Stepwise approach to establishing an ophthalmology wet laboratory Bonnie An Henderson, MD, Kelly J. Grimes, MS, Robert E. Fintelmann, MD, Thomas A. Oetting, MD Wet laboratories (wet labs) play an increasingly important role in ophthalmology surgical resi- dency training. We summarize the necessary components in establishing and maintaining a well-functioning wet lab and offer a stepwise guide for educators to improve the quality of the wet lab experience. We present 6 key factors in creating an ophthalmology wet lab that is, setting up the physical space, establishing appropriate faculty and curriculum, obtaining the prac- tice eye, stabilizing the eye, preparing the eye, and funding the wet lab. J Cataract Refract Surg 2009 35:1121���1128 Q 2009 ASCRS and ESCRS Competent surgical performance requires a level of expertise only gained through deliberate practice of key surgical steps.1 Surgical training laboratories (wet labs) have been shown to be an effective method for developing surgical proficiency.2,3 Wet labs pro- vide a risk-free environment in which residents are introduced to the technical aspects of surgery. This hands-on experience is necessary for developing tech- nique and confidence to improve surgical perfor- mance. Wet labs are a particularly important training tool in helping residents develop competency in cata- ract surgery.4 The delicate nature of ocular tissue and the small scale of the eye���s anatomical components result in a low tolerance for error. Indeed, the learning curve for cataract phacoemulsification surgery is steep, with complication rates increasing close to 10- fold between experienced surgeons and residents.5���12 Despite their important role in training, wet labs are limited by several factors. Maintaining a fully stocked wet lab fit with proper supplies and faculty personnel can be financially burdensome. Wet labs typically use human cadaver, porcine, or manufactured eyes (Ta- ble 1). Human cadaver eyes with a well-developed cat- aract and a clear cornea are difficult to find. Although porcine eyes are readily available, they differ signifi- cantly from human eyes, with the former having large anterior chambers, thick and more elastic anterior cap- sules, and large, soft lenses. Manufactured eyes from various materials can simulate portions of the proce- dure, such as nucleus removal, but are not as helpful for practicing other steps, such as creating the capsulorhexis. Despite such shortcomings, wet labs remain a neces- sary and useful preliminary alternative to practicing on live patients. Various improvements in wet lab models have been made to better simulate live sur- gery. Advances include cataract induction, animal eye preparation, and the development of globe-posi- tioning devices. Each advance has been reported in separate articles. By incorporating all previously re- ported methods, we provide a step-by-step manual for setting up a wet lab for training residents in cata- ract surgery, focusing on the use of porcine eyes. MATERIALS AND METHODS A review of the literature was performed on PubMed for ar- ticles related to cataract surgery teaching, wet laboratory, as- sessing competence, surgical skills, or surgical curriculum. Key words and terms were inducing cataract, cataract induc- tion, wet lab, ophthalmology wet lab, ophthalmology curriculum, teaching cataract, and phacoemulsification. Fifty-two peer-re- viewed articles were found. Methods for establishing a wet laboratory, preparing animal eyes, or creating surgical cur- ricula were summarized. Wet lab course directors and ad- ministrators in the ophthalmology education departments Submitted: November 6, 2008. Final revision submitted: January 2, 2009. Accepted: January 4, 2009. From the a private practice (Henderson, Grimes), Boston, Massa- chusetts, the Jefferson Medical College of Thomas Jefferson University/Wills Eye Institute (Fintelmann), Philadelphia, Pennsyl- vania, and the University of Iowa Hospitals and Clinics and the Veterans Affairs Medical Center (Oetting), Iowa City, Iowa, USA. No author has a financial or proprietary interest in any material or method mentioned Corresponding author: Bonnie An Henderson, MD, Ophthalmic Consultants of Boston, 52 Second Avenue, Suite 2500, Waltham, Massachusetts 02451, USA. E-mail: bahenderson@eyeboston. com. Q 2009 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/09/$dsee front matter 1121 doi:10.1016/j.jcrs.2009.01.027 SPECIAL REPORT

of academic institutions were consulted for sources of mate- rials for the wet labs. Six important factors in creating and maintaining an oph- thalmic surgical practice laboratory for animal eyes were identified. The factors are as follows: setting up the physical space, establishing appropriate faculty and curriculum, ob- taining the practice eye, stabilizing the eye, preparing the eye, and funding the wet lab. STEPS FOR ESTABLISHING A WET LAB The Accreditation Council for Graduate Medical Edu- cation (ACGME)13 has mandated that residents must have access to a wet lab or to simulators for skills de- velopment. It also requires some form of supervision or instruction within the lab. Although many larger programs have created wet labs, many smaller pro- grams do not have the resources to provide a fully functioning lab for trainees. For many programs with wet labs, the lab is often poorly maintained, with in- sufficient supplies and nonfunctioning equipment, and there is a lack of faculty supervision. Many pro- grams also do not have a formal curriculum therefore, the residents do not have structure for time spent in the lab. Many also do not have guiding benchmarks for evaluating improvement. To address these insuffi- ciencies, this article outlines important factors in creat- ing and operating a wet lab. Step 1: Setting Up the Physical Space A proper wet lab must have sufficient space for at least 2 people (student and teacher), an operating mi- croscope, a phacoemulsification machine, a table to place the eye, a sink with water supply, and a storage space. The minimum supplies include 2 sets of surgical instruments, blades, an ophthalmic viscosurgical de- vice (OVD), irrigating solution and tubing for the pha- coemulsification machine, irrigation/aspiration tips, intraocular lenses (IOLs), sutures, gloves, biohazard disposal containers, and sharps disposal containers. Ideally, a refrigerator���freezer and microwave would be available in the wet lab. The facilities and instru- ments must be dedicated for wet lab use only and should not be used for human surgery. A key factor in establishing a sustainable wet lab is having an assigned coordinator. A designated person must be responsible for maintaining the lab, taking inventory of contents, and ordering supplies when necessary. The wet lab must be cleaned and orga- nized on a regular basis. If a staff coordinator is not available, designating a single resident to be responsi- ble for the lab on a rotating schedule could be implemented. Step 2: Establishing Appropriate Faculty and Curriculum A wet lab can have sufficient space with abundant supplies. However, if the residents do not have the proper supervision while practicing in the wet lab, they may not be learning the correct surgical tech- niques. Instead, residents could be establishing im- proper patterns of holding instruments or could be performing potentially dangerous maneuvers. Resi- dents should have a regularly scheduled rotation for the wet lab. These sessions should always be staffed by a faculty member who can work with the resident one-on-one. If the resident chooses to continue practic- ing, he or she could have additional wet lab sessions that can be staffed by senior residents or could work unsupervised. Finding sufficient faculty members who are willing to regularly supervise residents in a wet lab is chal- lenging. Although most ophthalmologists agree that educating residents is an important mission, it is be- coming increasingly difficult to find physicians who are willing to volunteer time for this endeavor. Be- cause many academic departments are struggling fi- nancially, compensating faculty members is another hurdle in maintaining a wet lab. A wet lab curriculum is also crucial to creating an educational experience.4,5 Often, residents do not know what they are expected to learn in a wet lab. Thus, it is important for educators to provide a set of goals for lab participants. A recent study14 shows that phacoemulsification and capsulorhexis are the 2 most difficult steps in cataract surgery for residents to perform and that the curriculum should emphasize these skills. Another study15 found that phacoemulsi- fication and capsulorhexis are the preferred steps to practice during resident training. If possible, wet lab Table 1. Summary of animal and artificial lens sources for simulating curvilinear capsulorhexis and phacoemulsification. Source Simulation of CCC Simulation of Phacoemulsification Comment Human Good if cornea is not too cloudy Good if cornea is not too cloudy Difficult to obtain cloudy cornea unable to use in OR Porcine Too elastic Too soft Easy to obtain inexpensive messy, unable to use in OR Manufactured Too stiff OK Expensive easy to obtain clean 1122 SPECIAL REPORT: ESTABLISHING AN OPHTHALMOLOGY WET LAB J CATARACT REFRACT SURG - VOL 35, JUNE 2009