Skills assessment after a grape-based microsurgical course for ophthalmology residents: randomised controlled trial

AIMS

To introduce and assess a course using grapes as training models for ophthalmology residents to acquire basic microsurgical skills.

METHODS

Ophthalmology residents who were novices at microsurgery were included. Participants were randomised into a 1:1 ratio to a 4-hour training programme based on fruit models (group A) or virtual reality (VR) modulator and silicone suture pads (group B), respectively. Before and after training, questionnaires were designed to measure their self-confidence with ophthalmic operations and with their coming role as surgical assistants. After training, each participant provided their interest in further studying microsurgery and was assessed for their general competence of ophthalmic microsurgery on porcine eyes.

RESULTS

Eighty-three participants were included, with 42 ones in group A and 41 ones in group B. After training, participants in group A performed better in the uniformities of the suture span (p<0.05), suture thickness (p<0.05) and tissue protection (p<0.05) during the corneal suturing assessment. The overall scores of corneal suturing and circular capsulorhexis in the porcine eye in group A were comparable to those in group B (p=0.26 and 0.87, respectively). Group A showed a more positive attitude to withstand the training for more than 4 hours (p<0.001), as well as a higher willingness to receive more times of the training in the future (p<0.001).

CONCLUSIONS

Training models based on grapes are equal to VR simulators and silicon suture pads to provide solid training tasks for ophthalmology residents to master basic microsurgical skills, and might have advantages in lower economic cost, and easy availability.

TRIAL REGISTRATION NUMBER

ChiCTR2000040439.

Epidemiology and Management of Oculoplastic Disorders at a Tertiary Hospital: A 4-Year Review

PURPOSE

To describe the epidemiology and management of oculoplastic disorders at a tertiary hospital in Nigeria.

METHODS

This was a retrospective review of patients with oculoplastic disorders at the Department of Ophthalmology, Obafemi Awolowo University Teaching Hospitals Complex, IleIfe, Nigeria from January 2013 to December 2016. The general ophthalmology service records were reviewed to identify patients with oculoplastic disorders. Data retrieved from patient records included date of initial visit, age at presentation, gender, oculoplastic diagnosis and aetiology, modality of treatment given, and indications for patient referrals.

RESULTS

There were 563 (7.4%) patients with oculoplastic disorders, out of 7,575 ophthalmology department patients. They had 573 oculoplastic disorders in all. There were 281 (49.9%) males and 282 (50.1%) females. The median age at presentation was 28 years (range, 1 day to 100 years). Eyelid laceration (n=68; 11.9%) and chalazion (n=63; 11%) were the commonest disorders. Trauma (n=125; 21.8%) was the commonest aetiology, followed by inflammatory (n=121; 21.1%) and infective (n=108; 18.8%) causes. There were 162 (28.3%) surgical interventions; eyelid repair (n=67; 41.4%) was the commonest, followed by evisceration (n=25; 15.4%), and excisional biopsy (n=25; 15.4%). No patient had ptosis or lacrimal surgery. Orbital disorders (n=21; 42.9%) were the commonest indication for a referral elsewhere.

CONCLUSION

Eyelid laceration was the commonest oculoplastic disorder, trauma was the commonest aetiology, and eyelid repair was the commonest oculoplastic surgery done. Further training in oculoplastics with emphasis on ptosis, lacrimal and orbital surgery, as well as the provision of equipment needed for optimal oculoplastic service delivery are recommended.

Remote Surgeon Virtual Presence: A Novel Telementoring Method for Live Surgical Training

PURPOSE

We describe the first known use of telementoring in corneal surgery and technology combining a 3-dimensional microscope system, 5G live streaming technology, group chat software, and a virtual reality headset for intercontinental surgical supervision.

METHODS

Three surgeons in Toronto were proctored by a surgeon in Israel in the implantation of a novel keratoprosthesis device (CorNeat KPro; Ra'anana, Israel) into cadaver eyes. In Toronto, the NGENUITY platform (Alcon) transmitted high-definition, 3-dimensional images to the proctor in Israel who viewed the live video through a GOOVIS Virtual Reality headset with subsecond latency. This was made possible by the LiveU technology (Hackensack, NJ), which is a portable device to increase the bandwidth of transmission. The primary outcome was the successful completion of CorNeat KPro implantation. After each procedure, all surgeons completed a Likert scale questionnaire that assessed opinions on telementoring.

RESULTS

All participants implanted the CorNeat KPro device. There was significant satisfaction reported. A total cumulative score from the questionnaire was 149 of 150 from the operating surgeons, with a score of 135 of 150 by the proctor. All felt that there was excellent AV quality with no lag time and recommended the technology.

CONCLUSIONS

Telementoring is a promising tool that can traverse large distances for ophthalmic education.

Artificial intelligence and ophthalmic surgery

PURPOSE OF REVIEW

Artificial intelligence and deep learning have become important tools in extracting data from ophthalmic surgery to evaluate, teach, and aid the surgeon in all phases of surgical management. The purpose of this review is to highlight the ever-increasing intersection of computer vision, machine learning, and ophthalmic microsurgery.

RECENT FINDINGS

Deep learning algorithms are being applied to help evaluate and teach surgical trainees. Artificial intelligence tools are improving real-time surgical instrument tracking, phase segmentation, as well as enhancing the safety of robotic-assisted vitreoretinal surgery.

SUMMARY

Similar to strides appreciated in ophthalmic medical disease, artificial intelligence will continue to become an important part of surgical management of ocular conditions. Machine learning applications will help push the boundaries of what surgeons can accomplish to improve patient outcomes.

Microscope-integrated Intraoperative Optical Coherence Tomography for Anterior Segment Surgical Maneuvers

Purpose

To evaluate the potential value of microscope-integrated optical coherence tomography (MI-OCT) in anterior segment surgical maneuvers.

Methods

Twenty-four ophthalmology residents, who were randomly and evenly divided into two groups, performed four anterior segment surgical maneuvers (corneal tunnel, scleral tunnel, simple corneal suture, and corneal laceration repair) on porcine eyes with (group B) or without (group A) real-time MI-OCT feedback. All residents performed the maneuvers again without MI-OCT.

Results

Compared with group A, group B (with MI-OCT) showed better accuracy in the length/depth of the corneal tunnel and the length of the scleral tunnel. However, both groups showed similar performances in the depth of both the simple corneal suture and the corneal laceration suture. When both groups performed the maneuvers again without MI-OCT, group B still showed better results than group A for the length of both the corneal and scleral tunnels.

Conclusions

Primary results suggest that real-time MI-OCT images are valuable for some anterior segment surgical maneuvers and could be helpful in surgical training.

Translational Relevance

MI-OCT systems can be valuable in improving accuracy and decision making during anterior segment surgery and will be useful in surgical training.

Validation of a novel strabismus surgery 3D-printed silicone eye model for simulation training

PURPOSE

To demonstrate the validity of a new 3D-printed silicone model for practicing strabismus surgery, compared with the rabbit head, in terms of simulator fidelity.

METHODS

In this multicenter study, a validated questionnaire was developed to assess fidelity of the model and rabbit head. Participants were asked to rate overall globe, conjunctiva, muscle, and scleral fidelity using a 5-point scale. The survey instrument was disseminated at three strabismus instruction courses: at two meetings, participants practiced on the model and rabbit head prior to completing the questionnaire; at the third, instructors demonstrated advanced surgical skills using only the model and then completed the questionnaire. Repeated measures analysis of variance compared ratings. Pearson's or Spearman's correlation evaluated correlation between years of experience to participants' responses. Qualitative data were coded into themes.

RESULTS

A total of 47 participants completed the questionnaire. The model rated 18% higher than rabbit head for anatomical accuracy (mean difference, 0.667; P = 0.001) and 25% higher for position of eyes within the head (mean difference, 0.867; P = 0.006). More experienced participants were more likely to strongly agree that the silicone conjunctiva effectively mimics real conjunctiva (ρ = 0.337; P = 0.036) and that scleral tissue effectively mimics real sclera (ρ = 0.298, P = 0.042). Qualitative data supported the model.

CONCLUSIONS

This study demonstrated the validity of the surgical model in terms of fidelity compared to the rabbit head.

Ophthalmology residency training in India: Comparing feedback about how the training equips ophthalmologists to combat retinal diseases. READS report #6

Purpose

To document whether the residency training in management of retinal diseases has improved in 2000s to meet the increasing demand of retina care in India.

Methods

A survey, using a prevalidated questionnaire, was conducted by Academic and Research Committee (ARC) of the All India Ophthalmological Society (AIOS) in 2014-2016 among ophthalmologists to document teaching of retina-related clinical and surgical skills in the postgraduate residency program.

Results

The 144-item questionnaire was mailed to 4512 practicing ophthalmologists with residency training in two different periods, between 1967 and 2000 (group 1; 20th-century trained) and between 2003 and 2012 (group 2; 21st-century trained). Response was received from 320 (19.1%) of group 1 ophthalmologists and 531 (18.7%) of group 2 ophthalmologists. The average age was 49.2 ± 8.7 and 32.6 ± 4 years, respectively. Group 2 residents had received superior training in indirect ophthalmoscopy, slit lamp biomicroscopy using + 78 and + 90D lens, optical coherence tomography, fundus photography, and fluorescein angiography (all P < 0.001), but there was large variation between the training institutions. The residents were not taught vitreous and retinal detachment surgeries in either period of training.

Conclusion

Teaching of retina-related clinical skills have improved in Indian residency program, but there are variations across programs. This information might help redesign the ophthalmology residency programs to meet the demands of comprehensive eye care and universal health coverage of increasing retinal diseases in India.

How to Add Metacognition to Your Continuing Professional Development: Scoping Review and Recommendations

Participation in continuing professional development (CPD) is part of lifelong learning required by ophthalmologists. Metacognition is a new area of educational research. It is important because metacognitive skills are essential in medical education and likely to improve effectiveness of CPD activities. We systematically searched PubMed using the terms "metacognition" and "CPD" or "continuing medical education (CME)" and found only 5 articles. These articles were supplemented by a broadbased review of published literature including educational psychology, across the continuum of medical education. We summarize the techniques that may improve metacognition in CPD: awareness of and instruction in metacognition, awareness and mitigation of cognitive errors, appropriate needs analysis, and choosing appropriate activities. Metacognition and learning of new surgical techniques, the role of portfolios, and the role of the educator are described. The evidence is weak however, and it is usually extrapolated to CPD activities from other fields. Ophthalmologists may be able to improve their metacognitive skills in the CPD context, but the evidence supporting this is of low quality.

Residency Evaluation and Adherence Design Study III: Ophthalmology residency training in India: Then and now-Improving with time?

Purpose

To gauge the differences in ophthalmology residency training, academic, clinical and surgical, in the last three decades of the 20th century and the first decade of the 21st century.

Methods

A survey was conducted by the Academic and Research Committee of the All India Ophthalmological Society, in 2014-2016, using a prevalidated questionnaire, which was circulated to ophthalmologists to gauge the practicality of the teaching protocols of clinical and surgical skills during postgraduate residency program.

Results

Of the 1005 respondents, 320 ophthalmologists who completed residency between 1967 and 2002 (20th century trained) and 531 who completed a residency in 2003-2012 (21st century trained) fulfilled the inclusion criteria. The average age was 49.2 years (standard deviation [SD] 4) and 32.6 years (SD 4), respectively. Twenty-first century trained ophthalmologists rated their training significantly better than the 20th century trained ophthalmologists for slit lamp examination (P = 0.001), indirect ophthalmoscopy, gonioscopy, automated perimetry, optical coherence tomography, and fundus photography (all having P < 0.001), while the 20th century trained rated their teaching of refraction, synoptophore, diplopia charting better (all P < 0.001). The range of grading was 0-10 in all categories. The median number of surgeries performed independently by 20th century and 21st century trained (during their training period) were: intracapsular cataract extraction (ICCE) 10, 0; extracapsular cataract extraction (ECCE) 43, 18; small incision cataract surgery (SICS) 5, 55; phacoemulsification (Phaco) 0, 1; pterygium excision 20, 15; dacryocystectomy 11, 4; dacryocystorhinostomy 11, 2; chalazion 35, 30; trabeculectomies 5, 0; strabismus correction 0, 0; vitrectomy 0, 0; keratoplasty 0, 0; eyelid surgery 6, 2; and ocular emergencies 18, 20.

Conclusion

Teaching of many clinical skills had improved over decades. Cataract surgery training has shifted from ICCE and ECCE to SICS and Phaco, but other surgeries were still taught sparingly. There was an enormous variation across the country in residency training which needs immediate attention.

Early Performance on an Eye Surgery Simulator Predicts Subsequent Resident Surgical Performance

OBJECTIVE

To examine early performance on an eye surgery simulator and its relationship to subsequent live surgical performance in a single large residency program.

DESIGN

Retrospective study.

SETTING

Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology.

METHODS

In a retrospective study, we compared performance of 30 first-year ophthalmology residents on an eye surgery simulator to their surgical skills as third-year residents. Variables collected from the eye surgery simulator included scores on the following modules of the simulator (Eyesi, VRmagic, Mannheim, Germany): antitremor training level 1, bimanual training level 1, capsulorhexis level 1 (configured), forceps training level 1, and navigation training level 1. Subsequent surgical performance was assessed using the total number of phacoemulsification cataract surgery cases for each resident, as well as the number performed as surgeon during residency and scores on global rating assessment of skills in intraocular surgery (GRASIS) scales during the third year of residency. Spearman correlation coefficients were calculated between each of the simulator performance and subsequent surgical performance variables. We also compared variables in a small group of residents who needed extra help in learning cataract surgery to the other residents in the study.

MAIN OUTCOME MEASURES

Relationships between Eyesi scores early in residency and surgical performance measures in the final year of residency.

RESULTS

A total of 30 residents had Eyesi data from their first year of residency and had already graduated so that all subsequent surgical performance data were available. There was a significant correlation between capsulorhexis task score on the simulator and total surgeries (r = 0.745, p = 0.008). There was a significant correlation between antitremor training level 1 (r = 0.554, p = 0.040), and forceps training level 1 (r = 0.622, p = 0.023) with primary surgery numbers. There was a significant correlation between forceps training level 1 (r = 0.811, p = 0.002), and navigation training level 1 (r = 0.692, p = 0.013) with total GRASIS score. There was a significant inverse correlation between total GRASIS score and residents in need of extra help (r = -0.358, p = 0.003).

CONCLUSION

Module scores on an eye surgery simulator early in residency may predict a resident׳s future performance in the operating room. These scores may allow early identification of residents in need of supplemental training in cataract surgery.

Changes in UK ophthalmology surgical training: analysis of cumulative surgical experience 2009-2015

OBJECTIVE

To investigate changes in the patterns of cumulative surgical experience for ophthalmologists in the UK following the introduction of a new national training scheme.

DESIGN

Retrospective review of all surgical training records submitted to the UK Royal College of Ophthalmologists by trainees for the award of Certificate of Completion of Training (CCT) for the period 2009-2015.

SETTING

Secondary level care, UK.

PARTICIPANTS

539 trainees achieving CCT over the 7-year study period.

INTERVENTIONS

Higher specialist training or ophthalmology specialist training.

OUTCOME MEASURES

Number of CCT awards by years and procedures performed for cataract surgery, strabismus, corneal grafts, vitreoretinal (VR) procedures, oculoplastics and glaucoma.

RESULTS

Cataract surgical experience showed little change with median number performed/performed supervised (P/PS) 592, IQR: 472-738; mean: 631. Similarly, the median number of strabismus (P/PS 34), corneal grafts (assisted, 9) and VR procedures (assisted, 34) appeared constant. There was a trend towards increasing surgical numbers for oculoplastics (median 116) and glaucoma (57). Overall case numbers for ophthalmic specialist training (OST) trainees (7-year training programme) were higher than higher surgical training (HST) trainees (4.5-year programme) with the exception of squint (P/PS), corneal grafts (P/PS) and VR cases (P/PS).

CONCLUSIONS

Overall case numbers reported at time of CCT application appear stable or with a marginal trend towards increasing case numbers. HST (4.5-year programme) case numbers do not include those performed before entry to HST, and although case numbers tended to be higher for OST trainees (7-year programme) compared with HST trainees, they were not proportionately so.

Improving Resident Performance in Oculoplastic Surgery: A New Curriculum Using Surgical Wet Laboratory Videos

OBJECTIVE

To develop a new oculoplastic curriculum that incorporates learning theory of skill acquisition. To develop and evaluate the effectiveness of instructional videos for an oculoplastic surgical wet laboratory.

DESIGN

Proof of concept, randomized controlled trial.

SETTING

New York Eye and Ear Infirmary of Mount Sinai-tertiary care academic institution.

PARTICIPANTS AND METHODS

In total, 16 ophthalmology residents were randomly assigned to 1 of 2 groups and given either video and text or text instructions alone for the following 2 procedures: blepharoplasty and eyelid laceration repair. Operating time and esthetic result were measured, and the groups were statistically compared. A brief survey was administered.

RESULTS

We developed a new 6 component oculoplastics curriculum that incorporates concepts of the Fitts and Posner skill acquisition model and mental imagery. In the wet laboratory pilot study, the group that watched the video of the laceration repair showed better esthetic grades than the group that received text alone (p = 0.038). This difference was not found for the blepharoplasty (p = 0.492). There was no difference between groups in operating time for the laceration repair (p = 0.722), but the group that watched the blepharoplasty video required more time to complete the task than those that reviewed text only (p = 0.023). In total, 100% of residents reported the videos augmented their learning.

CONCLUSIONS

Methods to optimize surgical education are important given limited operating room time in oculoplastics, a subspecialty in which the number of surgeries performed during residency is relatively low. We developed a curriculum based on learning theory and sought to formally test one important aspect, surgical video for wet laboratories. Our pilot study, despite its limitations, showed that wet laboratory surgical videos can be effective tools in improving motor skill acquisition for oculoplastic surgery.

Animal Model for Retinopathy of Prematurity Laser Surgery Training

Peripheral retinal laser ablation for high-risk retinopathy of prematurity (ROP) improves visual outcomes. Some pediatric ophthalmology fellows receive little exposure to this procedure. The authors identified and evaluated an animal teaching model that simulates peripheral retinal laser ablation in human infants with ROP. [J Pediatr Ophthalmol Strabismus. 2017;54:e47-e49.].

[Simulation training in ophthalmology]

BACKGROUND

Simulation in medicine is an indispensable tool to improve doctors' responses to different situations, enhancing their performance. However, simulation in ophthalmology is a very recent trend, mainly because of the high complexity of developing newer teaching tools, with the need for highly realistic models, mostly in surgical ophthalmic simulation.

DISCUSSION

The whole development of simulation in ophthalmology, from the very first attempts that used basic models, to the newer virtual reality models, allows for a comprehensive, faster, and more efficient development of skills necessary in basic and advance procedures in ophthalmology, creating a better learning environment, improving costs, and developing a very promising panorama, in which simulation can be incorporated in teaching programs all around the globe.

CONCLUSIONS

Simulation in ophthalmology allows for better results in the formation of ophthalmologists, and it is becoming a new tool to achieve better results in medical and surgical procedures, thus improving outcomes and quality of care.

A Self-Directed Preclinical Course in Ophthalmic Surgery

OBJECTIVE

Medical students receive limited exposure to ophthalmology and ophthalmic surgery in the preclinical curriculum. To address this gap, the authors designed a self-directed preclinical elective course in ophthalmic surgery offered in the 2013-2014 academic year to all first- and second-year students at the study institution.

DESIGN

Prospective cohort study with anonymous Likert-style questionnaires and qualitative responses.

SETTING

Warren Alpert Medical School of Brown University, Providence, RI.

PARTICIPANTS

All current first- and second-year medical students at the Warren Alpert Medical School of Brown University enrolled in the preclinical elective in 2013-2014 were eligible to participate in the study.

METHODS

The course had 3 components: (1) 4 web-based didactic modules on common ophthalmic conditions with slide sets, surgical procedure videos and animations, and mandatory premodule and postmodule quizzes to assess for competency; (2) a 3-hour interactive virtual surgery simulation session on cataract surgery-related tasks; (3) a total of 2 shadowing experiences in the clinic and in the operating room. Each student completed an anonymous precourse and postcourse Likert-style questionnaire that assessed exposure to ophthalmology, favored components of the course, and interest in ophthalmology as a career.

RESULTS

Of the 22 students who signed up, 18 (81.8%) completed the course. Most students (76.5%; 14/18) felt there was inadequate exposure to ophthalmology in the medical curriculum. Students scored a mean of 44.0% on premodule assessments and 97.0% on postmodule assessments. All students completed the postcourse questionnaire: they all recommended the course to other medical students and increased their understanding of ophthalmology as a career. The most popular components of the course were the practical aspects of the elective (44.4%; 8/18) and virtual surgery simulation (44.4%; 8/18).

CONCLUSIONS

This course increased preclinical medical students' knowledge of ophthalmic surgery and suggests that flexible preclinical electives can help medical students explore clinical interests and career choices earlier in their medical education.

Validity of ophthalmology surgical competency assessment rubric for strabismus surgery in resident training

The Accreditation Council for Graduate Medical Education (ACGME) requires US residency programs to assess ophthalmology residents for competency in 6 core areas. Ophthalmic surgical skills are currently part of the ACGME "Patient Care" competency, although some have advocated for a seventh competency, "Surgical Skills." The Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery in Resident Training (

OSCAR

Strabismus) tool was designed to aid in the assessment of surgical skills using procedure specific behavioral anchors. The present study evaluated inter-rater agreement of the

OSCAR

Strabismus tool in the assessment of resident performance.

OSCAR

Strabismus evaluations of resident surgical strabismus cases were performed by a multinational group of faculty strabismus surgeons. Cronbach α statistical analysis of the completed evaluations revealed high inter-rater agreement, indicating the

OSCAR

Strabismus is a reliable tool to facilitate assessment of resident strabismus surgical skills.

Benchmarking the Wilmer general eye services clinics: baseline metrics for surgical and outpatient clinic volume in an educational environment

BACKGROUND

The Wilmer General Eye Services (GES) at the Johns Hopkins Hospital is the clinic where residents provide supervised comprehensive medical and surgical care to ophthalmology patients. The clinic schedule and supervision structure allows for a progressive increase in trainee responsibility, with graduated autonomy and longitudinal continuity of care over the three years of ophthalmology residency training. This study sought to determine the number of cases the GES contributes to the resident surgical experiences. In addition, it was intended to create benchmarks for patient volumes, cataract surgery yield and room utilization as part of an educational initiative to introduce residents to metrics important for practice management.

METHODS

The electronic surgical posting system database was explored to determine the numbers of cases scheduled for patients seen by residents in the GES. In addition, aggregated residents' self-reported Accreditation Council for Graduate Medical Education (ACGME) surgical logs were collected for comparison. Finally transactional databases were queried to determine clinic volumes of new and established patients. The proportion of resident surgeries (1(st) surgeon and assistant) provided by GES patients, cataract surgery yield and new patient rates were calculated. Data was collected from July 1(st), 2014 until March 31(st), 2015 for all 16 residents (6 third year, 5 second year and 5 first year).

RESULTS

The percentage of cataract, oculoplastics, cornea and glaucoma surgeries in which a resident was 1(st) surgeon and the patient came from the GES was 91.3, 76.1, 65.6, and 93.9 respectively. The new patient rate was 28.1% and room utilization was 50.4%. Cataract surgery yield was 29.2 DISCUSSION: The GES provides a significant proportion of primary surgeon opportunities for the residents, and in some instances, the majority of cases. Compared to benchmarks available for private practices, the new patient rate is high while the cataract surgery yield is low. The room utilization is lower than the 85% preferred by the hospital system. These are the first benchmarks of this type for an academic resident ophthalmology practice in the United States.

CONCLUSIONS

Our study suggests that resident-hosted clinics can provide the majority of surgical opportunities for ophthalmology trainees, particulary with regard to cataract cases. However, because our study is the first academic resident practice to publish metrics of the type used in private practices, it is impossible to determine where our clinic stands compared to other training programs. Therefore, the authors strongly encourage ophthalmology training programs to explore and publish practice metrics. This will permit the creation of a benchmarking program that could be used to quantify efforts at enhancing ophthalmic resident education.

An Eye Toward Improving: A new training approach in ophthalmic anesthesia provides qualitative and quantitative feedback

In ophthalmic anesthesia administration prior to surgeries for problems such as cataracts or glaucoma, the training of new doctors, as in other surgical specialties, is based on a model in which a student trains on a patient under the expert supervision of an experienced doctor. However, the traditional apprenticeship approach is problematic in eye surgery because ocular structures could potentially be damaged by those administering ophthalmic anesthesia for the first time. Apart from the obvious risk to patients, there is also the inability to quantify the performance of a trainee. One solution to these problems might be found in the development of a manikin-based ophthalmic anesthesia training system that can emulate the human ocular anatomy while providing real-time quantitative and qualitative feedback to the trainee during training.

A Multi-Electrode Electric Field Based Sensing System For Ophthalmic Anesthesia Training

Local anesthesia administration prior to ophthalmic surgery involves inserting a syringe needle into a confined intraorbital space at the proper position, angle and depth. During this procedure ocular structures must remain unhurt and systemic complications must be avoided while achieving quick akinesia and analgesia. Animal cadavers do not emulate human anatomy accurately and human subject based training entails risk to the patient. Therefore, a training system that closely replicates the human ocular and orbital anatomy and provides the trainee with real-time feedback on the safety and effectiveness of the block administered would help reduce risks involved with real life procedures. This paper presents an anatomically accurate, rapid-prototyped manikin based training system for ophthalmic anesthetic blocks. The depth of penetration of the needle, the proximity of the needle to extraocular muscles and the touch of the needle to the muscles or optic nerve is detected by a multi-electrode electric field/capacitive sensing system. The eye structure of the manikin does not have any electrical connections to it, rendering it replaceable, thus, enabling the emulation of anatomical variations due to pathologies of the eye. A virtual instrument measures and computes the position of the needle and displays it to the trainee through an intuitive GUI with a 3D display of the orbital anatomy. The proposed capacitive sensing scheme has been validated by tests performed on a prototype system, thus demonstrating its usefulness for practical training purposes.

Update on simulation-based surgical training and assessment in ophthalmology: a systematic review

TOPIC

This study reviews the evidence behind simulation-based surgical training of ophthalmologists to determine (1) the validity of the reported models and (2) the ability to transfer skills to the operating room.

CLINICAL RELEVANCE

Simulation-based training is established widely within ophthalmology, although it often lacks a scientific basis for implementation.

METHODS

We conducted a systematic review of trials involving simulation-based training or assessment of ophthalmic surgical skills among health professionals. The search included 5 databases (PubMed, EMBASE, PsycINFO, Cochrane Library, and Web of Science) and was completed on March 1, 2014. Overall, the included trials were divided into animal, cadaver, inanimate, and virtual-reality models. Risk of bias was assessed using the Cochrane Collaboration's tool. Validity evidence was evaluated using a modern validity framework (Messick's).

RESULTS

We screened 1368 reports for eligibility and included 118 trials. The most common surgery simulated was cataract surgery. Most validity trials investigated only 1 or 2 of 5 sources of validity (87%). Only 2 trials (48 participants) investigated transfer of skills to the operating room; 4 trials (65 participants) evaluated the effect of simulation-based training on patient-related outcomes. Because of heterogeneity of the studies, it was not possible to conduct a quantitative analysis.

CONCLUSIONS

The methodologic rigor of trials investigating simulation-based surgical training in ophthalmology is inadequate. To ensure effective implementation of training models, evidence-based knowledge of validity and efficacy is needed. We provide a useful tool for implementation and evaluation of research in simulation-based training.

Development of a new valid, reliable, and internationally applicable assessment tool of residents' competence in ophthalmic surgery (an American Ophthalmological Society thesis)

PURPOSE

To test the validity and reliability of a new tool for assessing residents' competence in ophthalmic surgery. Changing paradigms of ophthalmic education in the United States have influenced worldwide ophthalmic education and necessitated new methods of assessing resident competence. Accordingly, a new tool for assessing residents' competence in ophthalmic surgery (phacoemulsification) that could be applicable internationally was developed. We hypothesize that this instrument is valid and reliable.

METHODS

A panel of six international content experts adapted a previously published tool for assessing phacoemulsification. The tool (called the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric, or ICO-OSCAR:phaco) was reviewed by 12 international content experts for their constructive comments, which were incorporated to ensure content validity. Ten expert cataract surgery teachers then graded six recorded phacoemulsification surgeries with the ICO-OSCAR:phaco to investigate inter-rater reliability.

RESULTS

The coefficient alpha statistic (a measure of reliability/internal consistency) for the ICO-OSCAR:phaco as a whole was 0.92, and 17 of its 20 dimensions had alpha coefficients greater than 0.70.

CONCLUSIONS

The ICO-OSCAR:phaco is a valid and reliable assessment tool that could be applied internationally to satisfy the global need of new instruments to comply with emerging trends in ophthalmic education. A toolbox of similar surgical competency assessment tools is being developed.

Sharing vision-saving skills, while establishing lifelong friendships--in celebration of the 30th anniversary of the ORBIS flying eye hospital's first trip to Guangzhou, China

Thirty years ago, the ORBIS Flying Eye Hospital (ORBIS FEH) first landed in Guangzhou on September 21st 1982, remaining in the city for 18 days. Not only was this the ORBIS FEH's first trip to China to provide training in sight-restoring techniques, but the visit also turned a whole new chapter in the history of friendship between the Chinese and American ophthalmic communities. In the ensuing 30 years, the ORBIS FEH has visited China 22 times, landing in 25 different locations. The first DC-8 aircraft, retired formally in 1994, was subsequently presented by ORBIS to China as a token of the friendship between the Chinese and American people. This plane with its praiseworthy history is currently on display at the Chinese Aviation Museum in Beijing. The ORBIS FEH, originally dedicated by the highly respected American ophthalmologist David Paton, has as its defining goal the teaching and spreading of advanced ophthalmic surgical technology throughout the world, particularly in those areas where resources are scarce. Training of local ophthalmic staff as well as treating patients is its priorities, and thus it has received a warm welcome wherever it goes. The ORBIS FEH generates a ripple effect which has led to further improvements in eye care ever.

Sheep practice eye for ophthalmic surgery training in skills laboratory

Pig eyes are not available for surgical practice in the Middle East and Central Asia. We reviewed the literature to select an alternative animal practice eye based on biometry, availability, expense, and the ethical issue of animal sacrifice. Twenty enucleated sheep eyes were studied with an ultrasonography immersion technique, and a variety of techniques for globe harvesting were tested and compared. The sheep eye was judged to be the best practical choice for ophthalmic surgery practice and the "bone shattering" exenteration maneuver, the most efficient harvesting method. Several anterior segment procedures were performed in the sheep eyes. Introduction of this sheep model would be instrumental in the development of ophthalmology skills laboratories and surgical training in Middle Eastern and Central Asian regions.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Teaching and assessing competency in retinal lasers in ophthalmology residency

BACKGROUND AND OBJECTIVE

The Accreditation Council for Graduate Medical Education has mandated that residency programs teach and assess six specific competencies (ie, medical knowledge, patient care, communication and interpersonal skills, professionalism, practice-based learning, and systems-based learning). To the authors' knowledge, there is no standardized and widely used curriculum for teaching and assessing resident competencies in retinal lasers.

METHODS

The pertinent literature on resident education in retinal lasers is reviewed and specific "good practices" for teaching and assessing laser competency are presented.

RESULTS

Development and deployment of educational tools that teach and assess laser competency simultaneously; are reliable, reproducible, and valid; have low faculty time burden; and are affordable, generalizable, and fair are recommended.

CONCLUSION

Retinal laser competency can be taught and assessed in ophthalmology residency training programs. Future research will be needed to provide evidence that these teaching and assessment tools produce improved educational and patient outcomes and provide verifiable, reliable, and valid evidence of resident competence in retinal lasers.

Outcomes of autoconjunctival grafting for primary pterygia when performed by consultant compared with trainee ophthalmologists

PURPOSE

To define rates of recurrence and surgical complications of primary pterygia excision with autoconjunctival grafting when the surgery is performed by consultant ophthalmologists compared with trainee ophthalmologists.

METHODS

A total of 174 patients with primary pterygia treated by excision and autoconjunctival grafting were included for analysis. Patients were divided into two groups according to whether their surgery was performed by a consultant ophthalmologist (group A) or a trainee ophthalmologist (group B). Data were collected with respect to demographics, surgical complications and recurrence. Recurrence rates were analysed utilizing Fisher's exact test. Additionally, Kaplan-Meier survival curves for interval censored data were constructed. Surgical complications were analysed utilizing Fisher's exact test.

RESULTS

The recurrence rate in group A was 6.8% and in group B was 19.4%. This difference was statistically significant (P = 0.05). The rate of surgical complication occurring in group A was 6.6% and in group B was 23.3% and this was also statistically significant (P = 0.005). No relationship was found between either patient age or the size of pterygium and recurrence or complications in either group A or group B.

CONCLUSION

Autoconjunctival grafting is regarded as the gold standard for preventing pterygium recurrence following excision. This study suggests that the experience of the surgeon can influence success rates and complications. There is a significant learning curve indicating the need to supervise trainee surgeons.

Development and Face and Content Validity of an Eye Surgical Skills Assessment Test for Ophthalmology Residents

PURPOSE

The Accreditation Council for Graduate Medical Education has called for the development of new tools for teaching and assessment in core residency competencies. Aims of this study were to respond to this mandate by developing an objective method of evaluating the surgical skills of ophthalmology residents in a microsurgery laboratory environment that could become a part of the ophthalmic surgical curriculum and competency determination, and to evaluate the face and content validity of this assessment by surveying experts in the field.

DESIGN

Survey.

PARTICIPANTS

Twenty-two content experts (residency program directors and faculty members involved with resident surgical training).

METHODS

We have developed a 3-station (skin suturing, muscle recession, phacoemulsification/wound construction and suturing technique) wet laboratory surgical skills obstacle course for ophthalmology residents. Each station includes instructions to the resident for completing the task as well as assessment forms, a station-specific checklist, and a global rating scale of performance, for expert surgeons to complete while reviewing the resident's videotaped performance. To establish face and content validity, content experts were sent a detailed explanation of the assessment along with a survey to facilitate constructive feedback.

MAIN OUTCOME MEASURES

Survey responses.

RESULTS

Experts felt that the Eye Surgical Skills Assessment Test (ESSAT) is a useful and representative tool for assessing surgical skills of residents. Suggestions were incorporated, thus establishing the face and content validity.

CONCLUSIONS

The ESSAT has face and content validity. This tool will be useful for assessing residents' surgical skills in a laboratory environment and the impact of various teaching methods on performance. Further studies to establish the interrater reliability and construct validity of the ESSAT are underway.

Ophthalmology resident surgical competency: a national survey

PURPOSE

To describe the prevalence, management, and career outcomes of ophthalmology residents who struggle with surgical competency and to explore related educational issues.

DESIGN

Fourteen-question written survey.

PARTICIPANTS

Fifty-eight program directors at Accreditation Council on Graduate Medical Education-accredited, United States ophthalmology residency programs, representing a total of 2179 resident graduates, between 1991 and 2000.

METHODS

Study participants completed a mailed, anonymous survey whose format combined multiple choice and free comment questions.

MAIN OUTCOME MEASURES

Number of surgically challenged residents, types of problems identified, types of remediation, final departmental decision at the end of residency, known career outcomes, and residency program use of microsurgical skills laboratories and applicant screening tests.

RESULTS

One hundred ninety-nine residents (9% overall; 10% mean per program) were labeled as having trouble mastering surgical skills. All of the programs except 2 had encountered such residents. The most frequently cited problems were poor hand-eye coordination (24%) and poor intraoperative judgment (22%). Most programs were supportive and used educational rather than punitive measures, the most common being extra practice-laboratory time (32%), scheduling cases with the best teaching surgeon (23%), and counseling (21%). Nearly one third (31%) of residents were believed to have overcome their difficulties before graduation. Other residents were encouraged to pursue medical ophthalmology (22%) or to obtain further surgical training through a fellowship (21%) or a supervised practice setting (12%); these residents were granted a departmental statement of satisfactory completion of residency for Board eligibility. Twelve percent were asked to leave residency. Of reported career outcomes, 92% of residents were practicing ophthalmology, 65% as surgical and 27% as medical ophthalmologists. Ninety-eight percent of residency programs had microsurgical practice facilities, 64% had a formal teaching course, and 36% had mandatory practice time. Most programs (76%) did not perform applicant vision or dexterity screening tests; questions existed about the legality and validity of such tests.

CONCLUSIONS

The issue of ophthalmology residents who struggle to develop surgical competency appears common. Although many problems appear to be remediable with time, practice, and dedicated, patient teachers, more specific guidelines for a statement of surgical competency are likely necessary to standardize the Board certification process.

Virtual Reality in Ophthalmology Training

Current training models are limited by an unstructured curriculum, financial costs, human costs, and time constraints. With the newly mandated resident surgical competency, training programs are struggling to find viable methods of assessing and documenting the surgical skills of trainees. Virtual-reality technologies have been used for decades in flight simulation to train and assess competency, and there has been a recent push in surgical specialties to incorporate virtual-reality simulation into residency programs. These efforts have culminated in an FDA-approved carotid stenting simulator. What role virtual reality will play in the evolution of ophthalmology surgical curriculum is uncertain. The current apprentice system has served the art of surgery for over 100 years, and we foresee virtual reality working synergistically with our current curriculum modalities to streamline and enhance the resident's learning experience.

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.

Simple effective surgery for involutional entropion suitable for the general ophthalmologist

OBJECTIVE

To compare the long-term success, recurrence, and complication rate of involutional entropion surgery using the lateral tarsal strip and everting sutures when performed by surgeons in training (resident or fellow) and specialist oculoplastic surgeons (attending supervising physician).

DESIGN

Prospective, interventional, comparative, clinical case series.

PARTICIPANTS

Adult patients with involutional entropion.

METHODS

Lateral tarsal strip and everting sutures (LTS+ES) by residents, fellows, or attending supervising physician. A minimum of 12 months of postoperative follow-up was required.

MAIN OUTCOME MEASURES

Patients' symptoms and clinical examination to confirm a normal eyelid position (no entropion or secondary ectropion) at rest and with forced orbicularis contraction with the topical amethocaine (tetracaine) test. This test is described.

RESULTS

Fifty-five consecutive patients, aged 57 to 91 years (mean, 77 years) underwent LTS+ES surgery on 62 eyelids. Surgery was performed by a consultant ophthalmic oculoplastic surgeon (attending supervising physician) in 8 eyelids and by 20 different trainees, residents, and fellows in 54 eyelids. Six patients died (11%) within 6 months of surgery and 2 patients (3.5%) were lost to follow-up, resulting in 47 evaluable patients (54 eyelids). The follow-up period was 12 to 34 months (mean, 18 months). Fifty-three of 54 eyelids (98%) had a successful outcome with no recurrence. The surgery was effective when performed by different grades of surgeon (P>0.4).

CONCLUSIONS

The LTS+ES is a simple operation for the correction of involutional entropion that can be performed effectively by both residents and fellows.

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.