Ophthalmoscopy simulation: advances in training and practice for medical students and young ophthalmologists

Simulation device for shoulder reductions: overview of prototyping, testing, and design instructions

BACKGROUND

Shoulder dislocations are common occurrences, yet there are few simulation devices to train medical personnel on how to reduce these dislocations. Reductions require a familiarity with the shoulder and a nuanced motion against strong muscle tension. The goal of this work is to describe the design of an easily replicated, low-cost simulator for training shoulder reductions.

MATERIALS AND METHODS

An iterative, stepwise engineering design process was used to design and implement ReducTrain. A needs analysis with clinical experts led to the selection of the traction-countertraction and external rotation methods as educationally relevant techniques to include. A set of design requirements and acceptance criteria was established that considered durability, assembly time, and cost. An iterative prototyping development process was used to meet the acceptance criteria. Testing protocols for each design requirement are also presented. Step-by-step instructions are provided to allow the replication of ReducTrain from easily sourced materials, including plywood, resistance bands, dowels, and various fasteners, as well as a 3D-printed shoulder model, whose printable file is included at a link in the Additional file 1: Appendix.

RESULTS

A description of the final model is given. The total cost for all materials for one ReducTrain model is under US $200, and it takes about 3 h and 20 min to assemble. Based on repetitive testing, the device should not see any noticeable changes in durability after 1000 uses but may exhibit some changes in resistance band strength after 2000 uses.

DISCUSSION

The ReducTrain device fills a gap in emergency medicine and orthopedic simulation. Its wide variety of uses points to its utility in several instructional formats. With the rise of makerspaces and public workshops, the construction of the device can be easily completed. While the device has some limitations, its robust design allows for simple upkeep and a customizable training experience.

CONCLUSION

A simplified anatomical design allows for the ReducTrain model to serve as a viable training device for shoulder reductions.

Prospective, Randomized Trial Comparing Simulator-based versus Traditional Teaching of Direct Ophthalmoscopy for Medical Students

OBJECTIVE

To compare results of simulator-based vs traditional training of medical students in direct ophthalmoscopy.

DESIGN

Randomized controlled trial.

METHODS

First-year medical student volunteers completed 1 hour of didactic instruction regarding direct ophthalmoscopes, fundus anatomy, and signs of disease. Students were randomized to an additional hour of training on a direct ophthalmoscope simulator (n = 17) or supervised practice examining classmates (traditional method, n = 16). After 1 week of independent student practice using assigned training methods, masked ophthalmologist observers assessed student ophthalmoscopy skills (technique, efficiency, and global performance) during examination of 5 patient volunteers, using 5-point Likert scales. Students recorded findings and lesion location for each patient. Two masked ophthalmologists graded answer sheets independently using 3-point scales. Students completed surveys before randomization and after assessments. Training groups were compared for grades, observer- and patient-assigned scores, and survey responses.

RESULTS

The simulator group reported longer practice times than the traditional group (P = .002). Observers assigned higher technique scores to the simulator group after adjustment for practice time (P = .034). Combined grades (maximum points = 20) were higher for the simulator group (median: 5.0, range: 0.0-11.0) than for the traditional group (median: 4.0, range: 0.0-9.0), although the difference was not significant. The simulator group was less likely to mistake the location of a macular scar in 1 patient (odds ratio: 0.28, 95% confidence interval: 0.056-1.35, P = .013).

CONCLUSIONS

Direct ophthalmoscopy is difficult, regardless of training technique, but simulator-based training has apparent advantages, including improved technique, the ability to localize fundus lesions, and a fostering of interest in learning ophthalmoscopy, reflected by increased practice time.

Augmented Reality, Virtual Reality, and Game Technologies in Ophthalmology Training

Ophthalmology is a medical profession with a tradition in teaching that has developed throughout history. Although ophthalmologists are generally considered to only prescribe contact lenses, and they handle more than half of eye-related enhancements, diagnoses, and treatments. The training of qualified ophthalmologists is generally carried out under the traditional settings, where there is a supervisor and a student, and training is based on the use of animal eyes or artificial eye models. These models have significant disadvantages, as they are not immersive and are extremely expensive and difficult to acquire. Therefore, technologies related to Augmented Reality (AR) and Virtual Reality (VR) are rapidly and prominently positioning themselves in the medical sector, and the field of ophthalmology is growing exponentially both in terms of the training of professionals and in the assistance and recovery of patients. At the same time, it is necessary to highlight and analyze the developments that have made use of game technologies for the teaching of ophthalmology and the results that have been obtained. This systematic review aims to investigate software and hardware applications developed exclusively for educational environments related to ophthalmology and provide an analysis of other related tools. In addition, the advantages and disadvantages, limitations, and challenges involved in the use of virtual reality, augmented reality, and game technologies in this field are also presented.

Application of a 3D-printed eye model for teaching direct ophthalmoscopy to undergraduates

PURPOSE

This study aims to design an eye model that can simulate the fundus for teaching direct ophthalmoscopy and to evaluate its effectiveness.

METHODS

We first used 3D printing materials to make an eye model and then randomly assigned 92 undergraduates into group A (model-assisted training group) and group B (traditional training group) to test our model. After the same training time, real patients were used to test the students, with 120 s as the examination time limit. We recorded the students' ability to clearly see the optic disk, the time to determine the cup-to-disk ratio, and whether they were correct.

RESULTS

Forty-three students in group A (93.48%) successfully saw the fundus, while 21 in group B (45.65%) succeeded. The difference between the two groups was 47.83% (95% confidence interval, 29.59-66.07%, P < 0.0001). The median time to see the fundus was 29s (95% confidence interval 23-45 s) in group A, while an estimated minimum time in group B was 80 s, indicating that group A was significantly faster than group B (P < 0.0001).

CONCLUSIONS

This 3D-printed eye model significantly improved the students' study interest, study efficiency, and study results and is worthy of being promoted.

The Equivalency of the Binocular Indirect Ophthalmoscope Simulator to Peer Practice: A Pilot Study

SIGNIFICANCE

Optometric educators are constantly looking for learning and teaching approaches to improve clinical skills training. In addition, the COVID-19 pandemic has made educators scrutinize the time allocated to face-to-face teaching and practice. Simulation learning is an option, but its use must first be evaluated against traditional learning methods.

PURPOSE

The purpose of this study was to compare the training of binocular indirect ophthalmoscopy skills achieved by students and optometrists through deliberate practice on the Eyesi Indirect Ophthalmoscope simulator with deliberate practice using a peer.

METHODS

Students and optometrists were randomly allocated to practice on either the simulator or a peer. Binocular indirect ophthalmoscopy performance was assessed using a peer and the simulator as the patients at different time points. Knowledge and confidence were examined before and following all practice sessions using a quiz and survey.

RESULTS

Significant improvements in binocular indirect ophthalmoscopy performance using either a peer or the simulator as the patient for assessment were seen after 8 hours of student practice (P < .001) and after a half-hour practice time for optometrists (P < .001). There was no significant difference in performance overall between those practicing on a simulator and those practicing on a peer (P > .05). Confidence in ability to perform the technique was lower for students who had practiced on the simulator.

CONCLUSIONS

The simulator has similar efficacy to peer practice for teaching binocular indirect ophthalmoscopy to students and maintenance of this clinical skill for optometrists. Simulation does not replace the need for peer practice but may be a useful adjunct reducing the face-to-face hours required. These findings present a need for further research regarding diverse applications of the Eyesi Indirect Ophthalmoscope simulator in the curriculum for training optometry students and as a continuing professional development offering for optometrists, given the short exposure duration required to observe a significant improvement in skill.

Virtual and Augmented Reality Direct Ophthalmoscopy Tool: A Comparison between Interactions Methods

Direct ophthalmoscopy (DO) is a medical procedure whereby a health professional, using a direct ophthalmoscope, examines the eye fundus. DO skills are in decline due to the use of interactive diagnostic equipment and insufficient practice with the direct ophthalmoscope. To address the loss of DO skills, physical and computer-based simulators have been developed to offer additional training. Among the computer-based simulations, virtual and augmented reality (VR and AR, respectively) allow simulated immersive and interactive scenarios with eye fundus conditions that are difficult to replicate in the classroom. VR and AR require employing 3D user interfaces (3DUIs) to perform the virtual eye examination. Using a combination of a between-subjects and within-subjects paradigm with two groups of five participants, this paper builds upon a previous preliminary usability study that compared the use of the HTC Vive controller, the Valve Index controller, and the Microsoft HoloLens 1 hand gesticulation interaction methods when performing a virtual direct ophthalmoscopy eye examination. The work described in this paper extends our prior work by considering the interactions with the Oculus Quest controller and Oculus Quest hand-tracking system to perform a virtual direct ophthalmoscopy eye examination while allowing us to compare these methods without our prior interaction techniques. Ultimately, this helps us develop a greater understanding of usability effects for virtual DO examinations and virtual reality in general. Although the number of participants was limited, n = 5 for Stage 1 (including the HTC Vive controller, the Valve Index controller, and the Microsoft HoloLens hand gesticulations), and n = 13 for Stage 2 (including the Oculus Quest controller and the Oculus Quest hand tracking), given the COVID-19 restrictions, our initial results comparing VR and AR 3D user interactions for direct ophthalmoscopy are consistent with our previous preliminary study where the physical controllers resulted in higher usability scores, while the Oculus Quest’s more accurate hand motion capture resulted in higher usability when compared to the Microsoft HoloLens hand gesticulation.

Comparing Eyesi Virtual Reality Simulator and Traditional Teaching Methods for Direct Ophthalmoscopy: Students' Perspectives at Indiana University School of Medicine

Background The fundus examination is an essential part of any ophthalmologic evaluation. However, medical students and primary care physicians often lack confidence with direct ophthalmoscopy. Virtual reality simulators are being employed in medical education to teach this technically challenging examination.

Objective To compare medical student ratings of the Eyesi Direct Ophthalmoscope Simulator and traditional small group teaching methods for learning direct ophthalmoscopy skills.

Methods All medical students at Indiana University School of Medicine traditionally learn direct ophthalmoscopy in their first 2 years during a small group session led by a physician instructor. Students who later enrolled in ophthalmology clinical electives during 2019 and 2020 were invited to additionally complete the Eyesi Direct Ophthalmoscope Simulator virtual reality curriculum. A voluntary, anonymous survey was sent between June and August 2020 to students who had completed both the traditional and Eyesi simulator sessions. Students were asked to rate their confidence in performing direct ophthalmoscopy following each session, and to indicate which teaching method was superior and why. Chi-square analysis was used to compare categorical variables.

Results Students' confidence ratings for performing direct ophthalmoscopy were significantly higher following completion of the Eyesi simulator session compared with the traditional small group session (p < 0.001). Four-fifths of respondents felt that the Eyesi simulator was superior to the traditional small group for learning the skills of direct ophthalmoscopy, while one-fifth felt that the two sessions were equally effective (p < 0.001). None of the students responded that the small group session was the superior teaching method.

Conclusion The Eyesi Direct Ophthalmoscope Simulator was rated highly among medical students and offers distinct learning advantages that could not be replicated in a traditional small group environment, such as providing numerous examples of pathological findings and allowing unlimited examination time without concern for patient's inconvenience or light exposure. The Eyesi simulator is a promising tool for teaching direct ophthalmoscopy to medical students. Ultimately, familiarity with the fundus examination will enable future physicians across specialties to better evaluate and appropriately refer patients with ocular fundus pathology.

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.

Perceived usefulness and ease of use of fundoscopy by medical students: a randomised crossover trial of six technologies (eFOCUS 1)

BACKGROUND

Fundoscopy outside ophthalmology is in decline, and the technical demands of the traditional direct ophthalmoscope examination are likely contributing. Alternative fundoscopy technologies are increasingly available, yet valid comparisons between fundoscopy technologies are lacking. We aimed to assess medical students' perceptions of usefulness and ease of use of traditional and contemporary fundus-viewing technologies including smartphone fundoscopy.

METHODS

One hundred forty-six second-year medical students participated in a cross-sectional, randomised, cross-over study of fundoscopy methods. Medical students completed small group training sessions using six current fundoscopy technologies including: a non-mydriatic fundus camera; two types of direct fundoscopy; and three types of smartphone fundoscopy. A novel survey of perceived usefulness and ease of use was then completed by students.

RESULTS

Repeated-measures ANOVA found students rated both the perceived usefulness (p< 0.001) and ease of use (p< 0.001) of smartphone fundoscopy significantly higher than both the non-mydriatic camera and direct fundoscopy.

CONCLUSIONS

Smartphone fundoscopy was found to be significantly more useful and easier to use than other modalities. Educators should optimise student access to novel fundoscopy technologies such as smartphone fundoscopy which may mitigate the technical challenges of fundoscopy and reinvigorate use of this valuable clinical examination.

Twelve tips for teaching ophthalmology in the undergraduate curriculum

Ophthalmology education in the undergraduate medical curriculum has declined, and graduating healthcare professionals express discomfort with basic evaluation and management of ophthalmic complaints. With the growing aging population, ophthalmic needs will continue to rise, underscoring the need for increased eye care. This article offers 12 tips for increasing undergraduate ophthalmic education, which can be implemented strategically within limited established curricular time, or in novel ways outside the traditional curriculum. Within the curriculum, existing ophthalmology sessions can be enhanced through use of simulation technology and partnership with ophthalmology faculty. Additional curricular time can be justified through needs assessments and alignment of content with other disciplines, and ophthalmology content on licensing examinations. Finally, ophthalmology can be reinforced in service-based initiatives and through use of online resources and social media.

A systematic review of simulation-based training tools for technical and non-technical skills in ophthalmology

To evaluate all simulation models for ophthalmology technical and non-technical skills training and the strength of evidence to support their validity and effectiveness. A systematic search was performed using PubMed and Embase for studies published from inception to 01/07/2019. Studies were analysed according to the training modality: virtual reality; wet-lab; dry-lab models; e-learning. The educational impact of studies was evaluated using Messick's validity framework and McGaghie's model of translational outcomes for evaluating effectiveness. One hundred and thirty-one studies were included in this review, with 93 different simulators described. Fifty-three studies were based on virtual reality tools; 47 on wet-lab models; 26 on dry-lab models; 5 on e-learning. Only two studies provided evidence for all five sources of validity assessment. Models with the strongest validity evidence were the Eyesi Surgical, Eyesi Direct Ophthalmoscope and Eye Surgical Skills Assessment Test. Effectiveness ratings for simulator models were mostly limited to level 2 (contained effects) with the exception of the Sophocle vitreoretinal surgery simulator, which was shown at level 3 (downstream effects), and the Eyesi at level 5 (target effects) for cataract surgery. A wide range of models have been described but only the Eyesi has undergone comprehensive investigation. The main weakness is in the poor quality of study design, with a predominance of descriptive reports showing limited validity evidence and few studies investigating the effects of simulation training on patient outcomes. More robust research is needed to enable effective implementation of simulation tools into current training curriculums.

Does access to a portable ophthalmoscope improve skill acquisition in direct ophthalmoscopy? A method comparison study in undergraduate medical education

BACKGROUND

Direct ophthalmoscopy (DO) is an essential skill for medical graduates but there are multiple barriers to learning this. Medical students and junior doctors typically lack confidence in DO. Most students do not own an ophthalmoscope and learn via ward devices that vary in design and usability. The Arclight ophthalmoscope (AO) is an easy to use, low-cost and portable device that could help address device access. This study aimed to assess the impact of personal ownership of an AO on DO skill acquisition and competency amongst medical students in the clinical environment.

METHODS

Method comparison study with 42 medical students randomised to either traditional device ophthalmoscope (TDO) control or AO intervention group during an 18-week medical placement. Three objective assessments of DO competency were performed at the beginning and end of the placement: vertical cup to disc ratio (VCDR) measurement, fundus photo multiple-choice questions (F-MCQ) and model slide examination (MSE). DO examinations performed during the placement were recorded via an electronic logbook.

RESULTS

Students in both groups recorded a median number of six examinations each during an eighteen-week placement. There was no statistically significant difference between the groups in any of the objective assessment measures (VCDR p = 0.561, MCQ p = 0.872, Model p = 0.772). Both groups demonstrated a minor improvement in VCDR measurement but a negative performance change in F-MCQ and MSE assessments.

CONCLUSIONS

Students do not practice ophthalmoscopy often, even with constant access to their own portable device. The lack of significant difference between the groups suggests that device access alone is not the major factor affecting frequency of DO performance and consequent skill acquisition. Improving student engagement with ophthalmoscopy will require a more wide-ranging approach.

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.