Factors associated with confidence in fundoscopy

Eyesi direct ophthalmoscope simulator: an effective training tool for medical undergraduates

INTRODUCTION

Non-ophthalmologists often lack sufficient operational training to use a direct ophthalmoscope proficiently, resulting in a global deficit of basic ophthalmological skills among general practitioners. This deficiency hampers the timely diagnosis, referral, and intervention of patients. Consequently, the optimization of teaching tools and methods to enhance teaching efficiency is imperative. This study explores the effectiveness of the Eyesi Direct Ophthalmoscope Simulator (Eyesi) as an innovative tool for fundus examination training.

METHODS

Medical undergraduates were randomly assigned to Group A or B (n = 168). All participants completed a pre-training questionnaire. Group A received Eyesi training, while Group B underwent traditional direct ophthalmoscope (TDO) training. Subsequently, participants answered questionnaires relevant to their respective training methods. Both groups exchanged training tools and completed a summary questionnaire.

RESULTS

After training, 54.17% of participants believed that images presented by the Eyesi were consistent with the real fundus. Group A scored significantly higher than Group B in fundus structure recognition and self-confidence in examination. The degree of mastery over fundus theory score increased from 6.10 ± 0.13 to 7.74 ± 0.16 (P < 0.001) in Group A, but Group B did not demonstrate a significant difference. We also compared undergraduates' tendencies for different learning purposes, 75.59% of participants preferred the Eyesi to TDO as a training tool, and 88.41% of participants were receptive to introducing the Eyesi in training.

CONCLUSION

According to subjective participant feedback, Eyesi outperformed TDO in fundus observation, operational practice, and theoretical learning. It effectively equips undergraduates with fundus examination skills, potentially promoting the use of direct ophthalmoscopes in primary medical institutions.

A Systematic Review of Ophthalmology Education in Medical Schools: The Global Decline

TOPIC

This systematic review examined geographical and temporal trends in medical school ophthalmology education in relationship to course and student outcomes.

CLINICAL RELEVANCE

Evidence suggesting a decline in ophthalmology teaching in medical schools is increasing, raising concern for the adequacy of eye knowledge across the rest of the medical profession.

METHODS

Systematic review of Embase and SCOPUS, with inclusion of studies containing data on medical school ophthalmic course length; 1 or more outcome measures on student ophthalmology knowledge, skills, self-evaluation of knowledge or skills, or student course appraisal; or both. The systematic review was registered prospectively on the International Prospective Register of Systematic Reviews (identifier, CRD42022323865). Results were aggregated with outcome subgroup analysis and description in relationship to geographical and temporal trends. Descriptive statistics, including nonparametric correlations, were used to analyze data and trends.

RESULTS

Systematic review yielded 4596 publication titles, of which 52 were included in the analysis, with data from 19 countries. Average course length ranged from 12.5 to 208.7 hours, with significant continental disparity among mean course lengths. Africa reported the longest average course length at 103.3 hours, and North America reported the shortest at 36.4 hours. On average, course lengths have been declining over the last 2 decades, from an average overall course length of 92.9 hours in the 2000s to 52.9 hours in the 2020s. Mean student self-evaluation of skills was 51.3%, and mean student self-evaluation of knowledge was 55.4%. Objective mean assessment mark of skills was 57.5% and that of knowledge was 71.7%, compared with an average pass mark of 66.7%. On average, 26.4% of students felt confident in their ophthalmology knowledge and 34.5% felt confident in their skills.

DISCUSSION

Most evidence describes declining length of courses devoted to ophthalmology in the last 20 years, significant student dissatisfaction with courses and content, and suboptimal knowledge and confidence.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Harnessing the medical undergraduate human resource for screening of sight-threatening diabetic retinopathy

PURPOSE

To assess whether medical undergraduates can be trained to effectively screen diabetic retinopathy (DR) by statistical comparison with a retina specialist at a tertiary eye care center in India.

METHODS

Three final-year undergraduate medical students, having completed ophthalmology department rotation, received training from a retina specialist for grading DR, following which they were asked to grade a set of 50 fundus photographs centered on the macula with a view of 50° as sight-threatening DR (STDR), diabetic macular edema, and grade of DR. Agreement among the undergraduates and retina specialist was determined with the help of Cohen's Kappa coefficient.

RESULTS

Kappa coefficient between undergraduates for detection of STDR ranged from 0.695 to 0.817 and between each student and the retina specialist ranged from 0.663 to 0.712. The sensitivity and specificity for undergraduates' and retina specialist's detection of STDR were 93.93%-96.96% and 60%, respectively.

CONCLUSION

There was substantial agreement among the undergraduates as well as between the undergraduates and the retina specialist for the detection of STDR. Undergraduates also detected STDR with a high sensitivity. This study outlines the feasibility of training undergraduate students for screening DR.

Confidence of Emergency Department doctors in managing ophthalmic emergencies: a systematic review

BACKGROUND

Eye emergencies constitute a significant portion of attendances to general Emergency Departments (EDs) in the UK, therefore it is important to assess the confidence of doctors who work in this setting in managing these potentially sight- and life-threatening presentations. This systematic review aims to assess the confidence of UK doctors working in general EDs in managing ophthalmic emergencies.

METHODS

MEDLINE (Ovid), EMBASE (Ovid), ProQuest Central and Web of Science databases and grey literature were searched from inception to 1 October 2022 for publications that (1) featured doctors working in UK general EDs, (2) assessed doctors' confidence in managing ophthalmic emergencies, (3) contained original data, (4) were full-text, and (5) written in English. Methodological quality was assessed using the AXIS tool.

RESULTS

462 articles were screened, and 7 papers included for data extraction, which collectively assessed the confidence of 956 doctors working in EDs in managing ophthalmic emergencies. There was a widespread lack of confidence amongst foundation doctors, which has worsened over time. Most doctors lacked confidence in performing funduscopy and using the slit-lamp, and considered formal ophthalmology training received in EDs to be inadequate.

CONCLUSIONS

Evidence suggests a lack of confidence amongst foundation doctors in managing ophthalmic emergencies. High-quality evidence investigating the confidence amongst more experienced Emergency Medicine (EM) physicians was lacking. It is important to assess why foundation doctors feel so ill-prepared to manage eye emergencies and develop further ophthalmic training for doctors working in EDs. Further investigation exploring the confidence of EM trainees and consultants is required.

Neuroretinitis as a Complication of Cat Scratch Disease

In this case report, a patient with neuroretinitis from a Bartonella henselae infection is described, and insights into methods to distinguish this type of case from more common etiologies of optic nerve edema are presented. A 21-year-old female with a history of right monocular vision loss due to amblyopia presented to the emergency department (ED) with occipital headache, fever, dizziness, nasal congestion, and painless blurry vision in the left eye for one day. A lumbar puncture found a slightly high opening pressure but no evidence of meningitis. The patient was diagnosed with a viral illness and discharged with outpatient follow-up. The patient, however, had persistent central vision loss and recurring headaches and returned to the ED. Subsequent ultrasound of the patient's optic nerve revealed significant optic nerve swelling. A new working diagnosis of idiopathic intracranial hypertension was made, and the patient was started on oral acetazolamide. On the next day, she was seen by ophthalmology, and recent scratches from her cat were noted on her arm. She tested positive for B. henselae and was started on doxycycline and rifampin. Nearly two weeks after the initial presentation, a macular star pattern, indicative of neuroretinitis, was noted on the fundoscopic exam. The patient had recovered her vision by three months later. In ED cases with unilateral vision loss, early use of point-of-care ultrasound and infection with B. henselae should always be considered. Early serology testing may be warranted to allow for earlier treatment since classic signs of neuroretinitis may not be apparent at the onset.

Comparing the Diagnostic Utility of Conventional Direct Ophthalmoscopy with Smartphone Ophthalmoscopy among Medical Students

Purpose  To compare the diagnostic ability of medical students using smartphone ophthalmoscopy (SO) with conventional direct ophthalmoscopy (DO). Methods  Twenty-eight first- and second-year medical students were trained to use the SO and DO. They also attended educational seminars regarding optic nerve and retinal pathology and were given hands-on practice with each ophthalmoscopy method. Students were randomized 2:1 into one of the groups (DO or SO). Students then examined six patients and recorded their findings, ease of use, and confidence level on a questionnaire. Two attending ophthalmologists, masked to the randomization, graded the student questionnaires. A priori power calculation determined the sample size. The primary outcome measure was the percentage of correct diagnoses the students made. Two-sample t -test, Wilcoxon's rank-sum test, and Fisher's exact test were used to compare the outcomes. Results  Students using the SO outperformed students using DO in terms of mean percent correct (% correct) diagnosis (smartphone: 42% vs. direct: 23%; p -value = 0.0057), mean % correct photo match (smartphone: mean = 60% vs. direct: 32%; p -value = 0.0052), and mean % correct nerve/retinal descriptors (smartphone: 72% vs. direct: 59%; p -value = 0.0048). There was not a significant difference in terms of perceived ease of use (smartphone: mean = 3.3 vs. direct: mean = 2.6; p -value = 0.0945), or subjective confidence (smartphone: mean = 2.6 vs. direct: mean = 2.1; p -value = 0.0808) between the two groups. Conclusion  SO provides an alternate way for medical students to learn, diagnose, and describe ocular pathology.

Optimising fundoscopy practices across the medical spectrum: A focus group study

INTRODUCTION

Fundoscopy can be of great clinical value, yet remains underutilised. Educational attempts to improve fundoscopy utilisation have had limited success. We aimed to explore the barriers and facilitators underlying the uptake of clinical direct ophthalmoscopy across a spectrum of medical specialties and training levels.

METHODS

Ten focus groups were conducted with medical students (n = 42), emergency department doctors (n = 24), basic physician trainees (n = 7), hospital physicians (n = 6) and general practitioners (n = 7). Independent thematic analysis of transcripts was conducted by three investigators. A consensus thematic framework was developed, and transcripts were reanalysed using this framework.

RESULTS

Thematic analysis identified seven main themes: (1) technical barriers to performing fundoscopy examinations; (2) clinical culture and expectations regarding fundoscopy; (3) the influence of fundoscopy on clinical management; (4) motivation to perform the examination; (5) novel technology including smartphone fundoscopy, and the value of a digital fundus image; (6) training requirements, and; (7) use of limited resources.

CONCLUSION

Our results build a more nuanced picture of the factors which determine fundoscopy utilisation. As current barriers limit practice by clinicians and medical students, expertise and confidence performing and interpreting fundoscopy are lost. This shifts the balance of perceived clinical utility to futility in changing patient management, and reinforces a cycle of reducing fundoscopy utilisation. We identified important cultural barriers such as accepted incompetence, and misperceptions of senior discouragement. Emerging technologies reduce the technical barriers to fundoscopy. Therefore education should: focus on detecting pathology from digital images; clarify the role of fundoscopy in patient management, and; be targeted at key career progression points.

Comparison of conventional and wide field direct ophthalmoscopy on medical students' self-confidence for fundus examination: a 1-year follow-up

BACKGROUND

Fundus examination is an easy, quick and effective way to diagnose sight- and life-threatening diseases. However, medical students and physicians report lack of proficiency and self-confidence in perform fundoscopy. The aim of this study was to compare students' self-confidence in fundus examination, using two different direct ophthalmoscopes, 1 month and 1 year after practical training.

METHODS

In this prospective cohort, medical students (MS) of the same class were divided in small groups for PanOptic (PO) or conventional (CO) direct ophthalmoscope training. The intervention group encompassed MS of the 4th -year (class of 2019), and the control group encompassed MS of year behind (class of 2020). A questionnaire to measure self-confidence in fundoscopy technique assessing optic nerve, cup-to-disc ratio and macula was translated and validated to Portuguese, and applied 1-month and 1-year after practical training.

RESULTS

One-hundred and sixty-seven MS were enrolled (35 PO group, 38 CO group, and 94 control group). PO group had a significantly higher overall self-confidence comparing either control or CO groups, respectively (3.57 ± 0.65 vs. 2.97 ± 1.03 vs. 2.46 ± 0.87, p < 0.01) as well as in evaluate cup-to-disc ratio (3.09 ± 0.75 vs. 2.32 ± 0.87 vs. 1.46 ± 0.81, p < 0.01), optic disc margins (3.26 ± 0.85 vs. 2.71 ± 0.96 vs. 2.01 ± 0.97, p < 0.01) and macula (3.43 ± 1.12 vs. 2.89 ± 1.08 vs. 2.02 ± 0.89, p < 0.01) 1-month after practical training. One-year after intervention, CO group showed a significantly higher score compared to PO group in overall self-confidence (3.31 ± 0.69 vs. 3.18 ± 0.73, p = 0.03) and in optic disc margins assessing (3.16 ± 0.85 vs. 2.95 ± 0.78, p = 0.03), but not significant in the evaluation of cup-to-disc ratio (2.78 ± 0.97 vs. 2.68 ± 0.94, p = 0.08), and macula (3.34 ± 0.79 vs. 3.27 ± 0.98, p = 0.07).

CONCLUSIONS

Students were more confident in use PO as an instrument to perform direct ophthalmoscopy immediately after practical training, but confidence level of CO was higher compared to PO one year after practical training. These findings would help medical schools decide which ophthalmoscope to choose to teach fundus examination.

Teaching Smartphone Funduscopy with 20 Diopter Lens in Undergraduate Medical Education

Purpose

To assess attitudes of pre-clinical undergraduate medical students toward learning smartphone funduscopy (SF) and its appropriateness as a teaching tool.

Patients and Methods

Second year medical students received instruction on direct ophthalmoscopy (DO) and SF; they were then paired with a peer and randomly assigned to perform DO or SF first. The SF technique involved freehand alignment of the axes of the smartphone camera with a condenser lens. Both techniques were done through a maximally dilated pupil. A questionnaire was completed to acquire data on baseline experience, performance of both examination techniques, attitudes, and appropriateness. Statistical significance testing and Bland-Altman analysis were used to determine differences between DO and SF, and a multivariable mixed regression model was fitted to identify any predictors for positive attitudes toward DO or SF.

Results

One hundred thirty-seven (137) individuals completed the study. A similar proportion of students could identify the optic nerve, macula, and vessels using DO and SF. However, self-reported quality scores were higher for DO for the optic nerve (p = 0.006) and macula (p = 0.08). The mean (standard deviation) attempts to identify these major structures were 2.7 (SD 2.3) for DO and 4.5 (SD 2.9) for SF (p < 0.001). Attitudes of students were consistently more positive toward DO across the five questions assessed. A small subset of students had equally positive attitudes toward DO and SF. Improved quality scores were predictive of positive attitudes for both DO and SF. Ultimately, 24% of students preferred SF over DO.

Conclusion

Among inexperienced examiners of the fundus through a dilated pupil, SF is a non-inferior technique to DO in identifying structures. Despite overall favorable attitudes towards the more familiar DO, those students who quickly learned the SF technique had similar satisfaction scores. Teaching SF should be considered in undergraduate medical education.

Do Checklist-Induced Behavioral Changes Improve Self-Confidence in Fundoscopic Examination? A Mixed-Methods Study

Purpose

Fundoscopic exams are conducted during outpatient consultations to assess intracranial disease and complications from chronic diseases. Low level of confidence in these skills which physicians have is one of the causes that implementation frequency is low. Research has not yet identified specific measures through which the healthcare system may increase the implementation of fundoscopic exams nor a qualitative process that enables physicians to gain confidence in their fundoscopic exam skills. We introduced a checklist and conducted a mixed-methods study.

Methods

This study is a before-and-after study, within an embedded-experimental mixed-methods design. We sampled 15 physicians in the department of general medicine at a university hospital assigned to initial consultation. We introduced a checklist to verify whether the fundoscopic exam was implemented. Measures are implementation ratio of the fundoscopic exam to the total number of indication cases, and Visual Analog Scale (VAS) values for the confidence in procedure are measured before and after the intervention. We obtained qualitative data from interviews and used the Modified Grounded Theory Approach.

Results

We observed significant increases in the implementation ratio (19.2% (29/151 cases) vs 64.8% (105/162 cases), p<0.001) and in the VAS value for the confidence (1.89 mm vs 4.68 mm (p<0.001)). Analysis of the interviews revealed the following. To increase the implementation, it is necessary to reduce the <Lack of confidence> and <Forgetting>, which is prevented by the checklist. The <Lack of successful experiences in detecting abnormalities> leads to a <Lack of confidence>. Repeated executions result in <Successful experiences and confidence building>.

Conclusion

The intervention increased the implementation ratio, thereby increasing successful experiences and confidence among physicians. The growth of confidence boosted motivations to implement fundoscopic exams.

Non-simulator-based techniques in teaching direct ophthalmoscopy for medical students: a systematic review

Non-simulator-based examination methods of the fundal examination have shown to be cost-effective. We reviewed different non-simulator-based direct fundoscopy examination methods used in undergraduate curricula and their outcomes. PubMed (MEDLINE) and Cochrane Database of Systematic Reviews were searched using standard Medical Subject Heading (MeSH) terms ophthalmoscopy, medical education, undergraduate medical education, medical student, educational assessment and learning. The search included publications until 28^th February 2019. We obtained 34 articles after screening abstracts; of them, 12 articles were included in the qualitative synthesis. The studies were comprised of diverse teaching methods which included fundal photograph matching with corresponding eye, continuous education using community-based eye clinics, formal instructions and demonstrations prior to skills training, ophthalmoscopy skills practice using eye pathologies, teaching versus conventional ophthalmoscopy and group-based teaching. We concluded that non-simulator-based techniques such as use of fundal photograph matching of an eye of a volunteer, introduction to eye pathologies, smaller student groups and formal instructions with video demonstrations prior to skills training were highly effective in teaching direct ophthalmoscopy for undergraduate medical students.

Smartphone ophthalmoscopy: patient and student practitioner perceptions

It can take several years to become proficient at direct ophthalmoscopy; the instrument's single eyepiece allows only one individual to view the image at a time, which is considered disadvantageous during teaching. The introduction of smartphone ophthalmoscopes enables groups of teachers and students to view images together which could encourage peer-to-peer learning. In addition, the technology is significantly cheaper than the direct ophthalmoscope. User acceptability and engagement is essential to the success of any (medical) technological innovation. We sought to understand student opinions of a new commercially-available smartphone device for fundus examination, and compare usability to the traditional ophthalmoscope, from the perspective of both student practitioners and patients. Fifty-four undergraduate optometry students with prior experience of the traditional direct ophthalmoscope were asked to examine at least one eye with the D-EYE smartphone ophthalmoscope and also given an opportunity to experience the D-EYE from a patient's perspective. Minimal instructions were provided and all examinations conducted through undilated pupils. Participants completed an opinion survey to feedback on aspects such as the ease of handling and working distance. Compared to the direct ophthalmoscope, 92% of students preferred the (longer) working distance of the D-EYE; 77% felt it was easier to handle; and 92% preferred the patient experience with the D-EYE. Despite the positive feedback, only 43% of students preferred the D-EYE when assuming the role of the practitioner. Free text responses indicated that students felt the D-EYE may be most useful as a teaching tool. Student opinions indicated that smartphone ophthalmoscopes are an effective training tool for students as an accompaniment to learning the traditional ophthalmoscope method.

Use of a Versatile, Inexpensive Ophthalmoscopy Teaching Model in Veterinary Medical Student Education Increases Ophthalmoscopy Proficiency

Ophthalmoscopy is an important examination technique in the diagnosis of disease. Although it is difficult to learn, practice increases confidence and proficiency. Practicing ophthalmoscopy on live animals presents an additional level of complexity, so we sought to evaluate how students would respond to practicing ophthalmoscopy on an ocular fundus model. We constructed a simple and inexpensive model and allowed half of the students (49/100) in a first-year veterinary medicine class to practice ophthalmoscopy (direct, PanOptic, and indirect) for 20 minutes using the model. Students completed a questionnaire regarding ease of use, enjoyment, and recommendations for future use of the model immediately after the practice session. Six weeks later, we tested students' ability to correctly match a fundus to a photograph using indirect ophthalmoscopy. All students who used the model rated it as 'easy' or 'somewhat easy' to use. All students reported that they 'enjoyed' (93.9%) or 'somewhat enjoyed' (6.1%) using the model. Also, all students who used the model stated the models should continue to be used to aid student learning. Students who used the model were significantly more likely (p = .013) to correctly match a fundus photograph to the fundus being observed than students who had not used the model. These findings demonstrate that the model used in this study is well received by students and results in discernible gains in proficiency.

Comparison of smartphone ophthalmoscopy vs conventional direct ophthalmoscopy as a teaching tool for medical students: the COSMOS study

Purpose

To investigate the utility of smartphone ophthalmology for medical students for learning fundoscopy compared with direct ophthalmoscopy.

Methods

After 1 hour of didactic instruction on ophthalmoscopy, second-year medical students in a small group setting were randomized to start training with the direct ophthalmoscope vs smartphone ophthalmoscope and crossed over to the other instrument through the session.

Main outcome measures

Ability to visualize the optic nerve and retinal blood vessels in an undilated pupil as well as a survey evaluating ease of use, confidence, and ability to visualize the optic nerve with the two instruments.

Results

One hundred and one medical students participated. Significantly more medical students were able to visualize the optic nerve with the smartphone ophthalmoscope vs the direct ophthalmoscope in an undilated pupil (82.3% vs 48.5%, P<0.0001). Students reported a more positive experience with the smartphone ophthalmoscope, specifically regarding ease of use (median of 4 vs 3; P<0.0001), their confidence in performing ophthalmoscopy (median of 4 vs 3; P<0.0001), and their ability to visualize features of the optic nerve (median 4 vs 3; P<0.0001). A significant number of participants preferred the smartphone ophthalmoscope over the traditional direct ophthalmoscope for learning how to identify the optic disc and for evaluating patients (78.2% and 77.2%, respectively; P<0.0001).

Conclusion

Smartphone ophthalmoscopy may serve as a useful adjunctive tool to teach direct ophthalmoscopy as well as being an alternative for examining the fundus for noneye care physicians.

Addressing the 'forgotten art of fundoscopy': evaluation of a novel teaching ophthalmoscope

BACKGROUND

Direct ophthalmoscopy is an essential skill that students struggle to learn. A novel 'teaching ophthalmoscope' has been developed that allows a third person to observe the user's view of the fundus.

OBJECTIVES

To evaluate the potential use of this device as an aid to learning, and as a tool for objective assessment of competence.

METHODS

Participants were randomised to be taught fundoscopy either with a conventional direct ophthalmoscope (control) or with the teaching device (intervention). Following this teaching session, participant competence was assessed within two separate objective structured clinical examination (OSCE) stations: the first with the conventional ophthalmoscope and the second with the teaching device. Each station was marked by two independent masked examiners. Students were also asked to rate their own confidence in fundoscopy on a scale of 1-10. Scores of competence and confidence were compared between groups. The agreement between examiners was used as a marker for inter-rater reliability and compared between the two OSCE stations.

RESULTS

Fifty-five medical students participated. The intervention group scored significantly better than controls on station 2 (19.8 vs 17.6; P=0.01). They reported significantly greater levels of confidence in fundoscopy (7.3 vs 4.9; P<0.001). Independent examiner scores showed significantly improved agreement when using the teaching device during assessment of competence, compared to the conventional ophthalmoscope (r=0.90 vs 0.67; P<0.001).

CONCLUSION

The teaching ophthalmoscope is associated with improved confidence and objective measures of competence, when compared with a conventional direct ophthalmoscope. Used to assess competence, the device offers greater reliability than the current standard.