Keywords
3D printing - residency - education - ophthalmology - slit-lamp - cellphone - ultrasound
biomicroscopy
Three-dimensional (3D) printers are increasingly being used in medicine for surgical
planning, medical education, patient education, research, and device development.
Ophthalmology is a field that relies heavily on direct visualization of ocular structures
and is rich in instrumentation, making 3D printing potentially very useful.[1] 3D printers and the plastic filament (printing material) have become increasingly
affordable. Software for driving the printer and designing 3D models has also become
more user-friendly. Therefore, it has become feasible to provide trainees with access
to a 3D printer for education and experimentation. Here, we describe some of the innovative
uses of this technology that were performed by trainees in an ophthalmology residency
program.
Methods
A MakerGear M2 3D printer (MakerGear, Beachwood, OH) was connected to a dedicated
computer which was made available to medical students, residents, as well as clinical
and research fellows in the Department of Ophthalmology. It was placed in a common
area of the department offices that is only accessible to ophthalmology staff and
where trainees frequently take their breaks. The availability of the 3D printer was
communicated to individual trainees and during ophthalmology grand rounds to the entire
department. One medical student who was familiar with the technology helped trainees
assess the feasibility of their ideas and transmitted his knowledge to them. Sources
of training such as online videos and Web sites were also used.
Results
Project ideas originated from trainees with help from the faculty, and were based
on a need for certain items in the department or a gap that was identified by the
trainees and students. Having the physical 3D-printed item available for use drew
more individuals to suggest improvements in design and come up with other novel ideas.
One such project involved the manufacturing of slit-lamp cellphone adapters ([Fig. 1]) customized for various slit-lamps and cellphones by measuring the dimensions of
the slit-lamp oculars and the myriad cellphones owned by trainees.[2] This idea stemmed from the need for after-hours photography in the clinic and the
limited compatibility of the commercially available adapters to an ever increasing
number of phone manufacturers and models. These 3D-printed custom adapters were used
by residents for documentation of ocular findings in the clinic and in the emergency
department while on call, and provided photographs for consultation with the on-call
faculty and for regularly scheduled educational case presentations. They were also
used to document and teach various eye pathology and to demonstrate the use of the
slit-lamp to medical students during their ophthalmology rotation. Adapters were also
made to fit the surgical microscopes to obtain still images and video clips during
various ophthalmic procedures. Further modification on a previously described design[3] led to the manufacturing of a customized cellphone attachment for indirect ophthalmoscopy
for documenting posterior pole structures and related pathology.
Fig. 1 Printing of slit-lamp cellphone adapters.
A particularly innovative application was the manufacturing of a probe holder ([Fig. 2]) for ultrasound biomicroscopy (UBM).[4] The UBM probe was attached to a precision translation stage which allowed coordination
of the movement of the probe with the image acquisition ([Fig. 2]). This allowed precise image acquisition that led to high-resolution 3D anterior
segment imaging. Through this technology, structures were visualized in great detail
and volumetric measurement of these structures was possible.
Fig. 2 Ultrasound biomicroscopy probe holder.
The 3D printer has also been a great resource for our department's basic science faculty.
A custom experimental apparatus can often be 3D printed at a fraction of the cost
of traditional sources. The custom build apparats were easy to modify depending on
the need, and efficiently printed which helped tremendously on research turn around.
Our 3D printer has been used to help create a vertical tube rack and corneal flanges
for porcine outflow experiments, an OCT-mounted lens holder for an accommodation study
([Fig. 3]), a table-top globe holder for ex vivo imaging ([Fig. 4]), and many other tools.
Fig. 3 OCT-mounted lens holder for an accommodation study.
Fig. 4 Table-top globe holder for ex vivo imaging.
Each of these projects reached completion and was presented by the involved trainees
at national meetings.
A total of 23 trainees were surveyed: 18 residents, 3 fellows, and 2 medical students.
Twenty-one complete or partial responses to the survey questions were received. The
3D printer was found to be useful by 20 of 21 trainees who responded. Seventeen of
the 20 respondents indicated that they would use 3D printing after their graduation
if they have access to one. All 19 of the 19 respondents felt that the availability
of the technology can contribute to increased innovation in the ophthalmology department.
Nine out of 16 respondents expressed interest in formal training in both designing
and 3D printing, 3 were interested only in learning how to download and print 3D models
from online repositories, 2 preferred focusing on ideas and delegating the design
and manufacturing to the experienced user, and 2 felt that they had no further use
for the technology.
Discussion
There have been multiple reports on the use of 3D printers in ophthalmology. Some
educational uses include the reproduction of sections of the human orbit for the study
of anatomy[5] and the printing of 3D orbits for surgical training.[6] 3D printing was also used in surgical planning for orbital fracture repair[7] and in stereotactic surgery for uveal melanomas.[8] Other uses include the manufacturing of ocular prostheses[9] as well as various surgical instruments.[10] This is the first report in which a 3D printer was not only used for the creation
of surgical and educational tools but was used in itself as a tool to foster innovation
and creativity in an academic ophthalmic educational program.
What we have learned could be important for the future success of integrating 3D printers
into medical education programs. In similar settings, an individual who is well versed
in the usage of the 3D printing technology is necessary with a willingness to transmit
the knowledge to other users. Reminding the coworkers and students on how the 3D printer
could be utilized by demonstrating examples as well as allowing easy access to the
machine, designs, material, and expertise appears to help increase the use of the
technology. The prospect of improving the documentation of pathology, improving the
research and in turn allowing to be able to present at local and national meetings,
encouraged the usage of the 3D printer. The high demand was also fostered via a competition
for the most innovative and useful 3D-related project.
Much has been learned about the projects themselves as well, and about what makes
them successful. For example, despite wide adoption originally, the cumbersome design
of the cellphone adapters made them difficult to carry around at all times. This has
been addressed by placing several of these adapters in an accessible location in the
emergency department next to the slit-lamp that is used by the on-call residents and
emergency room staff. By having the 3D-printed device attached to a commonly used
piece of equipment such as the OCT, UBM, or slit-lamp, it becomes natural extension
of the apparatus, increasing its usefulness. Ideas on miniaturization of the design
of the slit-lamp adaptors are currently being worked on as well.
We encourage ophthalmology training programs to consider providing access to 3D printing
to their trainees, both to maximize learning engagement and creativity and to help
with efficiency in patient care. The technology proved to provide cost-saving measures
due to its efficacy in creating working solutions in the clinical and research arena.
As in many learning institutions (engineering, architecture, design, etc.), we see
the strong possibility of the 3D printing becoming part of the medical curriculum
where students will be encouraged to take on projects which would lead to a product
with novel medical applications in their respective fields of interest.
