PixEye Virtual Reality Training has the Potential of Enhancing Proficiency of Laser Trabeculoplasty Performed by Medical Students: A Pilot Study.

OBJECTIVE: To compare the surgical proficiency of medical students who underwent traditional training or virtual reality training for argon laser trabeculoplasty with the PixEye simulator.
MATERIALS AND METHODS: The cohort comprised of 47 fifth year male medical students from the College of Medicine, King Faisal University, Saudi Arabia. The cohort was divided into two groups: students (n = 24), who received virtual reality training (VR Group) and students (n = 23), who underwent traditional training (Control Group). After training, the students performed the trabeculoplasty procedure. All trainings were included concurrent power point presentations describing the details of the procedure. Evaluation of surgical performance was based on the following variables: missing the exact location with the laser, overtreatment, undertreatment and inadvertent laser shots to iris and cornea.
RESULTS: The target was missed by 8% of the VR Group compared to 55% in the Control Group. Overtreatment and undertreatment was observed in 7% of the VR Group compared to 46% of the Control Group. Inadvertent laser application to the cornea or iris was performed by 4.5% of the VR Group compared to 34% of the Control Group.
CONCLUSION: Virtual reality training on PixEye simulator may enhance the proficiency of medical students and limit possible surgical errors during laser trabeculoplasty. The authors have no financial interest in the material mentioned in this study.

INTRODUCTION

Argon laser trabeculoplasty (ALT) is one of the most effective modalities for treating open-angle glaucoma.12 For example, a success rate of almost 90% has been reported in open-angle glaucoma cases.34 The main complications of the procedure include intraocular pressure (IOP) spikes, post-laser uveitis and peripheral anterior synechia.45 These complications can be significantly minimized with appropriate training and accurate technique.67

The PixEyes–Ophthalmic Simulator (SimEdge SA, Loos France) [Figure 1] is a virtual reality tutoring system as well as an ophthalmology disease simulator. It simulates training in real conditions for diagnosis and laser treatment of diseases such as diabetic retinopathy, age-related macular degeneration, retinal vascular diseases and glaucoma. PixEyes is primarily designed for the treatment of retinal disorders.

Figure 1

Pix eyes stimulator

Traditionally, surgical training for medical students at King Faisal University includes attending theoretical sessions, video-projection sessions, and then performing the surgical procedure on animal eyes. However, students using PixEyes during training can experience the full scope of surgery on a computer akin to the real world.89 PixEyes is controlled by advanced computer technology that records and assesses all surgical maneuvers and decisions made by a student performing laser on a virtual eye. The advantage of this virtual reality training is that it likely reduces student apprehension when dealing with an actual patient. This state of the art training in ophthalmology, thereby help build confidence in budding ophthalmologists. The main features of this simulator include realistic handling of a contact lens, binocular projection of realistic images, adjustments similar to a slit lamp (width, height, brightness, etc), and accurate simulation of laser (power, duration, micromanipulator, etc). PixEyes includes built-in expert and student models. The expert model is used by the consultant to create an expert method of treating certain diseases. This simulated model can be saved and used by student to learn how to diagnose the disease or to compare their performance with their tutoring consultant. The student model is to diagnose certain cases, save the work and send it to the instructor or to compare their work with the pre-simulated instructor models. Simulator-based assessments can offer immediate feedback and correction of errors.9–11

MATERIALS AND METHODS

This study was registered with the Institutional Review Board (IRB) and approval was granted by the ethics committee (EC) of King Faisal University.

The cohort comprised 47 male students in the fifth year of the Faculty of Medicine, King Faisal University. The students were randomly assigned to receive training by one of two methods: virtual training on the PixEye simulator (VR Group, n = 24) or traditional training only (Control Group, n = 23). The training was preceded by a Power Point (Microsoft Corp., Redmond, WA, USA) presentation describing the details of laser trabeculoplasty. Following completion of training, each student was observed performing trabeculoplasty. Proficiency at trabeculoplasty was delivering the laser shot to the exact location, overtreatment, undertreatment and accidental laser shots to the iris and cornea.

The PixEyes simulator is shown in Figure 1. Comparison of both groups was performed with Fisher's exact test.

RESULTS

Laser shot delivery to the exact location was missed by 8% of the VR Group and 55% of the Control Group. This difference was statistically significant (Fisher's exact test, P = 0.001). There was statistically significantly greater overtreatment and undertreatment by the Control Group (46%) compared to the VR Group (7%), (Fisher's Exact test, P = 0.015). There were statistically significantly lower inadvertent corneal or iris burns in the VR Group (4.5%) compared to the Control Group (34%) (Fisher's Exact test, P = 0.01) [Table 1].

Table 1

Errors in laser trabeculoplasty performed by 5th year medical students compared to traditional training

DISCUSSION

Air pilots have been trained with virtual reality flight simulators for decades. These simulators have also been used to assess competency which is more cost effective than in-flight assessments. Recently, a number of surgical specialties have incorporated virtual reality simulation in surgical training programs.9

Laser photocoagulation plays a major role in ocular therapy. However the persistence of many postoperative complications indicates genuine difficulty in mastering the technique. With the use for virtual reality simulation, laser delivery and application can be practiced without subjecting patients to possible hazards.910

The outcomes from our study indicated that training with the PixEye simulator significantly enhanced the capability of medical student to perform laser trabeculoplasty. This is an encouraging outcome as our cohort represented medical students who would be relatively unfamiliar with the procedure compared to residents in ophthalmology. For example, ophthalmology residents may be inherently more proficient at the laser procedure due to past experience and/or greater familiarity with the eye. Future studies should compare the performance of residents in ophthalmology and to medical students to determine if the learning curve is faster after VR training and the differences in performance between groups.

Previous studies of virtual reality training for retinal photocoagulation,10–12 reported comparable results. However to our knowledge, there are no previous studies of with argon laser trabeculoplasty after virtual reality training.

Training with the PixEye simulator may make medical study more proficient at performing laser trabeculoplasty and limit possible errors in laser application thereby limiting complication.