the year following their training, these young surgeons performed an average of 21.5 SICS procedures as primary surgeons, compared to just 8.5 before their simulation training.3
They also assisted in more cases—24.6 on average compared to 10.9. Perhaps most importantly, patient safety saw a significant improvement, with complication rates reduced by 72%, and posterior capsular tear (PCT) rates dropping from 26.2% to 7.4% in the first year.3
Blended training
Oftalmo University (OU) is a learning space that redefines how ophthalmologists, particularly in low- and middle-income countries, acquire cataract surgery skills. Leveraging cutting-edge simulation tools, OU provides trainees with state-of-the-art technology that mimics real-life surgical scenarios, enabling them to refine their motor skills in a risk-free environment. But that’s not all.
The personalized teaching methodology at OU goes beyond mere technical training. Learning at OU “happens in a collaborative and supportive environment, and mentors provide tailored guidance and individual support,” noted Dr. Garcia, ensuring that each student’s unique learning needs are met and building their confidence from the ground up.
Having trained ophthalmologists from 140 different countries, the impact of OU’s comprehensive approach is profound. With a unique program that blends simulation, mentoring and psychological preparation, one graduate of OU performed an impressive 250 cataract surgeries in just one year.
In a world where one skilled ophthalmologist can potentially perform hundreds, even thousands of surgeries in a single year, the true challenge lies not in the scarcity of talent but in our collective approach to training and accessibility. By focusing on preparing more people, we don’t just multiply the number of surgeries; we multiply the hope, the potential, and the possibility for countless individuals.
Editor’s Note: Reporting for this story took place at the 42nd Congress of the European Society of Cataract and Refractive Surgery (ESCRS 2024), held from 6-10 September in Barcelona, Spain.
References
- Geary A, Wen Q, Adrianzen R, et al. Impact of distance cataract surgical wet laboratory training on cataract surgical competency of ophthalmology residents. BMC Med Educ. 2021;21(1):219.
- Geary A, Benavent S, Amador De La Cruz E, et al. Distance surgical mentorship for ophthalmologists in northern Peru. MedEdPublish (2016). 2019;8:45.
- Dean WH, Gichuhi S, Buchan JC, et al. Intense simulation-based surgical education for manual small-incision cataract surgery. JAMA Ophthalmol. 2021;139 (1):9-15.
