I am so thankful to the many mentors who have taught me surgery throughout my career. Many professors at the Jules Stein Eye Institute at UCLA spent years teaching me surgical techniques, clinical judgment and the keys to patient interactions, and I will be forever grateful for that.
But I have learned from many more mentors without spending a single day in the operating room with them. They have taught me with their lectures at major meetings, their personal communications and, lastly, with videos of their surgical procedures. Ophthalmic surgery is well suited to teaching videos because procedures are typically performed under a microscope and are relatively brief in length.
The godfather of ocular surgery videos is Robert H. Osher, MD, who has published his Video Journal of Cataract and Refractive Surgery since 1985. These videos were originally distributed on VHS cassette tapes; I still remember hunting for them when I was a resident 20 years ago. Each was full of incredible teaching, and I studied them diligently — even on my 13-inch television that had a cathode ray tube and just 240 lines of vertical resolution (about 640 × 240 equivalent pixels). Years later, this video journal transitioned to DVDs, which were much better at 720 × 480 pixels, and now it is presented in high definition, 1920 × 1080 pixels. With online streaming, this is now available in true high definition (1920 × 1080 pixels); even higher resolution 4K (3840 × 2160) will likely follow in the near future. Just going from VHS tape to standard HD brought more than 10 times as many pixels, which provides so much more detail for optimal learning.
With the proliferation of smartphones, I can watch these surgical videos from just about any location on the planet. A quick Internet search shows tens of thousands of cataract surgery videos, all of them available for instant streaming. Even rare conditions, such as posterior polar cataracts, have dozens of instructional videos devoted to them.
Physicians are intrinsically teachers because every interaction requires educating our patients about their conditions and courses of treatment. Physicians are also lifelong students to keep up with new technology and evolution within medicine. Many ophthalmologists are interested in teaching their colleagues and the next generation of surgeons, and an essential part of this is creating educational videos.
I have been recording ocular surgery videos for two decades, and I am convinced that it’s the best way to learn. This is the future of surgical education — so how do you get started?
The camera is critical
Most videos are shot through the surgical microscope, so a good-quality video camera and attachment tube are essential. The most common resolution is standard HD, or 1920 × 1080 pixels — this is the lowest resolution you should use. Filming in older formats with lower resolution makes the videos difficult to watch, so avoid them. 4K cameras output in 3840 × 2160, but these are much more expensive, and their output video files will be much larger, which makes storage and transfer of these files more challenging. Even though your smartphone has a true 4K camera for just a few hundred dollars, somehow when it comes to medical-grade cameras, the price shoots up by an order of magnitude or more.
As for the attachment tube, it splits the light coming into your oculars to send the image to the camera. These splitters can be 80:20, 70:30 or a similar designation, which means that 80% of the light will go to the surgeon’s oculars and 20% will go to the video camera, for instance. Then, you can send the video camera output to a recording device, which saves it as a file on a hard drive or USB memory stick.
Video file format matters, too
Some microscopes have built-in camera systems that facilitate the recording process. The downside, however, is that you then may be locked into its recording system, which may have an antiquated file-saving format called a codec.
At our teaching hospital, we purchased a new microscope less than a year ago — for more than the cost of a house. However, it only outputs the video files as MPEG2, which is an older and relatively outdated file format. In addition, this microscope does not output large video files, so a routine cataract case may be broken up into three or more video files that you will need to stitch together later. At another facility, we use a different microscope that outputs all surgeries as a single, complete video file with a modern MPEG4 codec, providing much smaller file sizes and much faster video transfer.
Also, pay attention to the output hardware. It should be the updated USB 3.0, which is up to 10 times faster than the older USB 2.0 format. How important is the codec and the type of USB port? Transferring the video file of a routine cataract surgery to a memory stick using our MPEG2/USB 2.0 microscope takes about 10 minutes, while using the MPEG4/USB3.0 microscope takes just a few seconds.
Adjust the picture quality
To make sure the colors in your video are true, set the white balance on the camera system. Typically, you can achieve this by placing a white material, such as a piece of paper, under the microscope and then starting the white-balance process. This sets the colors so that the white is truly white and the colors within the eye are true to life.
For recording cataract surgery, the red reflex must be emphasized by increasing the coaxial lighting and balancing it with the standard paraxial light (Figure 1). This exaggerated red reflex will make it much easier to see the fine details of the capsulorhexis during the surgery.
Record every case
Some of the best teaching videos show complications and their management, but we don’t always know which eyes will fall into this category before we start operating. For this reason, it is useful to record every surgery performed. You may end up discarding or over-writing the videos of routine cases, but the camera should be active and running for almost all surgeries.
Consider field of view and angles
Remember to keep the microscope centered on the operating field during the entire surgery. Some surgeons have a tendency to push the globe away while the phaco probe is in the eye, causing the eye to drift off the video capture. The field of view through the oculars is typically larger than the field of view of the video capture.
For teaching the correct hand positioning during surgery, the microscope view is limited because it shows only the tips of the instruments as they enter the eye. Setting up a second camera to record the hand positions is helpful. The second camera can be synchronized with the microscope view to create a picture-in-picture teaching video (Figure 2). We have even filmed videos showing the foot pedal position in relation to the microscope view of the cataract surgery (Figure 3).
Edit and voice-over
For surgeries of 10 minutes or less, the entire case can be shown so that viewers can see every step of the procedure. For longer cases (approximately an hour or more), edit the video down to the most important steps. Record an audio track as well so that actual instruction accompanies the action. When you edit the video, make sure the output format is the same resolution as the original raw video footage.
There are many video editing software packages, including some that come pre-installed on computers. While there may be some differences in the user interface, the output is standardized among these video editors.
When making the teaching video, keep the central theme of the lesson in mind. Adding a title slide makes this point clear and allows viewers to find the specific videos they wish to watch.
The challenging part with editing is that it takes time. For instance, a 5-minute video may take an hour or more just for the first draft. The 500+ teaching videos on CataractCoach.com have taken thousands of hours to edit.
Hosting and publishing the videos
While YouTube is the most popular video hosting site, others are out there. YouTube is free, widely distributed and has an app that is included on most smartphones. YouTube also automatically adjusts the output video format depending on the viewer’s device and Internet speed. You should write a good description for each video and then include keywords to help in the search functions. For example, for a tough case of cataract surgery in the setting of pseudo-exfoliation, be sure to include text about loose zonules and poor dilation.
Another option is to create your own website. I developed an independent website, CataractCoach.com , where I publish a new video/article every day. This site allowed me to incorporate text, photos and diagrams with my videos (Figure 4).
Making a surgical teaching video is a great way of demonstrating your techniques and of educating surgeons around the world.
I encourage you to check out my online teaching project, CataractCoach.com . Let me know if I can help you with your own surgical video project. OM