Microsurgical training on two virtual reality EyeSi simulators at the New Zealand National Eye Centre, Auckland University

I read with interest the article by Wadhwa et al regarding the impact of the Covid-19 pandemic on the eyecare system in Aotearoa-New Zealand. Covid-19 has placed an overwhelming burden on our healthcare system with a major impact on how ophthalmic services operate in New Zealand. Notably, ophthalmology is considered a high-risk subspecialty due to the compounded risk of virus exposure during close proximity ophthalmic examinations and high-volume outpatient clinics¹.

As Wadhwa et al noted, clinical activity in ophthalmology has significantly diminished during this global crisis, with the cancellation of many elective eye surgeries and limited access to outpatient clinics. As such, there are likely to be downstream effects of Covid-19 on ophthalmic surgical training and complication rates.

Contemporary ophthalmic surgery requires high levels of training and microsurgical skill attainment. Regrettably, with the curtailing of elective operative cases, ophthalmologists in training now have more limited opportunities to hone surgical skills. Importantly, rapid de-skilling of fine-motor skills has been shown to occur after six months, further compromised by factors such as anxiety and loss of confidence^2,3. Unsurprisingly, the attenuation of microsurgical skills may result in increased intraoperative and postoperative complications² that may be exacerbated by the presentation of more advanced cases due to increased surgical waiting times.

Based on the Auckland Cataract Study IV^4, the rate of any intraoperative complication is approximately 5% for registrars and 2.2% for consultants. However, the incidence of the most serious complication (posterior capsule rupture, 0.8%) is relatively low compared to the UK Cataract National Database (1.9%), while postoperative cystoid macular oedema occurs in 3.2% of cases⁴.

Interestingly, a recent study by Theodoraki et al² which evaluated the impact of cessation of regular cataract surgery during the Covid-19 pandemic in the UK, reported a statistically significant increase in posterior capsule rupture rate between two time points - P1 (prior to the pandemic) and P3 (after and during second lockdown) (1.67% vs 3.55%; P = 0.0022). Similarly, postoperative cystoid macular oedema has also increased substantially during this period (1.93% vs 6.86%; P < 0.0001), possibly reflecting more complicated surgery. Overall, these observations suggest that prolonged interruptions in regular cataract surgery may have a pernicious effect on microsurgical skills resulting in increasing operative complications.

The ongoing Covid-19 pandemic has raised concerns relating to the impact of surgical training programmes. Anecdotal discussion with ophthalmology trainees highlights similar concerns in Australasia. A focus on maximising training opportunities in clinically stretched environments, coupled with the utilisation of new microsurgical technological tools, such as EyeSi virtual reality cataract and retinal surgery simulators, may help trainees achieve and maintain skills in these challenging times.

References

1. Ferrara M, Romano V, Steel DH, Gupta R, Iovino C, van Dijk EH, Romano MR. Reshaping ophthalmology training after Covid-19 pandemic. Eye 2020 Nov;34(11):2089-97
2. Theodoraki K, Naderi K, Lam CF, Tan JK, Jameel A, Lai L, Garcia LO, Low S, Bhogal M, Robbie S, O’Brart D. Impact of cessation of regular cataract surgery during the Covid pandemic on the rates of posterior capsular rupture and post-operative cystoid macular oedema. Eye 2022 Feb 3:1-6
3. Maubon L, Nderitu P, O’Brart DP. Returning to cataract surgery after a hiatus: a UK survey report. Eye 2021 Aug 6:1-6
4. Han JV, Patel DV, Liu K, Kim BZ, Sherwin T, McGhee CN. Auckland Cataract Study IV: Practical application of NZCRS cataract risk stratification to reduce phacoemulsification complications. Clinical & Experimental Ophthalmology 2020 Apr;48(3):311-8

Dr Aaron Ong is a cornea clinical research fellow in the Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland

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