Preclinical training of future ocular surgeons: a French opinion-based study

PURPOSE

To assess ophthalmology residents satisfaction regarding surgical training during residency in France.

METHODS

A questionnaire consisting of 28 questions was designed and sent to residents of ophthalmology across the 27 French regions.

RESULTS

A total of 30.3% ophthalmology residents in France completed our questionnaire. All French regions participated. They rated 5,27 ± 2.42/10 the global surgical training during residency. They had performed at least one step of any type of ocular surgery for 93.4% of them, while 80.7% had completed at least one full cataract surgery, by the beginning of their second year of residency on average (Paris: 2.59 ± 1.36 semesters; regions: 4.05 ± 1.96 semesters, p < 0.0001). Only 48.9% identified a surgical mentor during their residency, but 82.2% did not clearly identify surgical goals & objectives during their training. Simulation was available for any type of ocular surgery to all residents in the Paris (Île-de-France) region and to 78.1% in other regions (p < 0.005). Residents who accessed drylabs and wetlabs gave a satisfaction score of 7.31 ± 1.89/10 and 6.39 ± 2.15/10 to it respectively. Simulation was a mandatory part of the curriculum for 35.2% of the resident. They commented on on reduced access to subspecialized surgery. They were willing for more access to simulation and surgery on real patients, as well for closer mentoring and clearly defined surgical goals within the curriculum.

CONCLUSION

Ophthalmology residents seemed globally satisfied with their surgical training nationwide, although we observed disparities across region. They largely acknowledged a lack of standard procedures nationwide. They acclaimed simulation during the initial phase of residency, progressively switching towards surgery on real patients. An "operating license" during residency could be a viable way for the resident to demonstrate that they have acquired enough surgical abilities to perform surgery on real patients.

Cataract surgical training in Europe: European Board of Ophthalmology survey

PURPOSE

To survey recently graduated European ophthalmologists concerning cataract surgery (CS) training opportunities.

SETTING

Countries affiliated to the European Board of Ophthalmology (EBO).

DESIGN

Cross-sectional study of anonymous survey results.

METHODS

A 23-question online survey was emailed to candidates who sat the EBO Diploma Examination as residents between 2018 and 2022.

RESULTS

821 ophthalmologists from 30 countries completed the survey. The mean residency duration was 4.73 (SD 0.9) years. The mean reported number of entire CS procedures performed was 80.7 (SD 100.6) at the end of residency, but more than 25% of respondents (n = 210) had received no live CS training during their residency. The self-confidence (scale, 1 to 10) to perform a simple case or challenging case, manage posterior capsular rupture, and realize a corneal stitch were rated 4.1, 3.2, 4.2, 2.4, respectively. We observed extensive variation in clinical exposure to CS and self-reported confidence to perform CS between European trainees. Females reported a mean of 18% fewer entire procedures than their male colleagues and were also less confident in their surgical skills (P < .05). Trainees in residency programs longer than 5 years performed fewer procedures and were less confident than trainees in residences of shorter duration (P < .001). The importance of fellowships to complete surgical education was rated 7.7 out of 10.

CONCLUSIONS

CS training across European countries lacks harmony. Female ophthalmology trainees continue, as in other specialties, to experience apparent gender bias. European level recommendations seem necessary to raise and harmonize competency-based CS training programs and promote post-residency fellowship training programs.

Harmonizing ophthalmic residency surgical training across Europe: A proposed surgical curriculum

BACKGROUND

One of the core aims of the European Union of Medical Specialists is to harmonize training across Europe by creating European Training Requirements for all medical specialties including Ophthalmology. The theoretical part is already defined by the EBO, however as ophthalmology also includes surgical skills, we herein propose a surgical minimum curriculum for ophthalmology residents in Europe.

METHODS

National and international ophthalmic training curricula which are publicly available in English were reviewed and compared. The final proposal was created from 5 criteria: 1. Disease prevalence; 2. Patient safety; 3. Case-trainee ratio; 4. Skill transfer; and 5. Technical difficulty.

RESULTS

In total 7 different training curricula from across the world were compared. Among the surgical procedures, cataract surgery has the highest median number of procedures required to be completed during residency: 86 procedures (50-350). Followed by oculoplastics: 28 procedures (10-40) and panretinal photocoagulation: 27.5 procedures (10-49) Full procedural competence is proposed in 9 surgical skills, including YAG laser posterior capsulotomy, retinal argon laser, intravitreal injection, corneal foreign body removal, removal of corneal sutures, facial and periocular laceration repair, eyelid laceration repair, minor eyelid procedures, and punctal occlusion. These procedures are deemed essential and feasible for all ophthalmology residents in Europe to perform independently upon completion of their training.

CONCLUSION

This proposal should be regarded as a recommendation based on comparable surgical curricula in use worldwide to establish standards across European countries and may serve as valuable insight to those responsible for compiling ETRs for ophthalmology, or their national curriculums.

Patient perspective on the participation of ophthalmology residents in their cataract surgery

OBJECTIVE

To determine the proportion of patients consenting to resident participation in cataract surgery and to identify factors predictive of consent.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

The 330 consecutive patients referred for cataract evaluation from February-April 2021 to 3 surgeons at a tertiary care referral centre in London, Ontario.

METHODS

Using a standardized disclosure script, individuals were asked about resident participation in their cataract surgery. A phone survey and medical record review were conducted to obtain clinical and demographic information. Predictors of consent were assessed using logistic regression modelling.

RESULTS

Responses were received from 279 individuals (85% response rate), with a mean age of 71.7 ± 8.6 years, and 113 were female. The consent rate was 71%. Prior negative experience with any medical trainee was an independent predictor for refusing resident participation (odds ratio [OR] = 3.10; 95% CI, 1.32-7.28; p = 0.009). Nonconsenters also had more prior negative experiences with other physicians (35% vs 23%; p = 0.031) and knew someone who had had a problem after eye surgery (36% vs 22%; p = 0.016). Individuals with an occupation involving apprenticeship (OR = 2.87; 95% CI, 1.08-7.67; p = 0.035) and those with a preoperative acuity of 20/200 or worse (OR = 2.78; 95% CI, 1.03-7.14; p = 0.043) were more likely to consent.

CONCLUSIONS

Patients should be explicitly asked about resident involvement. Negative experiences can make individuals reluctant to have learners involved in their future care. Patient education describing the apprenticeship model in medicine may increase consent.

Impact of COVID-19 on surgical specialist training as quantified by trainee complication rates for cataract surgery

BACKGROUND

Reduction in elective surgeries during the COVID-19 pandemic has negatively impacted surgical specialist training. Posterior capsule rupture rate (PCR), a complication of cataract surgery, is an objective measure of the quality of ophthalmic surgery. This study aimed to compare PCR pre- and post-COVID-19 in trainees and consultants.

METHODS

A single-centre consecutive cases series of cataract surgeries performed at Groote Schuur Hospital, between 1 February 2017 and 31 May 2021 were analysed. Our main outcome measure was the effect of the volume of cataract surgeries on PCRs between ophthalmology trainees and consultants before and after the COVID-19 reduction in elective surgeries on 23 March 2020.

RESULTS

During the study period, 4 157 cataract surgeries were performed (3 493 in the 38 months pre-COVID-19 and 664 in the 14 months post-COVID-19). Fourteen ophthalmology trainees and six consultants performed 2 919 and 1 238 cataract surgeries, respectively. In the trainees the PCR was 4.4% pre-COVID-19 and 10.0% post-COVID-19 (odds ratio [OR] 2.44; p < 0.001; CI 1.71-3.47; relative risk [RR] 2.29). The PCR of consultants remained unchanged with a PCR of 3.4% pre- and post-COVID-19 (OR 1.02; p = 0.97; CI 0.42-2.46; RR 1.02).

CONCLUSION

COVID-19 has caused a marked reduction in the volume of cataract surgery which has resulted in a deterioration in the performance of trainees, but not consultants, and quantifies the negative impact of the pandemic on surgical training in ophthalmology. This highlights the need to develop plans to improve surgical training during the COVID-19 recovery period.

The impact of distance cataract surgical wet laboratory training on cataract surgical competency of ophthalmology residents

BACKGROUND

This study assessed the impact of distance cataract surgical wet laboratory training on surgical competency of ophthalmology residents at a tertiary-level ophthalmic training center in Trujillo, Peru.

METHODS

Three five-week distance wet lab courses were administered through Cybersight, Orbis International's telemedicine platform. Weekly lectures and demonstrations addressed specific steps in phacoemulsification surgery. Each lecture had two accompanying wet lab assignments, which residents completed and recorded in their institution's wet lab and uploaded to Cybersight for grading. Competency was assessed through anonymous grading of pre- and post-training surgical simulation videos, masked as to which occurred before and after training, using a standardized competency rubric adapted from the Ophthalmology Surgical Competency Assessment Rubric (OSCAR, scale of 0-32). Day one best-corrected post-operative visual acuity (BVCA) was assessed in the operative eye on the initial consecutive 4-6 surgeries conducted by the residents as per the norms of their residency training. An anonymous post-training satisfaction survey was administered to trainees'.

RESULTS

In total, 21 ophthalmic residents participated in the courses, submitting a total of 210 surgical videos. Trainees' average competency score increased 6.95 points (95%CI [4.28, 9.62], SD = 5.01, p < 0.0001, two sample t-test) from 19.3 (95%CI [17.2, 21.5], SD = 4.04) to 26.3 (95%CI [24.2, 28.3], SD = 3.93). Visual acuity for 92% of post-training resident surgeries (n = 100) was ≥20/60, meeting the World Health Organization's criterion for good quality.

CONCLUSIONS

Structured distance wet lab courses in phacoemulsification resulted in significantly improved cataract surgical skills. This model could be applicable to locations where there are obstacles to traditional in-person training, such as the current COVID-19 pandemic.

Intense Simulation-Based Surgical Education for Manual Small-Incision Cataract Surgery: The Ophthalmic Learning and Improvement Initiative in Cataract Surgery Randomized Clinical Trial in Kenya, Tanzania, Uganda, and Zimbabwe

Importance

Cataracts account for 40% of cases of blindness globally, with surgery the only treatment.

Objective

To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees.

Design, Setting, and Participants

A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis.

Interventions

The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period.

Main Outcomes and Measures

The primary outcome measure was overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period.

Results

Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95% CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95% CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8% (42 of 537) for the intervention group and 26.6% (54 of 203) for the control group (difference, 18.8%; 95% CI, 12.3%-25.3%; P < .001).

Conclusions and Relevance

This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety.

Trial Registration

Pan-African Clinical Trial Registry, number PACTR201803002159198.

Simulation of advanced cataract surgery - validation of a newly developed test

PURPOSE

To develop and investigate an Eyesi simulator-based test for the more experienced cataract surgeon for evidence of validity.

METHODS

The study was a prospective interventional cohort study and carried out at the Copenhagen Academy for Medical Education and Simulation. The Eyesi Simulator was used for the test which was developed by three expert cataract surgeons. Ten cataract surgeons (>250 surgeries performed) and ten ophthalmic residents performed two repetitions of the test. The test consisted of four modules: Iris Expansion Ring insertion - level 1, Iris Expansion Ring extraction - level 2, Capsulorhexis - level 3 and Anterior Vitrectomy - level 6.

RESULTS

Internal consistency reliability showed Cronbach's alpha of 0.63. Test-retest reliabilities were significant for Iris Expansion Ring extraction - level 2 (p = 0.012) and Capsulorhexis - level 3 (p = 0.018). Differences between the two groups were only significant in both repetitions for the Iris Expansion Ring extraction - level 2 (p < 0.001 and p = 0.041, respectively). Furthermore, we found a statistically significant difference between the mean module scores for novices and the more experienced surgeons for Iris Expansion Ring insertion - level 1 (p = 0.021) and Capsulorhexis - level 3 (p = 0.019) in the first repetition.

CONCLUSION

The investigated modules show evidence of validity within several aspects of Messick's framework. However, the evidence is not strong enough to apply the test for certification purposes of cataract surgeons, but the modules may still be relevant in the training of advanced cataract surgical procedures.

Assessment of resident training and preparedness for cataract surgery

PURPOSE

To assess which surgical teaching methods are used for residency surgical training and which methods residents find most useful.

SETTING

Wilmer Eye Institute, Baltimore, Maryland, USA.

DESIGN

Retrospective observational cross-sectional study.

METHODS

A survey was developed and sent to residents at accredited ophthalmology training programs in the United States. The survey asked about demographics, program characteristics, surgical training methods, perceived initial preparedness, eventual competence, and difficulty with the steps of cataract surgery. The correlation between surgical training methods was compared with perceived preparedness, competence, and difficulty.

RESULTS

One hundred sixteen residents completed the survey. Discussing surgical procedures with senior surgeons or using surgical simulators preoperatively improved resident-perceived surgical competency in several areas, such as paracentesis. Residents who had preoperative discussions with senior surgeons were statistically less likely to report difficulty with surgical procedures, such as performing a clear corneal incision. The presence of a supervised wet lab or surgical simulator in a residency was also associated with improved resident-perceived surgical competency.

CONCLUSION

Educational resources, such as surgical simulators and supervised wet labs, tended to be associated with greater resident-perceived competency for steps in cataract surgery.

Trends in cataract surgery training curricula

PURPOSE

To evaluate trends in cataract surgery training curricula and factors affecting timing of resident participation as a primary surgeon.

SETTING

Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA.

DESIGN

Cross-sectional study of anonymous survey results.

METHODS

A description of the study and link to an online survey was e-mailed to program directors of each ophthalmology residency training program accredited by the Accreditation Council for Graduate Medical Education (ACGME).

RESULTS

Fifty-one (44%) of the 116 program directors completed the survey. First-year, second-year, and third-year residents performed a mean of 2, 25, and 155 phacoemulsification surgeries, respectively, as a primary surgeon. Only 1 program (2%) required residents to perform extracapsular cataract extraction (ECCE) before performing phacoemulsification. Clear corneal phacoemulsification was the first technique taught to trainees at 91% of programs. More than two thirds (71%) of program directors indicated that their program had a cataract surgery training curriculum designed to transition residents gradually to the operating room. These curricula included structured wet laboratory (92%) and lecture (89%) components. Inadequate resident knowledge and surgical skill base (57%) and anticipation of increased surgical complication risk (37%) were the most commonly reported factors impeding earlier exposure to phacoemulsification in residency.

CONCLUSIONS

Results show that residents today begin surgical training with phacoemulsification rather than ECCE, perform a higher number of phacoemulsification surgeries than is required by the ACGME, and begin performing phacoemulsification as early as their first or second year of residency. Despite these evolutions, 29% of respondent ACGME-accredited ophthalmology residency programs reported not having a formal cataract surgery training curriculum.

Comparison of Pediatric Cataract Surgical Techniques Between Pediatric Ophthalmology Consultants and Fellows in Training: A Video-Based Analysis

PURPOSE

To compare intraoperative technique and quality of surgical steps in pediatric cataract surgery between pediatric ophthalmology consultants and fellows in training.

METHODS

In a video-based analysis by two fellowship-trained pediatric ophthalmologists, 42 surgical videos of pediatric ophthalmology consultants and 34 videos of fellows in training were graded based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). Six steps in surgery were analyzed: wound construction, anterior continuous curvilinear capsulorrhexis, irrigation and aspiration, intraocular lens implantation, primary posterior capsulorrhexis with anterior vitrectomy, and wound suturing. Cohen's Kappa was used to rate inter-observer agreement.

RESULTS

Cohen's Kappa scores ranged from 0.6 to 0.8. The median scores for surgical steps for both analyzed groups were similar. The mean duration of surgery was shorter for consultants (24 minutes, range: 10 to 45 minutes) than for fellows (40 minutes, range: 15 to 70 minutes). The median age of patients operated on by consultants was younger (24 months, range: 2 to 180 months) than fellows (58 months, range: 10 to 150 months).

CONCLUSIONS

The quality of the surgical steps performed by pediatric ophthalmology consultants and fellows in training was similar. [J Pediatr Ophthalmol Strabismus. 2019;56(2):83-87.].

A Comprehensive Surgical Curriculum Reduced Intra-operative Complication Rates of Resident-performed Cataract Surgeries

OBJECTIVES

To evaluate the impact of a comprehensive cataract surgery curriculum on the incidence of intraoperative complications.

DESIGN

We retrospectively compared the total number of cataract surgeries that the residents performed in all of the teaching sites, and the incidences of intraoperative complications (anterior capsule tear, posterior capsule rent, vitreous loss, anterior vitrectomy, zonular dialysis, iris trauma, hemorrhage, dropped lens fragment, corneal wound burn, incorrect intraocular lens) for the surgeries performed at Massachusetts Eye & Ear by residents in the pre-intervention group (residents graduating in 2004 and 2005), before the implementation of a surgical curriculum, and the residents in the post-intervention group (residents graduating in 2014 and 2015).

SETTING

Ophthalmology residency program at a major academic institution.

PARTICIPANTS

Residents graduating in 2004, 2005, 2014, and 2015.

RESULTS

We reviewed 4373 charts. 2086 of those surgeries were performed at Massachusetts Eye & Ear. The incidence of posterior capsule rent/vitreous loss/anterior vitrectomy was lower in the post-intervention group (1.4% versus 7.7%, p < 0.0001). Other complications were also lower in the post-intervention group.

CONCLUSIONS

Implementation of a comprehensive cataract surgery curriculum focusing on pre-operative, intra-operative and post-operative interventions, with an emphasis on patient outcomes resulted in a decrease in the rate of intraoperative complications.

Competency-Based Education Assessment Tools for Laser Capsulotomy, Peripheral Iridotomy, and Selective Laser Trabeculoplasty

PURPOSE

To produce Competency-Based Education Assessment Tools (C-BEAT) for performance of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy, laser peripheral iridotomy (LPI), and selective laser trabeculoplasty (SLT) on an artificial eye model that can be used in competency-based medical education (CBME) of ophthalmology residents.

DESIGN

Survey.

PARTICIPANTS

Eight content experts (residency program director and faculty members involved in ophthalmology resident training).

METHODS

Task-specific checklists were created to assess the performance of Nd:YAG capsulotomy, LPI, and SLT on artificial eye models designed for each of these procedures, as well as a global rating scale (GRS). A modified Delphi process was used to establish face and content validity of the C-BEAT for lasers. Eight content experts participated in the Delphi process, and the consensus was achieved after 4 rounds.

MAIN OUTCOME MEASURE

Survey responses.

RESULTS

Final versions of checklists for Nd:YAG capsulotomy, LPI, and SLT, and a GRS for these laser procedures were produced with face and content validity. Modifications to the energy settings and the number of applications in the capsulotomy and peripheral iridotomy were implemented into the checklist and instructions, because the artificial models were not identical in their responses to the laser applications compared with real tissue.

CONCLUSIONS

The C-BEAT for lasers can be used in an examination setting within ophthalmology residency training programs to establish competency in these procedures before performing them on real patients. These tools help to meet the demand for assessment modalities within a CBME model that is being implemented into residency training worldwide. To establish interrater and construct validities, further studies are required.

Assessing Resident Cataract Surgery Outcomes Using Medicare Physician Quality Reporting System Measures

OBJECTIVES

To assess resident cataract surgery outcomes at an academic teaching institution using 2 Physician Quality Reporting System (PQRS) cataract measures, which are intended to serve as a proxy for quality of surgical care.

DESIGN

A retrospective review comparing cataract surgery outcomes of resident and attending surgeries using 2 PQRS measures: (1) 20/40 or better best-corrected visual acuity following cataract surgery and (2) complications within 30 days following cataract surgery requiring additional surgical procedures.

SETTING

An academic ophthalmology center.

PARTICIPANTS

A total of 2487 surgeries performed at the Massachusetts Eye and Ear Infirmary from January 1, 2011 to December 31, 2012 were included in this study.

RESULTS

Of all 2487 cataract surgeries, 98.95% achieved a vision of at least 20/40 at or before 90 days, and only 0.64% required a return to the operating room for postoperative complications. Of resident surgeries, 98.9% (1370 of 1385) achieved 20/40 vision at or before 90 days follow-up. Of attending surgeries, 99.0% (1091 of 1102) achieved 20/40 vision at or before 90 days (p = 1.00). There were no statistically significant differences between resident and attending cases regarding postoperative complications needing a return to the operating room (i.e., 0.65%, or 9 of 1385 resident cases vs 0.64%, or 7 of 1102 attending cases; p = 1.00).

CONCLUSIONS

Using PQRS Medicare cataract surgery criteria, this study establishes new benchmarks for cataract surgery outcomes at a teaching institution and supplemental measure for assessing resident surgical performance. Excellent cataract outcomes were achieved at an academic teaching institution, with results exceeding Medicare thresholds of 50%. There appears to be no significant difference in supervised trainee and attending cataract surgeon outcomes using 2 PQRS measures currently used by Medicare to determine physician reimbursement and quality of care.

A Cataract Surgery Training Program: 2-Year Outcome After Launching

BACKGROUND

To investigate whether a short-term training program can produce competent cataract surgeons.

METHODS

This observational pilot study enrolled 12 trainees who could not perform phacoemulsification independently. The training consisted of 2 phases. During the first 3-month phase, trainees were taught phacoemulsification through wet laboratory exposure and deliberate practice in patients at the training center in the Eye Hospital of Wenzhou Medical University in China. The second phase consisted of performing 50 cases at the trainees׳ home institution with supports from instructors of the first phase. Trainees׳ surgical results were followed-up. The surgical skill as measured by the Ophthalmology Surgical Competency Assessment Rubric (OSCAR) and surgical outcomes were analyzed.

RESULTS

During the first phase trainees performed 193.3 ± 95.4 wet laboratory cases and 557 eyes in patients. The complication rate was 0.54%. The OSCAR scores improved significantly (p < 0.01) in the first phase. At the second phase, all the trainees could carry out phacoemulsification at their home hospital and the complication rate was 1.87%. During the long-term follow-up, 4936 cases of phacoemulsification were performed and the complication rate was 0.87%.

CONCLUSIONS

Trainees succeeded in performing phacoemulsification safely and skillfully through a limited short period of training by wet laboratory exposure, deliberate practice in patients, and frequent formative feedback provided by the OSCAR tool.

Learning styles and the prospective ophthalmologist

PURPOSE

Understanding the learning styles of individual trainees may enable trainers to tailor an educational program and optimise learning. Surgical trainees have previously been shown to demonstrate a tendency towards particular learning styles. We seek to clarify the relationship between learning style and learned surgical performance using a simulator, prior to surgical training.

METHODS

The Kolb Learning Style Inventory was administered to a group of thirty junior doctors. Participants were then asked to perform a series of tasks using the EyeSi virtual reality cataract surgery simulator (VR Magic, Mannheim, Germany). All completed a standard introductory programme to eliminate learning curve. They then undertook four attempts of level 4 forceps module binocularly. Total score, odometer movement (mm), corneal area injured (mm(2)), lens area injured (mm(2)) and total time taken (seconds) recorded.

RESULTS

Mean age was 31.6 years. No significant correlation was found between any learning style and any variable on the EyeSi cataract surgery simulator.

CONCLUSION

There is a predominant learning style amongst surgical residents. There is however no demonstrable learning style that results in a better (or worse) performance on the EyeSi surgery simulator and hence in learning and performing cataract surgery.

MY EXPERIENCE OF TEACHING PHACOSURGERY ON VISALIS 100 IN SUDAN AND NIGERIA

At the invitation of the director of The National Eye Center, Kaduna, Nigeria and The Makkah Eye Hospital of Khartoum, Sudan I visited both these institutions to teach phacoemulsification surgery to their aspiring surgeons on Visalis 100 (Carl Zeiss Meditec, Germany). This article highlights the experience of teaching phacoemulsification surgery in foreign African countries like Nigeria and Sudan. In Nigeria I had the opportunity to give training in both wet lab and live surgery settings whereas in Sudan only hands-on live surgery. Sudan being an Islamic nation pigs are not slaughtered there and hence no pig eyes. Goat eyes differ significantly from human eyes and hence have almost no value in wet lab teaching. The training program included theoretical discussions, wet lab, surgery and finally discussions related to the days' surgery. It became clear that quality of learning depends on three main factors. Thorough understanding of theory and observation of senior surgeons in operation room Good wet lab and finally doing the surgery oneself in step by step manner. Dedicated teachers and instructors can make all the difference. The learning curve also significantly shortens if the trainees are exposed to all types of cataract surgery like ECCE, SICS and phacoemulsification surgery. The main problem faced by those surgeons who have done only ECCE/SICS is that they are not used to handling microscope and instruments in both hands at the same time. Hence I strongly recommend them wet lab where they can sit and practice using both hands and feet and microscope simultaneously and in coordinated fashion.

Introducing a New Surgical Technology: Controversies in Femtosecond Laser-assisted Cataract Surgery and Impact on Resident Surgical Training

Femtosecond laser-assisted cataract surgery is becoming more widely available as an option for patients considering cataract surgery. Controversies exist around determining the best platform for LCS, the potential global role and cost to the health care system of LCS, as well as the future of LCS in resident surgical training.

A broadly applicable surgical teaching method: evaluation of a stepwise introduction to cataract surgery

OBJECTIVE

Although cataract surgery is one of the most commonly performed surgeries in the country, it is a microsurgical procedure that is difficult to learn and to teach. This study aims to assess the effectiveness of a new method for introducing postgraduate year (PGY)-3 ophthalmology residents to cataract surgery.

SETTING

Hospital-based ophthalmology residency program.

DESIGN

Retrospective cohort study.

PARTICIPANTS

PGY-3 and PGY-4 residents of the Harvard Medical School Ophthalmology Residency from graduating years 2010 to 2012.

RESULTS

In July 2009, a new method of teaching PGY-3 ophthalmology residents cataract surgery was introduced, which was termed "the stepwise introduction to cataract surgery." This curriculum aimed to train residents to perform steps of cataract surgery by deliberately practicing each of the steps of surgery under a structured curriculum with faculty feedback. Assessment methods included surveys administered to the PGY-4 residents who graduated before the implementation of these measures (n = 7), the residents who participated in the first and second years of the new curriculum (n = 16), faculty who teach PGY-4 residents cataract surgery (n = 8), and review of resident Accreditation Council for Graduate Medical Education surgical logs. Resident survey response rate was 100%. Residents who participated in the new curriculum performed more of each step of cataract surgery in the operating room, spent more time practicing each step of cataract surgery on a cataract surgery simulator during the PGY-3 year, and performed more primary cataract surgeries during the PGY-3 year than those who did not. Faculty survey response rate was 63%. Faculty noted an increase in resident preparedness following implementation of the new curriculum. There was no statistical difference between the precurriculum and postcurriculum groups in the percentage turnover of cataracts for the first 2 cataract surgery rotations of the PGY-4 year of training.

CONCLUSIONS

The introduction of cataract surgery to PGY-3 residents in an organized, stepwise manner improved resident preparedness for the PGY-4 year of residency. This surgical teaching method can be easily applied to other surgical specialties.

Cataract surgeons outperform medical students in Eyesi virtual reality cataract surgery: evidence for construct validity

PURPOSE

To investigate construct validity for modules hydromaneuvers and phaco on the Eyesi surgical simulator.

METHODS

Seven cataract surgeons and 17 medical students performed capsulorhexis, hydromaneuvers, phaco, navigation, forceps, cracking and chopping modules in a standardized manner. Three trials were performed on each module (two on phaco) in the above order. Performance parameters as calculated by the simulator for each trial were saved. Video recordings of the second trial of the modules capsulorhexis, hydromaneuvers and phaco were evaluated with the modified Objective Structured Assessment of Surgical Skill (OSATS) and Objective Structured Assessment of Cataract Surgical Skill (OSACSS) tools.

RESULTS

Cataract surgeons outperformed medical students with regard to overall score on capsulorhexis (p < 0.001, p = 0.035, p = 0.010 for the tree iterations, respectively), navigation (p = 0.024, p = 0.307, p = 0.007), forceps (p = 0.017, p = 0.03, p = 0.028). Less obvious differences in overall score were found for modules cracking and chopping (p = 0.266, p = 0.022, p = 0.324) and phaco (p = 0.011, p = 0.081 for the two iterations, respectively). No differences in overall score were found on hydromaneuvers (p = 0.588, p = 0.503, p = 0.773), but surgeons received better scores from the evaluations of the modified OSATS (p = 0.001) and OSACSS (capsulorhexis, p = 0.003; hydromaneuvers, p = 0.017; phaco, p = 0.001).

CONCLUSIONS

Construct validity was found on several modules previously not investigated (phaco, hydromaneuvers, cracking and chopping, navigation), and our results confirm previously demonstrated construct validity for capsulorhexis and forceps modules. Interestingly, validation of the hydromaneuvers module required OSACSS video evaluation tool. A further development of the scoring system in the simulator for the hydromaneuvers module would be advantageous and make training and evaluation of progress more accessible and immediate.

A virtual cataract surgery course for ophthalmologists-in-training

Virtual reality (VR) surgery simulation is an emerging teaching tool to train residents in cataract surgery. The widespread adoption of virtual surgery has been limited, however, by high costs and the absence of standardized curricula and evidence demonstrating the impact of VR training on resident surgical outcomes. We outline a resident virtual cataract surgery course--freely accessible online--that we hope will contribute to the development of a standardized VR cataract surgery curriculum.

Virtual reality cataract surgery training: learning curves and concurrent validity

PURPOSE

To investigate initial learning curves on a virtual reality (VR) eye surgery simulator and whether achieved skills are transferable between tasks.

METHODS

Thirty-five medical students were randomized to complete ten iterations on either the VR Caspulorhexis module (group A) or the Cataract navigation training module (group B) and then two iterations on the other module. Learning curves were compared between groups. The second Capsulorhexis video was saved and evaluated with the performance rating tool Objective Structured Assessment of Cataract Surgical Skill (OSACSS). The students' stereoacuity was examined.

RESULTS

Both groups demonstrated significant improvements in performance over the 10 iterations: group A for all parameters analysed including score (p < 0.0001), time (p < 0.0001) and corneal damage (p = 0.0003), group B for time (p < 0.0001), corneal damage (p < 0.0001) but not for score (p = 0.752). Training on one module did not improve performance on the other. Capsulorhexis score correlated significantly with evaluation of the videos using the OSACSS performance rating tool. For stereoacuity < and ≥120 seconds of arc, sum of both modules' second iteration score was 73.5 and 41.0, respectively (p = 0.062).

CONCLUSION

An initial rapid improvement in performance on a simulator with repeated practice was shown. For capsulorhexis, 10 iterations with only simulator feedback are not enough to reach a plateau for overall score. Skills transfer between modules was not found suggesting benefits from training on both modules. Stereoacuity may be of importance in the recruitment and training of new cataract surgeons. Additional studies are needed to investigate this further. Concurrent validity was found for Capsulorhexis module.

Concurrent and face validity of a capsulorhexis simulation with respect to human patients

A prototype version of the ImmersiveTouch® virtual reality simulator was applied to capsulorhexis, the creation of circular tear or "rhexis" in the lens capsule of the eye during cataract surgery. Virtual and live surgery scores by residents were compared. The same three metrics are used in each mode: circularity of the rhexis, duration of surgery (sec), and number of forceps grabs of the capsule per completed rhexis (fewer is better). The average simulator circularity score correlated closely with the average live score (P = 0.0002; N = 4), establishing "concurrent validity" for this metric. Individuals performed similarly to each other in both modes, as shown by the low standard deviations for average circularity (virtual 0.92 ± 0.04; live 0.88 ± 0.04). By contrast, the standard deviations are high for the other two metrics, capsulorhexis duration (virtual 96.91 ± 44.23 sec; live 94.42 ± 65.74 sec, N = 8) and number of forceps grabs (virtual 10.66 ± 4.81; live 10.31 ± 5.23, N = 8). Nevertheless, the simulator was able to demonstrate that the surgeons with wide variations in total duration and number of capsular grabs in 2 to 4 trials of simulated surgery also had similar variations in live surgery, so that the simulator retains some realism or "face validity."

Holistic approach to pre-operative assessment for cataract patients

When patients agree to have cataract surgery it is important that they are fully assessed to determine their fitness for surgery. This article discusses the benefits of a nurse-led holistic approach to patient assessment, which, in practice, should be more than simply a 'tick-box exercise'. Essential components of the assessment include obtaining valid informed consent and performing biometry - the process by which the required dioptric power of an intraocular lens (IOL) implant is calculated prior to cataract surgery. It is a highly skilled procedure, which involves the measurement of corneal curvature and the axial length of the eye using either ultrasound or optical methods of biometry. This article examines the vital nursing roles aimed at improving the quality and efficiency of the patient's 'journey'.

A simulator to explore the role of haptic feedback in cataract surgery training

Phacoemulsification cataract surgery, a minimally invasive technique to remove a cloudy lens from the eye, is one of the most commonly performed surgical procedures in the western world. Conventional training for this procedure involves didactic lectures and practice on pig and human cadaver eyes, none of which allow trainees to form an accurate predictive model of human tissue behavior during surgery. A virtual environment simulator for capsulorrhexis, one of the first steps in cataract surgery, has been developed that allows a trainee to use surgical instruments to excise a circle of tissue on the anterior side of the lens capsule through tearing. The simulator invokes a deformable mass-spring-damper mesh model of the tissue that can be grasped and torn via shearing. A novel algorithm for mesh division and maintenance enables realistic tearing behavior. The trainee controls tool motion using a 3-degree-of-freedom haptic device, and haptic feedback is provided from the virtual tissue. Although the haptic feedback in a real capsulorrhexis procedure is below the human threshold of haptic sensing, this simulator enables an experiment to determine the effectiveness of "haptic training wheels" -- the idea of haptic training for a task without haptic feedback.

Patients' attitudes towards trainee surgeons performing cataract surgery at a teaching hospital

AIM

To evaluate patients' preferences of surgeon to perform their cataract surgery if given a choice between consultant and trainee.

METHODS

A questionnaire based patient satisfaction survey was conducted in a large University Teaching Hospital in the UK. One hundred and eighty patients undergoing first eye cataract surgery between January and March 2006 were asked a number of set questions on their preferences regarding the surgeon performing the operation. Primary outcome measure was the patient's preference for who would perform their cataract surgery (consultant or trainee).

RESULTS

Overall, 126 (70%) accepted that trainee surgeons should operate as part of their training. Only 102 (81%) of these (57% of the total) would be happy to be operated on themselves by a supervised surgical trainee. Ninety-eight (78%) patients objected to being operated on by a trainee if they were to be unsupervised. One hundred and forty-two (79%) patients stated they would choose to wait longer for their surgery if it meant that a consultant would perform their operation. This preference was held significantly more strongly among patients who had been listed for surgery from a consultant's clinic rather than from the pooled 'cataract clinic' (P=0.048). One hundred and forty-four (80%) patients thought they should be told the name and designation of the surgeon who was to perform their operation.

CONCLUSIONS

Patients undergoing their first cataract procedure appear to have a preference for their named consultant to perform their surgery. If 'patient choice' extends to the choice of operating surgeon, then there are clear implications for the training of future UK ophthalmologists.

A retrospective analysis to determine the effect of independent treatment centres on the case mix for microsurgical training

AIM

To determine the effect of Independent Sector Treatment Centres (ISTC) on microsurgical training.

METHODS

A novel scoring protocol for stratification of cases suitable for microsurgical training was devised. This scoring protocol was applied to all patients who underwent cataract surgery on a single consultant dedicated training list between September and November 2004. These patients are representative of patients remaining on the waiting list after ISTC selection, that is, the residual case mix. Patients who underwent cataract surgery on the same consultant list in the same period in 2003 were also analysed when there was no ISTC or other waiting list initiative in operation.

RESULTS

Data was available for 129 patients. Seventy three patients underwent cataract surgery between September and November 2003 and 56 patients underwent cataract surgery in the same period in 2004. Using the devised scoring protocol, the mean score in the 2003 group was 1.08 +/-1.75 (range, 0.0-10.5) and for the 2004 group the mean score was 2.31 +/-2.65 (range, 0.0-4.5). A Mann-Whitney test showed that there was a statistically significant difference between the scores in the two groups (P=0.0009). With Independent Sector Treatment Centre implementation the percentage of cases suitable only for consultants increased fourfold.

CONCLUSION

The decrease in suitable cases for training as shown in this study is likely to have serious consequences on microsurgical training in the UK. We recommend that the results of this study are considered in any current or future plans for ISTC continuation and expansion.

Teaching and assessing competence in cataract surgery

PURPOSE OF REVIEW

To review recent literature regarding innovative techniques, methods of teaching and assessing competence and skill in cataract surgery.

RECENT FINDINGS

The need for assessment of surgical competency and the requirement of wet lab facilities in ophthalmic training programs are being increasingly emphasized. Authors have proposed the use of standardized forms to collect objective and subjective data regarding the residents' surgical performance. Investigators have reported methods to improve visualization of cadaver and animal eyes for the wet lab, including the use of capsular dyes. The discussion of virtual reality as a teaching tool for surgical programs continues. Studies have proven that residents trained on a laparoscopic simulator outperformed nontrained residents during actual surgery for both surgical times and numbers of errors. Besides virtual reality systems, a program is being developed to separate the cognitive portion from the physical aspects of surgery. Another program couples surgical videos with three-dimensional animation to enhance the trainees' topographical understanding.

SUMMARY

Proper assessment of surgical competency is becoming an important focus of training programs. The use of surgical data forms may assist in standardizing objective assessments. Virtual reality, cognitive curriculum and animation video programs can be helpful in improving residents' surgical performance.

'Fast-track' cataract services and diagnostic and treatment centre: impact on surgical training

AIMS

To evaluate the impact of 'Action on Cataracts' and the development of Diagnostic and Treatment Centre (DTC) on cataract surgery training in the Central Manchester and Manchester Children's University Hospital's Trust.

METHODS

We compared all cataract extractions undertaken from April to September 2005 with the same 6-month time period over the preceding 5 years. Surgery was performed on one of four types of lists: Manchester Royal Eye Hospital standard lists (MREH), Cataract Services list, Waiting List Initiative list (WLI), and Diagnostic and Treatment Centre list (DTC). Surgeons were identified by their specific codes and divided into grades.

RESULTS

The total number of cataract operations undertaken on the standard MREH lists has declined significantly over the years (P<0.001 chi(2) test for trend). The number of cataract operations performed by both Specialist Registrars (SpRs) and Senior House Officers (SHOs) demonstrated a statistically significant decline over the years (P<0.001 for both cases, chi(2) test for trend), with the SHOs number dropping dramatically over the last 2 years. When comparing the number of operations performed by junior SpRs and senior SpRs, shift in the balance can be seen towards the senior surgeons. The proportion of operations performed by junior SpRs declined from 50% in 2000 to 28.2% in 2005.

CONCLUSION

Recent changes in cataract care provision have had a significant impact on training. Our results document for the first time that both higher and basic surgical trainees were affected. Future care of our patients could be comprised owing to lack of training.

The ORBIS Flying Eye Hospital

In the mid 1970s, Dr David Paton, a Houston ophthalmologist, conceived the idea of an airborne ophthalmic teaching hospital. He wanted to share eye care skills and expertise with health personnel in developing countries. With the help of benefactors, the charity ORBIS was formed 24 years ago with the aim of eliminating avoidable blindness worldwide by taking medical and surgical skills, readily available in the Western world, to areas of greatest need.

Teaching and Assessing Surgical Competency in Ophthalmology Training Programs

BACKGROUND AND OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) has mandated implementation of six new competencies in resident training in the United States. An implementation strategy is proposed to teach and assess cataract surgical competence.

PATIENTS AND METHODS

An intradepartmental Task Force for the ACGME competencies reviewed the literature for assessment tools to develop an implementation matrix for assessing surgical competence.

RESULTS

"Good practices" (gleaned from the literature) were adapted for the institution's needs and tested, including (1) written and explicit goals or objectives for each stage of training; (2) substitution of a criterion-referenced (Dreyfus model) scoring rubric for a norm-referenced, peer-benchmarked global evaluation; (3) use of formative rather than summative feedback; (4) incorporation of deliberate practice (Ericsson model); and (5) portfolio-based documentation of sentinel event markers and remediation.

CONCLUSION

An implementation matrix for teaching and assessing surgical competence might be useful for local compliance with the ACGME mandate.

Advantage of three dimensional animated teaching over traditional surgical videos for teaching ophthalmic surgery: a randomised study

BACKGROUND/AIM

Owing to the complex topographical aspects of ophthalmic surgery, teaching with conventional surgical videos has led to a poor understanding among medical students. A novel multimedia three dimensional (3D) computer animated program, called "Ophthalmic Operation Vienna" has been developed, where surgical videos are accompanied by 3D animated sequences of all surgical steps for five operations. The aim of the study was to assess the effect of 3D animations on the understanding of cataract and glaucoma surgery among medical students.

METHOD

Set in the Medical University of Vienna, Department of Ophthalmology, 172 students were randomised into two groups: a 3D group (n=90), that saw the 3D animations and video sequences, and a control group (n=82), that saw only the surgical videos. The narrated text was identical for both groups. After the presentation, students were questioned and tested using multiple choice questions.

RESULTS

Students in the 3D group found the interactive multimedia teaching methods to be a valuable supplement to the conventional surgical videos. The 3D group outperformed the control group not only in topographical understanding by 16% (p<0.0001), but also in theoretical understanding by 7% (p<0.003). Women in the 3D group gained most by 19% over the control group (p<0.0001).

CONCLUSIONS

The use of 3D animations lead to a better understanding of difficult surgical topics among medical students, especially for female users. Gender related benefits of using multimedia should be further explored.

Objective Assessment of Skills in Intraocular Surgery (OASIS)

OBJECTIVE

To establish an objective ophthalmic surgical evaluation protocol to assess residents' surgical competency and improve residents' surgical outcomes.

PARTICIPANTS

Eight experts in resident education from comprehensive ophthalmology, cornea, glaucoma, and retina services; 2 chief residents (postgraduate year 5 [PGY5]); and resident representatives from PGYs 2, 3, and 4 participated in the development of an objective assessment tool of skills in resident cataract surgery.

METHODS

Analysis of all resident cataract surgeries performed at our service from July 2001 to July 2003 led to the development of a 1-page objective evaluation form to assess residents' skills in cataract surgery. A panel of surgeons at the Massachusetts Eye and Ear Infirmary reviewed the database and the evaluation form and provided constructive feedback.

RESULTS

Development of a unique database of all resident cataract cases and constructive feedback by experts in resident teaching assisted in creating a 1-page evaluation form entitled Objective Assessment of Skills in Intraocular Surgery (OASIS).

CONCLUSIONS

OASIS has face and content validity and can be used to assess, objectively, surgical events and surgical skill. We believe the OASIS evaluation form and database will be a valuable tool for assessing ophthalmology residents' surgical skills at other residency programs as well.