Quantifying the educational benefit of additional cataract surgery cases in ophthalmology residency

Assessing Surgical Competency Among Fellows in Vitreoretinal Surgery: A Survey of Fellowship Program Directors and Fellows

PURPOSE

We surveyed vitreoretinal (VR) fellowship program directors (PDs) to elucidate how they assess surgical competency among VR fellows. In addition, we also surveyed fellowship program graduates for the years 2022 and 2023 regarding assessment metrics and tools used during VR fellowship training.

DESIGN

Web-based, cross-sectional descriptive study.

SUBJECTS

Fellowship PDs and recent fellowship graduates in the United States and Canada METHODS: The survey, distributed via email, queried participants about several aspects of assessing surgical competency in VR training including surgical numbers, teaching/assessment methods used to assess fellow surgical competency, comfort of fellows for various surgical procedures, appropriate degree of supervision, and criteria for a hypothetical national competence standard. A Likert scale was utilized for questions capturing participants opinion. Mean response scores were reported.

MAIN OUTCOME MEASURE

Comparison of responses between PDs and fellows RESULTS: Forty-two PDs (42.1%) (33: University-based and 9: Private institutions) and forty fellows (16.8%) (28: Academic and 12: Private institutions) responded to survey. Fellows expect a higher minimum number of vitrectomies (at least 300) by graduation compared to PDs (at least 200). Both PDs and fellows ranked direct observation of fellow (4.95), discussion with other faculty on fellow surgical performance (3.93), and outcomes of fellow surgical cases (3.88) (p>0.05), as top three teaching tools. Both PDs and fellows expressed high comfort levels with various complex surgeries, such as primary scleral buckle (4.45), proliferative vitreoretinopathy detachments (4.57), advanced diabetic retinal detachments (4.57), and giant retinal tears (4.64), by the time of graduation. Autonomy was also considered an important indicator of surgical competence by both groups. However, apart from direct surgical experience, fellows rated other educational tools lower than PDs. There was overall agreement between the groups on several aspects of a hypothetical national competence standard.

CONCLUSION

This survey identified key tools utilized to assess surgical proficiency were direct observation of surgery by attending, discussions about fellow performance among faculty, and outcomes of fellow surgical cases. Both groups emphasized that by graduation, fellows should be proficient in several complex vitreoretinal surgeries. These findings suggest a need for a more systematic approach to assess surgical competency of VR fellow.

Low-Cost Task Trainer for In Utero Fetal Stent Placement

INTRODUCTION

Some fetal procedures such as intrauterine fetal stent placement remain rare, and simulation is needed to help learners and specialists in attaining and maintaining technical competence. We sought to design and assess a low-cost, easily assembled yet clinically relevant task trainer for fetal stent placement.

METHOD

The simulator was constructed using 2 quart-sized freezer bags filled with ultrasound gel and sealed with clear packing tape. The bags were stacked vertically in a transparent plastic container with ultrasound gel applied between the bags when ultrasound was used. This task trainer was used to deploy in utero stents with or without the use of ultrasound. It has been used at the annual meeting of the Society for Maternal-Fetal Medicine since 2015, the annual meeting of the International Society of Ultrasound in Obstetrics and Gynecology in 2015 and 2016, and at regional Maternal-Fetal Medicine Fellow simulation workshops since 2016. Participants were asked to complete a 5-point Likert scale survey regarding the model's realism and usefulness in training.

RESULTS

One hundred thirty-three course participants evaluated the task trainer. The median rating for realism of the ultrasound images, haptic feel of stent deployment, and usefulness in training was 5 (interquartile range, 4-5). Seven physicians participated in the timed assessment of model assembly, stent deployment, and model reassembly. The average times required for the freezer bag task trainer were 2.3 minutes (2.20-2.35), 1.0 minutes (0.70-1.93), and 0.1 minutes (0.08-0.10), respectively. For the porcine tissue-based model tested in parallel, the average times were 6.0 minutes (5.00-7.06), 3.7 minutes (3.63-3.75), and 3.3 minutes (3.00-3.70), respectively.

CONCLUSIONS

This low-cost simulator was rated highly when used to practice in utero stent deployment and allows for numerous repetitions in each training session. It could be a valuable tool in training novice providers and allow more experienced providers to maintain competence in this low-volume procedure.

Assessing the surgical competency of novice surgeons by using a three-dimensional heads-up display microscope

PURPOSE

To evaluate the surgical performance of novice surgeons operating on a three-dimensional (3D) heads-up display system compared to those using a traditional microscope (TM).

METHODS

Prospective study design in a private practice setting. Twenty novice surgeons with similar experiences in cataract surgery were selected. Each surgeon performed 20 phacoemulsification cataract surgeries: 10 surgeries on the 3D heads-up display microscope, and 10 surgeries using a TM system. Data were collected from a total of 400 patients operated on by 20 surgeons. Outcome measures were recorded and graded according to the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric-Phacoemulsification system. The main outcome measure was mean surgical competency scores.

RESULTS

Overall, 400 data points were equally distributed between TM (200) and 3D (200) surgeries. The mean surgical competency scores were 60.19 (11.41) for TM surgeries and 62.99 (11.11) for 3D surgeries. 3D surgeries had significantly higher surgical competency scores than TM surgeries ( P = 0.013). The mean surgical duration for TM and 3D surgeries was 35.98 (6.02) min and 34.31 (7.12) min, respectively. 3D surgeries took significantly less time than TM surgeries ( P = 0.012). The overall mean best corrected visual acuity in the logarithm of the minimum angle of resolution units was 0.27 (0.42); in TM and 3D surgeries, it was 0.28 (0.43) units and 0.26 (0.41) units, respectively.

CONCLUSION

The 3D heads-up display system enhances stereopsis in cataract surgery, making it a valuable training tool for novice surgeons in phacoemulsification procedures.

The argument for two-handed cataract surgery in veterinary ophthalmology

Despite access to contemporary phacoemulsification technology and the strong shift to two-handed nucleofractis techniques in human medicine, a one-handed, single incision approach has persisted among Diplomates of the American College of Veterinary Ophthalmologists. The perpetuation of techniques such as bowl-sculpting one-handed phacoemulsification in veterinary medicine is multifactorial; it is likely associated with the lack of two-handed training in residency programs, the challenges of learning on complex cases, the ease of teaching one-handed versus two-handed techniques to a resident, and the lack of specific instrumentation available designed for larger lens size, among other factors. Additionally, variation in globe and palpebral fissure size in veterinary patients complicates the training of cataract surgery. Finally, many mentors or mentors' mentors, were trained alongside previous generations of MD surgeons who performed bowl sculpting techniques during the transition from extracapsular cataract extraction to phacoemulsification, and understandably, are not comfortable teaching a two-handed technique consistently. The authors have observed an unwillingness to convert from one-handed to two-handed technique in the post-residency career for most veterinary ophthalmologists; this could be due to the high expectations becoming a specialist, especially when the stakes are as high as in phacoemulsification. Therefore, the authors advocate for hands-on training in multiple nucleofractis techniques, including two-handed methods during residency training. Simply put, if residents are not trained and comfortable with two-handed techniques by the end of residency, they are less likely to make further changes later in their career. In this article, we aim to explore the proposed rates of one-handed versus two-handed mentors currently teaching veterinary phacoemulsification, the history of cataract surgery, and to discuss the benefits of two-handed nucleofractis techniques. The authors will also illustrate and provide videos as well as some tools for veterinary ophthalmologists wishing to learn two-handed techniques.

Residency Program Characteristics Associated with Higher Cataract Surgery Volume

PURPOSE

Prior research has shown that ophthalmology residents improve their cataract surgery competency as they perform additional surgeries beyond the 86 minimum cases mandated by the Accreditation Council for Graduate Medical Education (ACGME). Therefore, cataract surgery volume is an important benchmark for ophthalmology programs. Understanding the possible influence of residency program characteristics on resident cataract surgery volume may help educators in identifying areas for improvement and aid applicants in choosing between programs. The aim of this study was to assess residency program characteristics associated with higher mean cataract surgery volume for ophthalmology residents.

METHODS

We conducted a retrospective, cross-sectional analysis of the San Francisco Match Program Profile Database to assess various program characteristics from the 113 listed ophthalmology residency programs. The associations between program characteristics and the mean cataract surgery volume per graduating resident (CSV/GR) over years 2018-2021 were analyzed using multiple linear regression.

RESULTS

Out of 113 listed residency programs, 109 (96.5%) were included in our study. Across all programs, the mean (SD) CSV/GR was 195.9 (56.9) cases with a range of 86 to 365 cases. In multiple linear regression analysis, the presence of a Veteran Affairs (VA) training site (β = 38.8, P = .005) and the number of approved fellows per year (β = 2.9, P = .026) were positively correlated with higher mean CSV/GR. The 85 (78.0%) programs with VA training sites had a higher mean (SD) CSV/GR of 204.1 (55.7) cases compared to 166.7 (52.7) cases in the 24 (22.0%) programs without VA sites (P = .004). The mean CSV/GR increased by 2.9 cases for each additional fellow slot after adjusting for other factors. The number of approved residents per year, affiliation with a medical school, and the number of faculty were not significantly associated with CSV/GR.

CONCLUSION

All ophthalmology residency programs included in this study currently meet or exceed the ACGME requirements for cataract surgery case numbers. The presence of a VA training site and a higher number of fellowship positions were associated with higher mean resident cataract surgery volumes. Residency programs may consider further investing in these areas when seeking to improve resident surgical education. Additionally, residency applicants prioritizing cataract surgery volume may consider these factors when evaluating programs.

Ophthalmic Education: The Top 100 Cited Articles in Ophthalmology Journals

Purpose  To identify the top 100 (T100) cited articles on ophthalmic education and examine trends and areas of focus in ophthalmic education. Methods  A literature search was conducted for articles published between 2011 and 2021 related to ophthalmic education within ophthalmology journals using the ISI Web of Science Core Collection database. The search was performed in June 2022 and was conducted using the search phrase ([educat* OR teach* OR instruct* OR train* OR "medical student*" OR residen* OR fellow* OR undergrad* OR postgrad* OR "faculty" OR "attending"] AND *ophthalm*). Results were analyzed using VOSviewer v.1.6.18 and statistical analysis was performed using Microsoft Excel. Results  The majority of articles were published in the Journal of Cataract & Refractive Surgery (19%), followed by Ophthalmology (12%), and Eye (12%). Articles were most often published in the year 2013 (15%), followed by 2014 (12%) and 2012 (12%). Articles most commonly originated from English-speaking countries, including the United States (43%), England (14%), Canada (8%), and India (8%). Topics most often examined in ophthalmic education were resident education (51%), medical school education (21%), and surgical training (21%). The most common study types were cohort studies (22%), case series (21%), and prospective trials (16%). There were 16 institutions that produced more than one article in the T100 articles list. Conclusion  The T100 articles on ophthalmic education were primarily U.S. based and focused on resident education, surgical training, and medical school ophthalmic curriculum. Further research into ophthalmic education is warranted to establish evidence-based curricula guidelines.

Opportunity Cost to Attending Surgeons of Intraoperative Training for Residents in Cataract Surgery

Purpose

To estimate the opportunity cost to attending surgeons of teaching residents cataract surgery in the operating room.

Patients and methods

Operating room records at an academic teaching hospital from July 2016 to July 2020 were analyzed in this retrospective review of cases. Cases were identified using Current Procedural Terminology (CPT) codes 66982 and 66984 for cataract surgery. Outcomes measured include operative time and work relative value units (wRVUs). Cost analysis was performed using the generic 2021 Medicare Conversion Factor.

Results

Of 8813 cases, 2906 (33.0%) included resident involvement. For CPT 66982 cases, median (interquartile range (IQR)) operative time was 47 (22) minutes with resident involvement and 28 (18) minutes without (p<0.001). For CPT 66984 cases, median (IQR) operative time was 34 (15) minutes with resident involvement and 20 (11) minutes without (p<0.001). Median wRVUs was 78.5 (20.9) with resident involvement and 61.0 (14.4) without (p<0.001) which converted to an opportunity cost (IQR) per case of $1393.72 ($1055.63). Among cases involving residents, median operative time was significantly higher during the first and second quarters (p<0.001) and for every quarter when compared to cases performed by attendings only (p<0.001).

Conclusion

Teaching cataract surgery in the operating room is associated with a considerable opportunity cost for attending surgeons.

Artificial Intelligence for Personalised Ophthalmology Residency Training

Residency training in medicine lays the foundation for future medical doctors. In real-world settings, training centers face challenges in trying to create balanced residency programs, with cases encountered by residents not always being fairly distributed among them. In recent years, there has been a tremendous advancement in developing artificial intelligence (AI)-based algorithms with human expert guidance for medical imaging segmentation, classification, and prediction. In this paper, we turned our attention from training machines to letting them train us and developed an AI framework for personalised case-based ophthalmology residency training. The framework is built on two components: (1) a deep learning (DL) model and (2) an expert-system-powered case allocation algorithm. The DL model is trained on publicly available datasets by means of contrastive learning and can classify retinal diseases from color fundus photographs (CFPs). Patients visiting the retina clinic will have a CFP performed and afterward, the image will be interpreted by the DL model, which will give a presumptive diagnosis. This diagnosis is then passed to a case allocation algorithm which selects the resident who would most benefit from the specific case, based on their case history and performance. At the end of each case, the attending expert physician assesses the resident's performance based on standardised examination files, and the results are immediately updated in their portfolio. Our approach provides a structure for future precision medical education in ophthalmology.

Cataract surgery training: Report of a trainee's experience

BACKGROUND

To report a trainee's experience gained in the cataract extraction training program after the COVID-19 pandemic.

METHODS

An ophthalmologist was trained in phacoemulsification and intraocular lens (IOL) implantation in the ETAPE foundation, Eye Center, Cairo for a period of 4 weeks by three expert cataract surgeons. The training was tailored to the previous trainee's experience according to his residency logbook and supervised by one expert cataract surgeon. The training included didactic lectures, clinical observations, and hands-on practical experience. In addition, the trainee was provided with a logbook to record details of patients operated on and procedures observed.

RESULTS

The trainee performed 58 phacoemulsification surgery with IOL implantation and two extracapsular cataract extraction over the 4 weeks. Seven patients underwent intraoperative complications. Surgical time (ST) improved from 48.77 ± 9.65 min in the 1^stweek to 19.34 ± 1.31 min during the last week of training (P = 0.046). Poisson regression showed that patients affected by less severe cataracts were more likely to exhibit a lower incidence of complications than patients affected by more severe cataracts. In addition, patients operated on during the 1^stweek were more likely to show a higher incidence of complications than those operated on during the last week.

CONCLUSIONS

The 4-week surgical training effectively improved surgical confidence and micro incisional skills according to ST reduction and complication rate occurrence. Ophthalmologists benefit from enhancing their cataract skills in a short time following a well-structured cataract extraction course. This could undoubtedly lead to improved surgical outcomes for patients undergoing cataract extraction.

The impact of surgeon's experience and sex on the incidence of cystoid macular edema after uneventful cataract surgery

PURPOSE

To assess the rate of pseudophakic cystoid macular edema (pCME) in uneventful cataract surgery in surgeons in training vs experienced surgeons and to analyze the rate of pCME according to surgeon's sex.

METHODS

Medical reports post phacoemulsification between 2010 and 2018 at the Department of Ophthalmology, Medical University of Graz, Austria, were reviewed for pCME. A running lifetime number of preceding cataract surgeries was used to express hands-on experience. A cut-off number of 300 surgeries was defined to distinguish between surgeons in training and experienced surgeons. Outcome parameters were incidence of pCME, patient's sex and age, laterality of eye, coexistence of pseudoexfoliation syndrome (PEX), duration of surgery and surgeon's sex.

RESULTS

25.422 surgeries on 18.266 patients were included. The majority was performed by experienced surgeons (23.139, 91.0%) vs 2.283 (9.0%) by surgeons in training (25 surgeons, 9 (36%) female and 16 (64%) male). pCME occurred in 32 eyes (1.4%) following surgery by surgeons in training and in 152 eyes (0.7%) following surgery by experienced surgeons. Chance for pCME was 1.57 higher in training surgeries (95% CI 1.03-2.41, p = 0.034) and longer duration (OR = 1.04; 95% CI 1.02-1.07, p = 0.001). After excluding the first 100 surgeries for every surgeon in training similar results were observed. No difference in risk for pCME was found between female and male surgeons in both groups (training and experienced surgeons).

CONCLUSION

In conclusion, the rate for pCME after uneventful cataract surgery is significantly higher for surgeons in training but steadily decreasing and associated to surgical time. No difference in the risk for pCME was found between female and male surgeons.

The Cataract Surgery Learning Curve: Quantitatively Tracking a Single Resident's Operative Actions Throughout Their Training

PURPOSE

To track operative phases of cataract surgery over a resident's training to measure action times and frequencies as a surrogate for competency and skill progression.

DESIGN

An n = 1 panel study.

METHODS

Cataract surgery video recordings performed by a single resident between 2021-2022 were collected. Only full-length videos of adequate quality without supervisor intervention were included. The start and end times of 19 distinct operative phases of cataract surgery were manually labeled by a trained annotator. Timeseries analysis was employed to measure the direction and magnitude of trends in the resident's surgical timing for each action across their first year of training.

RESULTS

The dataset comprised 100 videos spread across the resident's sixth to 760^th cases. The median total time was 11.6 minutes (IQR 10.1-14.4 minutes), with overall speed increasing at a rate of 43.4 seconds for every 10 videos (95% CI 35.1, 52.7 seconds). Nine operative phases significantly decreased in time throughout training. The main incision, phacoemulsification, and hydrodissection had the greatest improvements in speed relative to their average procedural time. There was an average of 26.9 distinct operative actions (excluding idle periods) in each video (range 20-50).

CONCLUSIONS

This is the first study to quantitatively track operative times and frequencies across all relevant actions in cataract surgery and derive learning curves for each. Consistent with previous works, it was found that a basic level of surgical competency was achieved after performing 80 cases. In addition, results from this study indicated that the next level in skill advancement towards surgical finesse occurs after 300 cases.

Survey of Ophthalmology Training Experiences Among Young Ophthalmologists in the Asia-Pacific

PURPOSE

To describe ophthalmology training experiences across the Asia-Pacific (APAC).

DESIGN

Survey study.

METHODS

We utilized an anonymous online survey, which was previously validated and conducted in Europe, through Young Ophthalmologist leaders from the national member societies of the Asia-Pacific Academy of Ophthalmology (APAO) from September 2019 to July 2021. Responses were based on a 5-point Likert scale (where applicable) and data were analyzed using Microsoft Excel. Our main outcome measures were differences between regions, that is, Southeast Asia (SEA) and Western Pacific (WP); and seniority, that is, trainees/junior ophthalmologists and senior ophthalmologists.

RESULTS

We collated 130 responses representing 20 regions in the APAC region. The year of completion of ophthalmic training ranged from 1999 to 2024. The mean duration of training was 3.7±1.0 years. Most (98/130, 75%) indicated an interest for a common training standard across the APAC. Comparing SEA and WP trainees, both regions had similar working environments, but those in SEA reported significantly lower remuneration than their counterparts in WP ($600 vs $3000, P <0.05). WP trainees performed more phacoemulsification surgeries (76 WP vs 19 SEA), while SEA trainees conducted more manual small incision cataract surgeries (157 WP vs 1.5 SEA per duration of training). Senior ophthalmologists performed more cataract surgeries (210.9 senior ophthalmologists vs 40.1 junior ophthalmologists). Trainees had less confidence in medical competency areas such as interpreting an electroretinogram/visual evoked potential/electrooculogram (SEA=1.8, WP=2.1) and conducting an angiography (SEA=2.8, WP=3.4).

CONCLUSIONS

Our study highlighted heterogeneity among ophthalmology training experiences in the APAC region, with the majority indicating an interest in a common training standard.

Defining operative experience targets in surgical training: A systematic review

BACKGROUND

The surgical learning curve is an observable and measurable phenomenon. Operative experience targets are well established as a proxy measure for operative competence in surgical training across jurisdictions. The aim of this study was to critique the available evidence regarding the relationship between operative experience in surgical training and trainee competence.

METHODS

A systematic review of the PubMed, Embase, Web of Science, and Cochrane library databases was conducted in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses guidelines. Articles were sought that defined the relationship between procedural volume in surgical training and trainee competence, proficiency, or mastery. The educational impact of included studies was evaluated using a modified Kirkpatrick model.

RESULTS

Of 3,672 records identified on database searching, 30 papers were ultimately included. Fourteen studies defined operative experience thresholds using operative time as a surrogate measure of competence, whereas another 8 used trainer assessments of operative performance (Kirkpatrick level 3). A further 5 studies were able to determine the relationship between trainee case volumes and subsequent patient outcomes (Kirkpatrick level 4b).

CONCLUSION

Many studies have recorded competent trainee performance in key index procedures after reaching experience threshold numbers in excess of currently mandated targets across jurisdictions. The evidence relating current operative experience targets to patient outcomes across a range of surgical subspecialties of surgical subspecialties is lacking. This review supports a move toward criterion-based referencing of operative performance targets in surgical training.

Learning Curves for Electromagnetic Navigation Bronchoscopy Using CUSUM Analysis

BACKGROUND

Electromagnetic navigation bronchoscopy (ENB) is a relatively new and technically demanding procedure for the guidance of bronchoscopic biopsy to help locate small lung lesions. The results in experienced hands are well described. However, we do not know the results in unexperienced hands-in other words, we have no knowledge about how fast you can learn the procedure.

AIM

The aim of this study was to draw learning curves for beginners in ENB using Cumulated Sum (CUSUM) analysis, a method for quantitative evaluation of the learning curves for clinical procedures.

METHODS

Four operators from 3 centers without prior ENB experience were enrolled. The outcome of consecutive ENB procedures was assessed and classified as either diagnostic or nondiagnostic based on sample adequacy. Learning curves were drawn based on diagnostic yield.

RESULTS

A total of 215 procedures were assessed. For 2 of the operators (operators 1 and 4), at least 25 to 30 procedures were necessary to obtain competency whereas operators 2 and 3 showed more horizontal learning curves indicating an overweight of diagnostic procedures from the beginning.

CONCLUSION

Operators achieve competences in ENB at different paces. This must be taken in account when beginners start to learn the procedure. There is a huge need for a structured educational program and a validated test to determine competences.

Trends in Ophthalmology Resident Operative Experience and the Early Impact of the COVID-19 Pandemic

Purpose This study aimed to evaluate trends in ophthalmology resident operative experience and the early impact of the novel coronavirus disease 2019 (COVID-19) pandemic.

Design Present study is a retrospective analysis of the Accreditation Council for Graduate Medical Education (ACGME) Case Log System.

Participants Anonymized graduating resident case logs from 2011 to 2020 academic years (AYs) were examined for this study.

Methods Regression analysis for each procedure category was performed to identify trends between 2011 and 2019 AYs. Unpaired two-tailed t-test compared 2018 to 2019 and 2019 to 2020 AY's for each category surgeon (S) and as surgeon and assistant (S + A).

Main Outcome Measures Mean and median cases as (S) and (S + A) during 2011 to 2019 AYs. Comparison between 2018 to 2019 and 2019 to 2020 AY's for each category as (S) and (S + A) to evaluate the impact of the COVID-19 pandemic.

Results Total ophthalmology procedures as (S) rose from a mean of 479.6 to 601.3 (p < 0.001; R 2 = 0.96; Δ/year = 16.9) and a median of 444 to 537 (p < 0.001; R 2 = 0.97; Δ/year = 13.1). Total procedures as (S + A) rose from a mean of 698.1 to 768 (p < 0.01; R 2 = 0.83; Δ/year = 9.07) and a median of 677 to 734 (p < 0.05; R 2 = 0.61; Δ/year = 6.64). Cataract procedures as (S) rose from a mean of 152.8 to 208 (p < 0.001; R 2 = 0.99; Δ/year = 7.98) and a median of 146 to 197 (p < 0.001; R 2 = 0.97; Δ/year = 7.87). Cataract procedures as both (S + A) rose from a mean 231.4 to 268.7 (p < 0.001; R 2 = 0.95; Δ/year = 5.5) and a median of 213 to 254 (p < 0.001; R 2 = 0.93; Δ/year = 5.33). Between 2018 to 2019 and 2019 to 2020 AYs, the first pandemic year was associated with significant reductions in total procedures (601.3–533.7 [p < 0.0001]) as (S) and 768.0 to 694.4 (p < 0.0001) as (S + A), cataract surgery (208–162.2 [p < 0.0001]) as (S) and 268.7 to 219.1 (p < 0.0001) as (S + A), and glaucoma surgery (16.3–14.2 [p = 0.0068]) as (S) and 25.6 to 22.6 (p = 0.0063) as (S + A).

Conclusion During 2011 to 2019 AYs, cataract, intravitreal injections, glaucoma, and total procedures increased significantly. During the early period of the COVID-19 pandemic (2019–2020 AY), national halting of elective procedures had a precipitous effect on resident cataract surgery experience to volumes similar to 2013 to 2014 AY where the mean was twice the current required minimum number. With few exceptions, other procedure volumes remained stable.

Evolution of a Glaucoma Fellow's Surgical Training: Improvements in Tube Shunt Case Times during the Academic Year

Purpose The aim of the study is to report changes in tube shunt placement surgical case times for glaucoma fellows during the course of the academic year.

Patients and Methods Electronic health records were retrospectively reviewed to determine patient demographics, surgical case times (defined as procedure start time to procedure end time), and glaucoma fellow involvement. Only cases with a glaucoma fellow as the primary surgeon were included. Operative case times were compared by first and second halves of the academic year (beginning in July and ending in June) using a two-tailed t-test.

Results Five hundred and seventy-three individual tube shunt surgeries (385 Ahmed, 188 Baerveldt) performed by 28 glaucoma fellows (17 females, 11 males) at Duke University Eye Center and University of North Carolina Medical Center were included. Overall, case times were significantly shorter in the second half of the academic year as compared with the first (55.3 ± 17.1 minutes vs. 61.0 ± 17.4 minutes, p <0.001). Both male (57.3 ± 16.8 minutes vs. 63.2 ± 18.6 minutes, p = 0.008) and female (53.5 ± 17.3 minutes vs. 59.3 ± 16.4 minutes, p = 0.003) fellows demonstrated shorter case times over the academic year; additionally, female fellows trended toward shorter case times than male fellows in both the first half (p = 0.072) and second half (p = 0.053) of the academic year. Fellows also exhibited shorter case times with both Ahmed implants (54.1 ± 16.2 minutes vs. 59.3 ± 15.8 minutes, p = 0.002) and Baerveldt implants (57.8 ± 18.9 minutes vs. 64.2 ± 20.0 minutes, p = 0.025) cases over the academic year. Baerveldt case times were significantly longer than Ahmed cases in the first half (p = 0.028) and trended toward being longer than Ahmed cases in the second half (p = 0.070).

Conclusion Across 5 years at two academic institutions, glaucoma fellows had shorter primary tube shunt surgical case times in the second half of the academic year. These findings reflect improvement in surgical efficiency throughout glaucoma fellowship. These findings should be taken into consideration when scheduling trainee surgeries at academic medical centers at different points in the academic year.

Assessing the Phacoemulsification Learning Curve Utilizing Duration of Each Step

PURPOSE

To assess the phacoemulsification learning curve for ophthalmology residents using duration for each step.

SETTING

Single tertiary, training site hospital.

DESIGN

Cross sectional study examining duration of cataract surgery steps as a function of categorized experience levels.

METHODS

Emory Ophthalmology PGY-3 and PGY-4 residents operating at Grady Memorial Hospital between April 2017 and February 2018 were eligible to participate. Duration in seconds for each step of surgery was calculated for incisions, continuous curvilinear capsulorrhexis (CCC), hydrodissection, nucleus disassembly, quadrant removal, cortical cleanup, intra-ocular lens insertion, closure, and this outcome was analyzed as a function of different experience levels.

RESULTS

528 surgeries were included out of 549 total surgeries recorded. Six categories of experience levels were established A-F, increasing by increments of 50. There was an overall downward trend across various steps across the eight case categories, and several adjacent categories demonstrate statistically significant differences. The three most time-intensive steps early in training were nucleus disassembly (336.5 ± 16.5 secs), quadrant removal (275.1 ± 18.0 secs) and cortical cleanup (244.2 ± 24.6 secs). There was a sustained drop in mean duration for all steps through at least Category D, with most steps showing a drop through Category F.

CONCLUSIONS

There is a benefit to a higher case load, well above the ACGME-mandated 86 cases. Improvements in efficiency were observed after 250 cases with nuclear disassembly and CCC demonstrating a significant decrease in operative time.

Resident physician concordance in tomographic fluid detection in näive patients with neovascular age-related macular degeneration (AMD)

PURPOSE

To analyze the presence of subretinal fluid (SRF), intraretinal fluid (IRF) and subretinal pigment epithelial fluid (SRPEF) in näive patients with exudative neovascular AMD at baseline and at one year follow-up and treatment, in clinical practice, and perform a concordance analysis between resident physicians.

METHODS

A retrospective analysis of the näive patients who attended our service for 6months between 2016-2017 by neovascular AMD was performed. Optical coherence tomography (OCT), at baseline and at one year follow-up, were analyzed from independently by two resident doctors, determined the presence or not of SRF, IRF, SRPEF. A retina specialist ophthalmologist intervened in cases where there was no consensus among resident physicians. A descriptive and interobserver concordance analysis was performed.

RESULTS

27 eyes of 24 patients were evaluated, 20.8% being men and 79.16% women, with a mean age of 78.57±8years. 32.14% of the eyes presented the three types of fluid before the start of treatment and the frequency of the different fluids at the beginning and at the end of the follow-up were respectively: SRF, 82.1% and 50%; IRF, 57.1% and 41.7%, and SRPEF, 67.9% and 79.2%). The Kappa analysis of interobserver concordance in the evaluation of the different fluids at the beginning and at the end of the follow-up were respectively: SRF, 0.88 and 0.67; IRF, 0.86 and 0.91, and SRPEF, 0.65 and 0.78.

CONCLUSIONS

The presence of SRF, IRF, RPEF in clinical practice, in the debut of neovascular AMD has a similar distribution to that presented in international clinical trials. The agreement between resident physicians is very good for SRF and IRF and good for SRPEF in the debut of the disease and good for SRF and IRF and very good for SRPEF at one year of treatment.