Discussion
Ngenuity®, Ngenuity, ®
COMPLICATION, RETINA, TRANSMISSION, SECONDARY, LENS
Telementoring is a promising tool that can overcome geographical barriers to ophthalmic education. This study reinforces the rationale that telementoring plays a teaching role similar to traditional face-to-face mentoring in surgical training of this scleral fixation technique using a 4-haptic intraocular lens and Gore-Tex CV-8 polytetrafluoroethylene sutures. We lack evidence in terms of group differences for superiority comparing face-to-face and telementoring, in addition to presenting comparable results regarding surgical success and failure. Considering surgeons with more than 13 years of experience since residency, there was a tendency for better results in the face-to-face group.Telemedicine has seen astounding growth in recent years due to advances in key digital innovations in information and communication technology. Telementoring is an arm of telemedicine that uses data transmission technology to provide real-time supervision and technical assistance for surgical procedures from a specialist in a remote geographic location. It has advantages compared to traditional mentoring, including travel costs, distance, and availability.Several studies in various medical specialties sought to compare the applicability of telementoring in clinical practice, comparing it with traditional face-to-face mentoring. In a systematic review conducted to evaluate the effectiveness of telementoring compared with on-site mentoring, Bilgic et al. [In our study, 44% of the participants were retina and anterior segment specialists, 39% were fellows, and 17% were ophthalmology residents, however, the randomization created a balanced group in terms of demographics, such as age, career, sex, and previous use of the NGENUITY® system (57% of the participants had previously experienced the system). The primary outcomes evaluated were the global score (the sum of each score on the rubric), surgical failure, and surgical time (in seconds). As expected, we found that the overwhelming majority of our sample reached surgical success, with the success rate being similar between the two groups (98.5% in the face-to-face, and 95.5% in the telementoring), and this difference was not statistically significant (p-value = 0.619). The findings seemed to indicate that both mentoring techniques are effective, with no superiority of one over the other—the global score revealed no statistically significant difference (p-value = 0.373), with a mean score of 18.91 and 18.66 in the face-to-face and telementoring groups, respectively (The duration of the procedure also showed no statistically significant difference (p-value = 0.775), with a mean surgical time of 2.234,73 seconds (approximately 37 minutes and 15 seconds) in the face-to-face group, and 2.209,36 seconds (approximately 36 minutes and 49 seconds) in the telementoring group.Regarding surgical failures, the face-to-face group reported one case (1.5%) whereas the telementoring group described three cases (4.5%). Nevertheless, the values obtained were not statistically significant (p-value = 0.619). The surgical failure from the face-to-face group occurred because of IOL damage during the Akreos® implantation, and this also occurred in two cases for the telementoring group. The third case of surgical failure in the telementoring group occurred due to a technical problem in the transmission of images at the end of the mentoring period. In this case, the transmission image froze at the end of the procedure disabling the mentor to assist with the two last steps of the surgery (suture placement and burying of the suture points). This technical problem was related to the surgery recording software which ended unexpectedly and terminated the transmission.with respect to the technical problems, we recorded a total of eight occurrences (6%) of which six (75%) were related to temporary interruptions in communication that resolved spontaneously and were probably related to network instability. Only one of the participants reported an episode of transmission delay, which did not influence the training outcome. Transmission delay is a very important concept that should be carefully examined when testing telementoring equipment. In our study, the mentor was located in a room next to where the mentee was conducting surgical training. Over long distances such as different cities, states, or countries, the delay can vary and exert a more relevant impact on telementoring. However, with advances in technology and the internet, as well as high-speed networking, these problems tend to be progressively reduced.With regard to secondary outcomes, we obtained statistically significant values with a higher mean score in the "communication" (4.94 vs. 4.77; p-value = 0.014) and "SimulEYE® use" (4.8 vs. 4.62; p-value = 0.037) items in the face-to-face mentoring group compared to telementoring group. The topics "mentoring experience" and "Ngenuity use" showed no statistically significant difference. We were not able to precisely substantiate the higher mean score in the topic "SimulEYE® use", since the item used by the participants had exactly the same characteristics. On the other hand, the "communication" item is understandable, since face-to-face mentoring does not present any communication challenges, while telementoring can be influenced by several issues such as volume, delay, and susceptibility to technical failure, among others.Our study has limitations, mainly because it included only one surgical technique, about the results of which may or may not be extrapolated to other ophthalmological surgeries. In addition, telementoring with large distances between mentor and mentee was not evaluated, as both were only a room away. We also raise the limitations of reproducibility of telementoring implementation, which includes cost, equipment requirements, and legal and ethical issues. In addition, a pre-existing relationship between mentor and mentee is required (for example, through pre-telementoring sessions).In this study, we used the Ngenuity® 3D Visualization System, which allowed the mentor to have the same 3D view that the main surgeon experienced, during face-to-face training. In the telementoring group, the mentor followed and assisted with the procedure in real-time with the images being transmitted through a teleconferencing platform in 2D. Another camera captured the audio and images of the surgeon’s face for communication between the mentee and the mentor.In order to fully implement telementoring in ophthalmology, updated versions of Ngenuity® could be developed by taking into account the possibility of real-time transmission of the surgeon’s 3D visualization, audio transmission to allow different surgeons to interact simultaneously, even at great distances, with optimized reproducibility. That way, any viewer may experience the same view that the main surgeon is experiencing, with real-time transmission and 3D imaging, whether on-site or virtually.Studies on telementoring in ophthalmology are limited. Camara et al. [To the best of our knowledge, this study is the first to compare face-to-face and telementoring groups in ophthalmic surgery. We chose the scleral fixation technique using a 4-haptic intraocular lens (Akreos A060 Baush & Lomb, Rochester, NY) and Gore-Tex CV-8 polytetrafluoroethylene sutures (W.L. Gore & Associates, Newark, DE) due to the fact that it is relatively recent, and most ophthalmologists still have no experience with it. In addition, it is a technique that presents good results with low complication rates.In conclusion, this study demonstrates that telementoring is an encouraging educational tool that can overcome geographical barriers to ease the transfer of abilities and knowledge. More studies are needed to explore the impact of telementoring in other ophthalmological surgeries.