Training in cataract surgery in virtual reality simulators

REVIEW ARTICLE

SAVIAN, Tiago Rezende ^[1], FRAGA, Carolina Cândida De Resende ^[2], FRAGA, Ana Laísa Cândida De Resende ^[3]

SAVIAN, Tiago Rezende. FRAGA, Carolina Cândida De Resende. FRAGA, Ana Laísa Cândida De Resende. Training in cataract surgery in virtual reality simulators. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 01, Vol. 06, pp. 05-22. January 2020. ISSN: 2448-0959, Access Link: https://www.nucleodoconhecimento.com.br/health/training-in-cataract

SUMMARY

Ophthalmology training programs quickly responded to the need for evaluation and improvement by developing a variety of evaluation and surgical improvement tools. Cataract surgery with phacoemulsification is a challenging procedure for surgeons who are in training to improve safety, efficiency and accuracy. In the present study, the auxiliary learning tools were discussed, by several authors, outside and in the operating room that the residency and study and continuing improvement programs incorporated into their curriculum to improve surgical skills. Studies published between January 2014 and June 2019 that were available in English, in full text in the Medline/Pubmed electronic database, were chosen. The application of VR simulators is not an entirely new technology, but its application in the area of cataract surgery by phacoemulsification for virtual surgical training and evaluation purposes is still in its initial phase. The results of the experimental studies presented in this literature review demonstrate that VR simulators have the potential and ability to be applied as a viable proficiency assessment tool in the four main complete procedures of cataract surgery by phacoemulsification.

Keywords: Ophthalmologic surgical procedures, cataract, virtual reality, phacoemulsification, computational simulation.

1. INTRODUCTION

In an effort to ward off the difficulties associated with qualitative, subjective and delayed preceptor assessments, virtual reality (VR) tools were designed to assess the surgical ability of students, residents and physicians in a timely and objective manner.

The evaluations appear in the form of peri and postoperative results, adjustments, laboratories, video evaluations, records of self-reported procedures, virtual reality simulators, motion analysis systems, specific checklists of procedures and global classification scales, in the present study virtual reality simulators were evaluated.

Among the virtual reality simulators, three simulation devices were developed for use in cataract surgery: Eyesi® (VRmagic, from Germany), PhacoVision® (Melerit Medical, Sweden) and MicrovisTouch® (ImmersiveTouch, USA). Most studies published in the literature use the Eyesi ®.

It has been reported[4] that this device provides systematic, effective and reliable surgical training at a lower cost. There are few studies on the MicrovisTouch simulators® and PhacoVision®. The features of MicrovisTouch® are the advantages of receiving tactile feedback and having an adjustable virtual head, however, this device has only one stage of capsulorrexe and none of the other modules available in the Eyesi ®. The Cataract Surgery Simulator (Eyesi®) is regularly used in surgical training to facilitate the transition to practical application.

Cataract is the leading cause of blindness and the surgical rate of cataract is used as an indirect indicator of access to cataract services in a country. According to data exposed by who estimated that 285 million people worldwide suffer some type of visual impairment, many (80%) of which are preventable[5].

Since many of these patients do not receive adequate ophthalmologic care, studies are needed to investigate the existing reasons that support this barrier to such care. In latin American regions, lack of awareness and uncontrollable costs seem to be the central barriers to care².

In 2014, the Pan American Health Organization’s (PAHO)[6] Action Plan for the Prevention of Blindness and Visual Impairment used data on ‘surgical cataract coverage’ (from epidemiological studies on blindness and visual impairment in Latin America) as an indicator of access to ophthalmologic services.

Results of nine different studies throughout Latin America showed that coverage of cataract surgeries was lower in rural areas with socioeconomic deficiencies, indicating inequities in the distribution of ophthalmologic services. In addition, using cross-sectional eye health research, a comparative assessment conducted in seven Latin American countries showed that the prevalence of blindness and moderate visual impairment were concentrated in the most socially disadvantaged areas, while surgical cataract coverage and optimal cataract surgery results were concentrated among the richest and most socially favored areas[7].

And what is causing this inequality in services? According to Wang et al.[8] the surgical rate of cataract and economic indicators are closely associated, indicating the strong influence of the availability of resources on the provision of health care. Considering this relationship, it is important to be innovative in providing low-cost services and invest strategically in the development of capacity to meet the surgical needs of cataracts in low-resource environments.

Therefore, this research was important in presenting the new technologies in training of ophthalmology students. Aiming to show the related studies and their results under discussion.

2. METHODOLOGY

2.1 SEARCH STRATEGY

Studies published between January 2014 and June 2019 that were available in English, in full text in the Medline/Pubmed electronic database, were chosen. The limit in 2019 for inclusion of publications was to emphasize new studies and proposals. The research included terms of The MeSH: Ophthalmology AND Ophthalmologic Surgical Procedures AND Cataract AND Virtual Reality AND Phacoemulsification AND computer simulation.

2.2 ELIGIBILITY CRITERIA

Studies that addressed the theme in the primary way. The results of training of residents or physicians in simulators in cataract surgery were considered eligible for inclusion if they involved the training results of residents or physicians in cataract surgery.

We apply the following exclusion criteria: articles prior to the minimum date of inclusion, which had no full text for reading. Preference was given to publications of the last 5 years (2014 – 2019).

2.3 SELECTION OF ARTICLES

The authors independently reviewed and selected the titles and abstracts of articles and manuscripts to identify potentially relevant studies addressing the subject. Manual searches were not performed. Finally, full-text copies of the studies that had met the results, descriptors and objective of training by virtual reality were considered.

3. RESULTS

At Pubmed Central, 13 studies were listed, where abstracts were read, and of these, 09 were separated for reading in full. Also included were 3 studies that were found by reference and citation, totaling 12 articles. As follows:

Table 1 – Authors and works listed for discussion

Source: Authors (2019).

4. DISCUSSION

Sadideen et al[9]. addressed in their research whether expertise, or expertise, would be inherent in certain individuals for surgery, without improvement through training. The concept of surgical expertise and the processes involved in its development are topical, and there is a constant effort to identify reliable measures of specialized performance in surgery. The study explored whether specialists in surgery are “born” or “made”, with reference to educational theory and pertinent literature.

They conclude in the foreground that ininato talent plays an important role, but it is insufficient by itself to produce a specialist in surgery. Multiple theories that explore the acquisition of motor skills and memory are relevant, and Ericsson’s theory of the development of competence followed by deliberate self-practice has been especially influential⁶.

They reiterate that psychomotor and non-technical skills are necessary for progression considering current training curricula; surgery specialists are adaptive specialists who stand out in them. It cites that the literature suggests that surgical expertise is achieved through practice; that is, surgical specialists are made, not born⁶.

They recognize that a deeper understanding of the nature of specialist performance and their development will ensure that training programs in surgical education are of the highest quality possible, and that surgical educators should seek to develop an expertise-based approach, with expert performance as a reference⁶.

At another time Sadideen et al.6 ask if surgeons (the good ones) can be “made” and argue that long before real knowledge develops, it is necessary to achieve competence. Some may naturally achieve this due to inborn talent, still requiring proper practice, and otherwise may require much more practice to achieve the same level of competence. But what if simple practice does not result in obtaining such competence?

The authors cite some studies, where it can be argued that these are limited by the type and duration of the training that was provided and can only be considered as an “instantaneous” view of a very complex and multifactorial environment. However, they confirm that the existence of different learning curves among individuals is a reflection of their innate technical skills. The main challenge for the modern surgical educator is to develop training programs that can deal with these deficiencies for each individual – regardless of their innate ability⁶.

Following the line of study of skills, Tecle et al.[10] investigated the improvement of microsurgical skills through deliberate practices. Microsurgical skills are extremely important for the field of neurosurgery and other surgical specialties, such as plastic surgery and cardiothoracic surgery. However, the learning of microsurgical skills has become increasingly challenging due to the limitation of resident duties.

Microsurgical skills are extremely important for the field of neurosurgery and other surgical specialties, such as plastic surgery and cardiothoracic surgery. However, learning microsurgical skills has become increasingly challenging because of limited hours of service; decentralization of care; and the proliferation of alternative therapies (although these are often complementary). Then, the authors point out that deepening the potential of deliberate practice can influence microsurgical training⁷.

Bergqvist et al[11]. established and evaluated a systematic training program to be included in the ophthalmological curriculum. For this, they used medical students (n = 20) missing about one year to graduate and without previous ophthalmologic experience in this prospective and randomized study in two groups.

Group A (n = 10) completed the Eyesi cataract simulator training program once a week for 4 weeks, while Group B (n = 10) completed once a week in the first and last week. Two cataract surgeons were used to determine two different levels of reference scores. Score per module analyzed two different levels of Capsulorrexe (A and B), hydraulic maneuver, phacoemulsification, divide and conquer, overall score, total time, corneal injury, capsule rupture and capsule injury by ultrasound were recorded⁸.

As a result, Group A surpassed Group B in several modules, achieved a significantly higher number of reference scores (p <0.01) and caused fewer complications with respect to capsule rupture (p = 0.01) and capsule damage by ultrasound (p <0.05). Both Groups A and B improved their performance and also became more efficient (p <0.01 for both groups). Group A presented a positive learning curve for total score (p <0.01), capsulorrex A (p <0.01), capsulorrexe B (p <0.01) and hydraulic maneuver (p = 0.01). Group B showed significant improvement for the overall score (p <0.01), maneuver and phacoemulsification (p = 0.02) divided and presented the score (p <0.01). With the results, the authors concluded that repetitive training with a systematic training program, based on modules validated in the Eyesi simulator, showed to improve the simulated skills in cataract surgery. A higher skill level and more reference points were achieved with more training. In addition, the program was optimized to be applied in the standard ophthalmological curriculum for training in cataract surgery⁸.

Ng et al[12]. they took a pilot course in cataract surgery simulation in a virtual environment in Hong Kong, using the validated training modules in the three-dimensional cataract operation environment generated by the Eyesi computer (VRmagic®, Germany) for residents. They conducted a cross-sectional research after the course for participants and non-participants with the objective of identifying the barriers perceived by residents in learning phacoemulsification procedures, and whether simulation training at Eyesi changed these perceptions.

The authors identified the main learning barriers in cataract extraction surgery by phacoemulsification perceived by ophthalmologic residents in Hong Kong, it was expected that more advanced residents, and trainees who could complete phacoemulsification most of the time without requiring medical intervention, also had the lowest scores of difficulty in surgical tasks⁹.

However, after adjusting for these two potential confounding factors, the simulation of training in Eyesi was significantly associated with increased confidence in more difficult surgical tasks. The virtual reality simulation training in eyesi’s validated modules, followed by proficiency assessment, seemed to be effective in reducing the perceived difficulties in performing the most demanding phacoemulsification procedures in terms of skills in real patients, as evaluated by the residents⁹.

The authors⁹ conclude that the ultimate goal of using the simulator is to improve patient safety and results by trainees/students. Given the widespread adoption of simulator-based training by universities and tertiary ophthalmic centers in many parts of the world, there is an imminent need for a robust clinical study to justify the effectiveness of implementing virtual reality simulator training modules in structured phacoemulsification surgery training programs.

In the study of Staropoli et al.[13] the hypothesis was that simulation training performed before the first cataract surgery would reduce complication rates during the initial cataract rotation in the second year of residency in ophthalmology for residents of the third year of graduate school.

Training in the Eyesi simulator became mandatory for ophthalmology residents of the third year of graduate studies prior to cataract surgery at the authors’ institution (University of Miami Miller School of Medicine). The study consisted of evaluating the complication rates of 11 simulator-trained residents (study group) compared to their 11 simulated immediate predecessors (comparison group). The complication data were obtained from the Morbidity and Mortality records and compared using fisher’s exact test and a questionnaire was directed to the residents in the perceived utility assessment of simulation training¹⁰.

The study sought a significant reduction in the complications of live cataract surgery, associated with the addition of training in surgical simulation. They concluded that any complication, PCT and vitreous prolapse rates were lower after simulation training (P = 0.037, P = 0.032, P = 0.032, respectively). Posterior capsular ruptures and vitreous prolapse determine the significance of any complication analysis and have been reported as the most common complications in cataract surgeries performed by residents¹⁰.

For the research of Oflaz, Köktekir and Okudan[14] cataract surgery is one of the most common surgical procedures in ophthalmology, where the procedure requires good coordination and a long learning curve. The authors agree that numerous studies indicate that simulator and laboratory training increase surgical performance, shorten residents’ learning curve, and reduce complications related to the in vivo procedure.

The authors concluded that the simulators can find a place in practice, as they allow coaches to explain aspects of the surgical technique to inexperienced residents, without time restrictions, and they can freely observe the technique in question. As real patients are not involved in the procedure, simulators provide a less stressful and more convenient environment for both residents and coaches¹¹.

Performing the procedure first in the simulator and then in real patients may be more appropriate from an ethical point of view. It instills student self-confidence before operating on real patients and helps prevent some of the potential medical-legal problems. In a way, simulator training is ideal for physicians to stimulate surgeon confidence before real surgical procedures and prevent possible complications¹¹.

Wisse et al[15]. they conducted a prospective cohort study where comparative analysis using a paired t-test demonstrated a significant increase in efficacy in relation to cataract surgery in reality after completion of cataract training in the simulator (p = 0.005). In addition, they found a significant correlation between the total tasks to complete cataract training and the self-efficacy scored after working with the simulator (p = 0.038). The motivation in relation to the simulator remained stable over time and did not appear to be influenced by the simulator’s or real-life performance.

Evidence was found that the performance in the simulator correlated with the self-efficacy of the residents, scored after the simulator training, supporting the theory that self-efficacy is determined by the previous performance, and this seemed, for the authors, inversely related to the ease of performing a task: the delivery of a greater effort leads to greater satisfaction and greater perceived self-efficacy in relation to this specific task¹².

Thomsen et al.[16] did a research to delineate the correlation between the performance of cataract surgery between a virtual reality simulator and a real-life surgery using two objective evaluation tools with evidence of validity.

Cataract surgeons with different levels of experience were included in the study. All participants performed and recorded three standard cataract surgeries before completing a proficiency test in the EyeSi virtual reality simulator. Standard cataract surgeries were defined as: (1) surgery performed under local anesthesia, (2) patient age> 60 years and (3) visual acuity> 1/60 preoperatively.

A motion tracking score was calculated by multiplying the average length of the course and the average number of movements of the three actual surgical videos of complete procedures. The EyeSi test consisted of five abstract modules and two procedure modules: intracapsular navigation, antitremor training, intracapsular tremor training, forceps training, bimanual training, capsulorrexe and phacoemulsification, divide and conquer. Eleven surgeons were enrolled. After a designated warm-up period, the proficiency test in the EyeSi simulator was strongly correlated with real-time performance measured by the cataract surgical video motion tracking software with a Pearson correlation coefficient of -0.70 (p = 0.017)¹³.

Performance in the EyeSi simulator is significantly and highly correlated with actual surgical performance, however, it is recommended that performance evaluations be made using various data sources.

The following year, Thomsen et al.[17] evaluated surgeons with levels of fitness and variable surgical experience. The sample consisted of 18 participants who performed surgical cataract training in a virtual reality simulator (EyeSi) until a proficiency-based test was approved. The primary outcome was technical performance, measured by the Objetive Structured Assessment of Cataract Surgical Skill (OSACSS) evaluation scale. The classification scale consists of task-specific items and global indexes, which are classified from 1 point “inadequate performance” to 5 points “well executed”. Thus, the evaluation of technical performance included 13 specific items of tasks, which were classified using the original 5-point classification scale.

The results of this study suggest that proficiency-based virtual reality training can improve surgical performance, not only of novice surgeons, but also of surgeons at an intermediate level. The conclusion that can be drawn is that the improvement of technical skills is transferable from a simulated configuration to the operating room¹⁴.

According to the study by Chung et al[18]. the acquisition of dexterity and the training of surgical skills outside the operating room is a growing topic in the field of education of residents. It has been shown that the habit of playing video games improves motor skills and the coordination of movements in manual dexterity tests. Although individual studies on the effect of video games on surgical simulation skills have been controversial, several reviews suggest that the act of playing weekly video games benefits the surgeon’s learning, improves surgical time and reduces the number of errors in laparoscopic simulators.

Thus, the study aimed to determine the effect of fine motor activity and non-dominant training on hands on cataract surgical simulator (Eyesi) performance in a prospective controlled study at the University of Iowa and Veterans Affairs Health Care Systems, Iowa City, Iowa, USA. The method consisted of completing a questionnaire by medical students and evaluating microsurgical dexterity at baseline using the three tasks of the surgical simulator: navigation, forceps and dexterity with both hands¹⁵.

Participants were randomized into the control or intervention group, which consisted of writing, completing a labyrinth, eating and brushing their teeth once a day with a non-dominant hand. They returned 4 weeks after the initial evaluation for the simulator follow-up test. The results corroborated that regular video game players had higher scores than non-players in navigation (P= 0.021) and bimanual tasks (P= 0 .089)¹⁵.

All participants showed statistically significant improvements in all 3 follow-up tasks after a single initial evaluation in the surgical simulator (navigation: P < 0.004; forceps: P <0.001; bimanual: P < 0.004). Non-dominant hand training with daily activities did not show statistically significant differences for dominant hands or non-dominant hands. O grupo de intervenção (n = 17) tendeu para uma melhora maior do que o grupo controle (n = 16) na navegação (14,78 versus 7,06; P = 0, 445) e tarefas bimanuais (15,2 versus 6,0; P = 0.324) no follow-up (CHUNG et al., 2017).

The authors concluded that the common video game improves the reference microsurgical performance measured in the surgical simulator. Simulation performance improved significantly in the intervention group and in the control group after one (01) session in the simulator. Although not statistically significant, training the non-dominant hand with daily activities showed a tendency to improve navigation and ambidextrous performance¹⁵.

Landis et al[19]. the purpose of investigating the impact of resident training with a cataract surgical simulator under the perception of patients about the involvement of the resident in cataract surgery and to identify the characteristics of the patient associated with the willingness to perform cataract surgery performed by residents.

An anonymous survey of 26 questions was distributed to 430 consecutive patients at the Hershey Center of Pennsylvania, USA. The research included demographic information, questions evaluating the willingness to have a resident involved in cataract surgery, and issues evaluating the knowledge of the role of residents in patient care. Patients were randomly assigned to one of the two groups. Patients assigned to group one watched a brief video explaining the role of a surgical simulator in the training of residents, and were then asked to complete the research. Patients assigned to group two were asked to complete the research without watching the video. The standard t-test was used to compare demographic data. Reasons for possibilities (O.R.[odds ratio]) were used to compare the answers between the two groups¹⁶.

Four hundred and ten patients (95.3%) completed the research, including 203 patients in group one and 207 patients in group two. Compared to patients in group two, patients in group one were twice as likely to express a willingness for a resident to perform their cataract surgery (O.R. 2,02; p <0,001). In all patients, men were more likely than women to express a willingness for a resident to perform their cataract surgery (O.R. 1,65; p = 0,0065). Overall, 25% of patients expressed willingness to allow a resident to perform their cataract surgery, and this percentage increased to 54% if patients were told that an experienced cataract surgeon supervises the resident. Ninety-five percent of patients felt they should be informed in advance if cataract surgery was to be performed by a resident¹⁶.

Patients were more likely to express a willingness to allow a resident to perform their cataract surgery after watching a video explaining the role of a surgical simulator in training residents for cataract surgery. A complete process of informed consent, including information on the supervision of cataract surgery performed by residents and a brief video detailing the training of residents with a surgical simulator, may increase the patient’s willingness to allow residents to participate in cataract surgery¹⁶.

Sikder et al[20]. in their literature review they mention that virtual simulators have been widely implemented in medical and surgical training, including ophthalmology. The growing number of articles published in this field requires a review of the available results to evaluate current technology and explore future opportunities.

They conducted a pubmed survey and a total of 10 articles were reviewed. The virtual simulators showed construct validity in many modules, successfully differentiating user experience levels during simulated phacoemulsification surgery. The simulators also showed improvements in laboratory performance. The implementation of simulators in residency training has been associated with a decrease in complication rates of cataract surgery¹⁷.

The authors concluded that virtual reality simulators are an effective tool for assessing performance and differentiating the level of skill of students/residents. In addition, they may be helpful in improving surgical ability and patient outcomes in cataract surgery. Future opportunities include the use of technical improvements in simulators for education and research¹⁷.

The aim of the study by Lam, Sundaraj and Sula[21]iman was to review the capacity of virtual reality simulators in the application of cataract surgery training by phacoemulsification. The review included scientific publications on cataract surgery simulators that were developed by different groups of researchers, along with commercialized surgical training products such as EYESI® and PhacoVision®.

The review included the simulation of the main surgical procedures of cataract, that is, corneal incision, capsulorrexe, fasciculation and intraocular lens implantation in several virtual reality surgery simulators. Ponic realism and visual realism of the procedures are the main elements to mimic the actual surgical environment. The involvement of ophthalmology in virtual reality research since the early 1990s has had a great impact on the development of surgical simulators¹⁸.

They concluded that most of the most recent cataract surgery training systems are capable of offering high fidelity in visual feedback and naptical feedback, but visual realism, such as the rotational movements of an eyeball with response to force applied by surgical instruments, is still lacking in some of them. The evaluation of surgical tasks performed in the simulators showed a significant difference in performance before and after training¹⁸.

FINAL CONSIDERATIONS

Evidence-based virtual reality (VR) training programs were successfully used in training novice surgeons in other fields of surgery. Some smaller ophthalmologic studies have established construct validity for a limited number of tasks in the VR simulator, comparing primarily novices with experienced surgeons.

Our study made it clear that training is helpful in improving acuity and similar results have been reported for both more experienced individuals in ophthalmology and residents. Fast learning is also common for other surgical simulator tasks. Simulator training proved to be beneficial in early clinical performance in other medical fields, such as colonoscopy and laparoscopic surgery.

Seymour et al. (2002) showed that tissue damage, such as injuries and burns, was five times more likely to occur in the untrained group compared to the RV-trained group. In the two modules studied, the students learned to deal with the instrument more efficiently and cautiously within the model’s eye. The simulator, therefore, has the potential to be part of the initial training of new cataract surgeons.

The application of VR simulators is not an entirely new technology, but its application in the area of cataract surgery by phacoemulsification for virtual surgical training and evaluation purposes is still in its initial phase. The results of the experimental studies presented in this literature review demonstrate that VR simulators have the potential and ability to be applied as a viable proficiency assessment tool in the four main complete procedures of cataract surgery by phacoemulsification.

The authors who compared the simulators found, for example, that the performance of the Eyesi simulator was significantly correlated with the surgical performance of cataract in reality. This suggests that the increased use of VR simulators in the evaluation of surgical competence can be justified. In addition, it indicates that the Eyesi simulator can be a valuable tool for assessing surgical competence.

REFERENCES

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HOSLER, Matthew R. et al. Impact of resident participation in cataract surgery on operative time and cost. Ophthalmology, v. 119, n. 1, p. 95-98, 2012.

LAM, Chee Kiang; SUNDARAJ, Kenneth; SULAIMAN, Mohd Nazri. A systematic review of phacoemulsification cataract surgery in virtual reality simulators. Medicina (Kaunas, Lithuania), v. 49, n. 1, p. 1-8, 2013.

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APPENDIX – FOOTNOTE REFERENCES

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5. WHO – WORLD HEALTH ORGANIZATION. Universal eye health: a global action plan 2014-2019. 2013.

6. PAHO. PAN AMERICAN HEALTH ORGANIZATION. Health in the Americas: 2012 edition. Regional outlook and country profiles. Washington: PAHO, 2012.

7. LIMBURG, Hans; SILVA, Juan C.; FOSTER, Allen. Cataract in Latin America: findings from nine recent surveys. Revista Panamericana de Salud Pública, v. 25, p. 449-455, 2009.

8. WANG, Wei et al. Cataract surgical rate and socioeconomics: a global study. Investigative ophthalmology & visual science, v. 57, n. 14, p. 5872-5881, 2016.

9. SADIDEEN, Hazim et al. Surgical experts: born or made?. International Journal of Surgery, v. 11, n. 9, p. 773-778, 2013.

10. TECLE, Najib et al. Enhancing Microsurgical Skills Through Deliberate Practice. World Neurosurgery. 2018.

11. BERGQVIST, Joel et al. Establishment of a validated training programme on the E yesi cataract simulator. A prospective randomized study. Acta ophthalmologica, v. 92, n. 7, p. 629-634, 2014.

12. NG, Danny Siu-Chun et al. impact of virtual reality simulation on learning barriers of phacoemulsification perceived by residents. Clinical Ophthalmology (Auckland, NZ), v. 12, p. 885, 2018.

13. STAROPOLI, Patrick C. et al. Surgical simulation training reduces intraoperative cataract surgery complications among residents. Simulation in Healthcare, v. 13, n. 1, p. 11-15, 2018.

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15. WISSE, Robert PL et al. The Eyesi simulator in training ophthalmology residents: results of a pilot study on self-efficacy, motivation and performance. BMJ Simulation and Technology Enhanced Learning, v. 3, n. 3, p. 111-115, 2017.

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^[1] General Practitioner graduated from UNIMES – Metropolitan University of Santos, city of Santos/ SP. Lawyer and bachelor’s degree in law from CESUR – Center for Higher Education of Rondonópolis, city of Rondonópolis/ MT. Postgraduate in Labor Procedural Law from UGF – Gama Filho University, City of Rio de Janeiro/RJ.

^[2] Physiotherapist graduated from PUC-GO – Pontifical Catholic University of Goiás, city of Goiânia/GO. Academic of the 6th year of the medical course at UNIMES – Metropolitan University of Santos, city of Santos/ SP.

^[3] Veterinary Physician graduated and Master’s degree from UFMT – Federal University of Mato Grosso, city of Cuiabá/ MT. Academic of the 3rd year of the medical course of FAMP – Morgana Potrich College, city of Mineiros / GO.

Sent: January, 2020.

Approved: January, 2020.