Ophthalmology resident surgical competency: a national survey

DMEK surgical training: An instructional guide on various wet-lab methods

Descemet membrane endothelial keratoplasty (DMEK) is a partial-thickness corneal transplantation procedure that involves selective transplantation of the Descemet membrane and endothelium. DMEK offers significant advantages over other keratoplasty techniques, such as faster visual rehabilitation, better final visual acuity due to minimal optical interface effects, lower risk of allograft rejection, and less long-term dependence on topical steroids. Despite all its advantages, DMEK has been found to be more challenging than other corneal transplantation techniques, and its steep learning curve appears to be an obstacle to its widespread use and adoption by corneal surgeons worldwide. DMEK surgical training laboratories (wet labs) provide a window of opportunity for surgeons to learn, prepare, manipulate, and deliver these grafts in a risk-free environment. Wet labs are a significant learning tool, especially for those institutions that have limited tissue availability in their local centers. We provide a step-by-step guide for preparing DMEK grafts using different techniques on human and nonhuman models with instructional videos. This article should eventually help the trainees and the educators understand the requirements for performing DMEK and conducting a DMEK wet lab and develop their skills and interests from a wide variety of available techniques.

Educational Concerns About the Safety of Cataract Surgery During Residency: The E3CAPS Pedagogic Study

INTRODUCTION

Cataract surgery is the most common surgical procedure performed in France. While the incidence of intraoperative complications affecting visual prognosis is extremely low, given the large number of patients operated on, the absolute number of patients affected by complications is quite high. Complication rates are significantly higher when ophthalmology residents (ORs) perform the surgery. Although lack of experience remains the main risk factor, sleep deprivation may adversely affect ORs' successful surgery rate. The value of the EyeSi® surgical simulator in initial training has been demonstrated to increase cataract surgery safety through the transfer of surgical skills from the simulator to the operating room. However, there is no consensus regarding how much training is needed before the first-time ORs are allowed to operate. There is also no scientific evidence that sleep deprivation is associated with a decrease in surgical performance. Establishing a validated protocol for cataract surgery training using the EyeSi surgical simulator (referred to further as the EyeSi) and identifying risk factors for intraoperative complications related to sleep deprivation will improve cataract surgery safety and lead to the reorganization of our healthcare systems.

METHODS AND PLANNED OUTCOMES

This multi-centre educational cohort study will include two distinct axes which will both aim to reduce the risks of cataract surgery. Enrollment will include 16 first-year ORs for Axis 1 and 25 experienced residents for Axis 2, all from the University Hospitals of Nantes, Tours, Angers and Rennes. Axis 1 will focus on investigating the learning curve of first-year ORs using the EyeSi, following the training program recommended by the "College des Ophtalmologistes Universitaires de France" in order to set up a future "licence to operate." Axis 2 will evaluate the impact of sleep deprivation on the surgical performance of experienced ORs using the EyeSi.

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT05722080.

Evaluation of Surgical Requirements and Competencies of the Saudi Ophthalmology Training Program in a Tertiary Eye Specialist Hospital- A Cross-Sectional Study

Purpose

To evaluate the adequacy of a Saudi ophthalmology training programs in achieving the competencies outlined by the Saudi Commission for Health Specialties (SCFHS) and the Accreditation Council for Graduate Medical Education (ACGME) and to assess resident satisfaction with their training.

Methods

A cross-sectional survey was sent electronically to all trainees (n=50) enrolled in the King Khaled Eye Specialist Hospital (KKESH) ophthalmology training program by email and messaging app (Whatsapp). The survey was sent between January 20, 2021, and January 30, 2021. It evaluated the level of satisfaction with surgical training and skills. The surgical logbooks of all trainees were extracted, and identifiers were removed. Then they were compared with SCFHS and ACGME curriculums for ophthalmology training.

Results

Out of 50 invitees, 47 returned the questionnaire. All trainees were confident they could meet surgical requirements by the end of their training. Most trainees were satisfied (n=29, 61.7%) with their performance in core competency requirements. There was no difference between female and male trainees' comfort levels when performing surgical steps in core competency requirements (P=0.2). Senior trainees seem more satisfied with their performance, especially in core competency requirements (P=0.087). All trainees practice at the wet lab and a virtual reality simulator to improve their skills. Obstacles faced during training were highlighted, including low exposure in the operating theater (n=18, 37.50%), competition on cases (n=5, 10.42%), attending surgeons not willing to teach (n=5, 10.42%), COVID-19 pandemic (n=5, 10.42%), and complex cases (n=4, 8.33%).

Conclusion

The outcomes of the current study indicate that trainees at KKESH were adequately satisfied with their surgical training in general. Also, competencies outlined by both the SCFHS and the ACGME were adequately fulfilled.

Using the language of surgery to enhance ophthalmology surgical education

Background

Currently, surgical education utilizes a combination of the apprentice model, wet-lab training, and simulation, but due to reliance on subjective data, the quality of teaching and assessment can be variable. The "language of surgery," an established concept in engineering literature whose incorporation into surgical education has been limited, is defined as the description of each surgical maneuver using quantifiable metrics. This concept is different from the traditional notion of surgical language, generally thought of as the qualitative definitions and terminology used by surgeons.

Methods

A literature search was conducted through April 2023 using MEDLINE/PubMed using search terms to investigate wet-lab, virtual simulators, and robotics in ophthalmology, along with the language of surgery and surgical education. Articles published before 2005 were mostly excluded, although a few were included on a case-by-case basis.

Results

Surgical maneuvers can be quantified by leveraging technological advances in virtual simulators, video recordings, and surgical robots to create a language of surgery. By measuring and describing maneuver metrics, the learning surgeon can adjust surgical movements in an appropriately graded fashion that is based on objective and standardized data. The main contribution is outlining a structured education framework that details how surgical education could be improved by incorporating the language of surgery, using ophthalmology surgical education as an example.

Conclusion

By describing each surgical maneuver in quantifiable, objective, and standardized terminology, a language of surgery can be created that can be used to learn, teach, and assess surgical technical skill with an approach that minimizes bias.

Key message

The "language of surgery," defined as the quantification of each surgical movement's characteristics, is an established concept in the engineering literature. Using ophthalmology surgical education as an example, we describe a structured education framework based on the language of surgery to improve surgical education.

Classifications

Surgical education, robotic surgery, ophthalmology, education standardization, computerized assessment, simulations in teaching.

Competencies

Practice-Based Learning and Improvement.

Ophthalmology Residency in the United States: The Case for a National Curriculum

To identify strategies for effective curriculum development and implementation in United States (US) ophthalmology residency training programs. A literature review was conducted for all English-language PubMed/Medline articles relating to ophthalmology residency education or curriculum/curricula. Despite ACGME-defined program requirements outlining curricular goals for US ophthalmology residency training programs, there is no comprehensive, national curriculum with detailed plans for instruction of necessary topics within the 36-month residency training period. Several articles identify a need for detailed curricula on various topics, propose ideas on how residency programs could create curricula, and explore ways of assessing resident competence. There is a paucity of literature evaluating how ophthalmology residents best learn various ophthalmology topics. We need to develop an intentional, comprehensive, and timely national curriculum for ophthalmology residency programs in the US, with detailed plans on how to meet curricular objectives and consideration of the most effective teaching strategies for different ophthalmology concepts.

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

PURPOSE

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

DESIGN

An n = 1 panel study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Surgical Results of Phacoemulsification Performed by Residents: A Time-Trend Analysis in a Teaching Hospital from 2005 to 2021

Purpose

To report a long-term trend of surgical results of phacoemulsification performed by residents in a teaching hospital.

Methods

This study analyzed 1,409 consecutive cases of phacoemulsification performed by residents under a single supervisor from July 2005 to March 2021. The 15.75-year period was divided into seven equal intervals for time-trend analysis. Main Outcome Measures. Rates of completion and complications were collected to assess the surgical results.

Results

The overall completion rate was 60.5% (852/1409), and the intraoperative complication rate was 14.5% (204/1409). The completion rates from the first to the seventh interval were 44.7%, 54.2%, 60.6%, 50.6%, 65.1%, 72.5%, and 81.8%, respectively. The completion rate improved significantly with time, mainly in the steps of anterior capsulorhexis and nucleus emulsification. The intraoperative complication rates from the first to the seventh interval were 27.4%, 20.4%, 14.0%, 11.8%, 8.2%, 9.6%, and 7.3%, respectively. The complication rate also decreased significantly with time, mainly in the steps of anterior capsulorhexis, nucleus emulsification, and cortex removal. The major complications included anterior capsulorhexis tear (n = 95), vitreous loss (n = 40), iris damage or prolapse (n = 36), and posterior capsule tear without vitreous loss (n = 29). There was a significant improvement of surgical results with the level of residency in the completion rate but not in the complication rate.

Conclusions

With a long-term evolution in the surgical training curriculum, it is possible to reach a goal of both higher completion and lower complication rates of resident-performed phacoemulsification.

Ophthalmic Telesurgery with a Low-Cost Smartphone Video System for Surgeon Self-Reflection and Remote Synchronous Consultation: A Qualitative and Quantitative Study

SUMMARY

More than a third of the global burden of blindness is due to cataracts, yet cataract surgery is one of the most cost-effective surgical treatments in medicine. Poor surgical outcomes in many settings remain a major challenge, raising concerns about the quality and efficacy of surgical training. Reflective learning from video recordings of a trainees' surgical performance has a high educational impact and is available routinely for surgical training within high-resource institutions. However, the prohibitive cost and limited portability of current surgical video recording systems make its use problematic in low-resource settings and outreach environments.

OBJECTIVE

The study's aim was to evaluate the potential of smartphone-captured surgical videos for surgeon learning via self-recording and self-review as well as the potential to support live telesurgical consultation.

METHODOLOGY

A quantitative and qualitative methodology was used to explore and describe the utility and acceptance of smartphone videos in two training facilities in Nepal. Twenty surgeries were recorded on the smartphone for surgeon self-review, to assess image quality, and its application to measure performance against the International Council of Ophthalmology (ICO) Ophthalmology Surgical Competency Assessment Rubrics (OSCAR) SICS Rubric. The same system was used to transmit 15 different surgeries live via Skype from Nepal to an ophthalmologist surgical trainer in South Africa to evaluate the feasibility of live consultation.

FINDINGS

Overall video quality was described as high in 65% and moderate in 35% for the videos recorded for self-review. In the surgeries streamed via Skype, quality was described as high in 92.9% and moderate in 7.1%. There were no instances where the video quality was described as poor. The video quality was good enough that the surgeons could measure against ICO-OSCAR rubric in all cases.

DISCUSSION

The video quality of smartphone-captured surgical videos was found to be high and gained acceptance for reflective teaching and learning purposes. The extended telesurgical potential and portability of the smartphone enables use across many settings. More studies over a longer period are needed to determine how they can support training and learning in cataract surgery.

Resident Skills Assessment in Corneal Suturing: A Comprehensive Review of Currently Proposed Educational Programs and Evaluation Tools

Purpose This study aimed to perform a comprehensive review of publications proposing educational programs for resident skills assessment in corneal suturing.

Methods An extensive online article search in PubMed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PISMA) reporting guidelines was performed to identify prospective comparative studies or prospective before/after studies published up to March 2021 and reporting the assessment of ophthalmology residents' skills in corneal suturing during dedicated training sessions.

Results Three studies were identified for review. The first reported the efficiency of an electromagnetic tracking system placed on the surgeon's fingers coupled with a computer analysis of movements and time to identify surgeons with different backgrounds in corneal suturing. The second reported the efficiency of the reference system in assessing the improvement of corneal suturing conducted by residents after a training session, with video-based assessment for economy and confidence of movement, limiting tissue damage and precision of operative technique, reviewed by blind assessors. The third proposed an innovative remote corneal suturing training method using Zoom for direct feedback to the residents. The stitch quality was assessed for length, depth, radiality, and tension. The results were similar when compared with a group of residents without feedback.

Conclusion This review underlines the rarity and disparity of available tools for corneal suturing assessment, justifying the need for more complete models to be designed. These should consider body ergonomics and stitch quality and time. Comparative studies involving novices and attendings may provide reliable evaluation of existing gaps and specific metrics to target, helping residents to approach their superiors' experience.

Ophthalmic Microsurgery Lab for Medical Students: Enhancing Learner Intrinsic Motivation and Comfort with Microsurgery

Objective This study aimed to evaluate the impact of an ophthalmic microsurgery laboratory on medical students' intrinsic motivation, explicit interest in ophthalmology, and comfort with microsurgical skills.

Design In this noncontrolled trial, medical students attended a Zoom-based lecture on corneal suturing, watched an instructional video on operating microscopes, and attended a wet laboratory on corneal suturing. Participants completed pre- and posttest surveys assessing comfort with microsurgical skills and explicit interest in ophthalmology. Additionally, the posttest survey included items from the Intrinsic Motivation Inventory (IMI).

Setting This study was conducted at a single academic medical center.

Participants A total of 20 students enrolled in the MD program at the University of California, San Francisco School of Medicine.

Results Pre- and posttest response rates were 100% (n = 20) and 90% (n = 18), respectively. Comfort with microsurgical skills increased significantly between pre- and posttest surveys with large effect sizes (95% confidence interval [CI]; p-value): loading a needle, 1.67 (1.04–2.29; p < 0.001); passing a suture, 1.72 (1.04–2.40; p < 0.001); knot tying, 1.05 (0.34–1.76; p = 0.004); using a microscope, 0.83 (0.04–1.63; p = 0.040); and suturing under a microscope, 1.44 (0.88–2.00; p < 0.001). Comparing pre- and posttest surveys, students reporting moderate to extreme interest in ophthalmology increased from 44 to 61%. Intrinsic motivation was high, indicated by the mean IMI Interest score reaching 93% of the maximum score. Multiple linear regression analyses predicted that IMI Interest scores increased with higher scores of familiarity (p = 0.002), explicit interest in ophthalmology (p = 0.042), and comfort with microscopes (p = 0.005), knot tying (p = 0.026), and performing surgical maneuvers under a microscope (p = 0.032).

Conclusion Ophthalmic microsurgery laboratories may increase medical students' explicit interest in ophthalmology, comfort with microsurgical skills, and intrinsic motivation. Future studies are needed to evaluate the impact of microsurgical electives on students' objective skills and specialty selection.

Emotion in remediation: A scoping review of the medical education literature

OBJECTIVES

Remediation can be crucial and high stakes for medical learners, and experts agree it is often not optimally conducted. Research from other fields indicates that explicit incorporation of emotion improves education because of emotion's documented impacts on learning. Because this could present an important opportunity for improving remediation, we aimed to investigate how the literature on remediation interventions in medical education discusses emotion.

METHODS

The authors used Arksey and O'Malley's framework to conduct a scoping literature review of records describing remediation interventions in medical education, using PubMed, CINAHL Complete, ERIC, Web of Science and APA PsycInfo databases, including all English-language publications through 1 May 2020 meeting search criteria. They included publications discussing remediation interventions either empirically or theoretically, pertaining to physicians or physician trainees of any level. Two independent reviewers used a standardised data extraction form to report descriptive information; they reviewed included records for the presence of mentions of emotion, described the mentions and analysed results thematically.

RESULTS

Of 1644 records, 199 met inclusion criteria and were reviewed in full. Of those, 112 (56%) mentioned emotion in some way; others focused solely on cognitive aspects of remediation. The mentions of emotion fell into three themes based on when the emotion was cited as present: during regular coursework or practice, upon referral for remediation and during remediation. One-quarter of records (50) indicated potential intentional incorporation of emotion into remediation programme design, but they were non-specific as to how emotions related to the learning process itself.

CONCLUSION

Even though emotion is omnipresent in remediation, medical educators frequently do not factor emotion into the design of remediation approaches and rarely explicitly utilise emotion to improve the learning process. Applications from other fields may help medical educators leverage emotion to improve learning in remediation, including strategies to frame and design remediation.

Survey of Microinvasive Glaucoma Surgery and Other Glaucoma Surgical Experience among United States Ophthalmology Residency Programs

Purpose  The aim of the study is to assess the state of glaucoma surgical training in United States ophthalmology residency programs, including experience with microinvasive glaucoma surgery (MIGS). Design  The design of the study is anonymous, internet-based national survey. Participants  Current United States ophthalmology residents of residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Methods  An anonymous survey link was emailed to all 120 accredited United States ophthalmology residency programs inviting residents to participate in an assessment of residency glaucoma surgical experience. Survey responses were collected between January 21, 2019 and March 4, 2019 and analyzed using descriptive statistics. Main Outcome Measures   The main outcomes of the study are demographic information, practice intentions, and anticipated primary surgical experience with ACGME-required glaucoma procedures and MIGS procedures, as self-reported by U.S. ophthalmology residents. Results  Of the estimated 1,479 U.S. ophthalmology residents, 161 residents participated (10.9%). A total of 118 residents (73.2%) reported any degree of anticipated MIGS primary surgical experience during residency, with the iStent being the most familiar technique. The likelihood of any anticipated MIGS experience during residency was not significantly different by geographic region ( p  = 0.16), however, anticipated volume varied significantly ( p  = 0.037). Of the 113 respondents who reported an intention to manage glaucoma surgically in their eventual practice, 25 (22.1%) reported no anticipated primary MIGS experience during residency. 73.3% of residents anticipating MIGS experience anticipated 0 to 10 cases, with 42.9% anticipating less than 5 cases as primary surgeon. Conclusion  MIGs are not a required component of the glaucoma surgical curriculum for U.S. ophthalmology residents. Although the majority of ophthalmology residents surveyed intend to manage glaucoma surgically in eventual practice, most receive minimal experience with these novel techniques during residency. Surgical training is variable by geographic region.

Teaching Ethics and Professionalism: A National Survey of Ophthalmology Residency Program Directors

Background While ethics and professionalism are important components of graduate medical education, there is limited data about how ethics and professionalism curricula are taught or assessed in ophthalmology residency programs.

Objective This study aimed to determine how U.S. ophthalmology residency programs teach and assess ethics and professionalism and explore trainee preparedness in these areas.

Methods Directors from accredited U.S. ophthalmology residency programs completed an online survey about components of programs' ethics and professionalism teaching curricula, strategies for assessing competence, and trainee preparedness in these areas.

Results Directors from 55 of 116 programs (46%) responded. The most common ethics and professionalism topics taught were informed consent (38/49, 78%) and risk management and litigation (38/49, 78%), respectively; most programs assessed trainee competence via 360-degree global evaluation (36/48, 75%). While most (46/48, 95%) respondents reported that their trainees were well or very well prepared at the time of graduation, 15 of 48 (31%) had prohibited a trainee from graduating or required remediation prior to graduation due to unethical or unprofessional conduct. Nearly every program (37/48, 98%) thought that it was very important to dedicate curricular time to teaching ethics and professionalism. Overall, 16 of 48 respondents (33%) felt that the time spent teaching these topics was too little.

Conclusion Ophthalmology residency program directors recognized the importance of an ethics and professionalism curriculum. However, there was marked variation in teaching and assessment methods. Additional work is necessary to identify optimal strategies for teaching and assessing competence in these areas. In addition, a substantial number of trainees were prohibited from graduating or required remediation due to ethics and professionalism issues, suggesting an impact of unethical and unprofessional behavior on resident attrition.

Remote corneal suturing wet lab: microsurgical education during the COVID-19 pandemic

PURPOSE

To study the feasibility and efficacy of a new remote wet lab for microsurgical education using a corneal suturing task.

SETTING

Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.

DESIGN

Prospective randomized controlled study.

METHODS

Ten ophthalmology residents were stratified by postgraduate year and randomized to perform a corneal suturing task consisting of placing the 4 cardinal sutures for a penetrating keratoplasty in porcine eyes with or without remote ophthalmology attending feedback. Subsequently, both groups repeated the same task without remote feedback to test whether initial remote feedback affected subsequent performance. Finally, the group without feedback was crossed over to repeat the same corneal suturing task with remote feedback. The effectiveness of the remote wet lab was assessed subjectively by survey and objectively by grading each suture pass.

RESULTS

Resident-reported comfort with corneal suturing improved significantly after the remote wet lab for all residents. Residents and attendings rated the remote wet lab as equally or more effective compared with previous in-person wet labs and overall effective in corneal suturing. Attendings rated the remote wet lab as effective in multiple domains of microsurgical education using a modified microsurgical global rating scale. Objective corneal suturing performance was similar for both groups.

CONCLUSIONS

The remote wet lab was feasible and effective for training ophthalmology residents in corneal suturing. This represents a new social distancing compliant platform for microsurgical education during the COVID-19 pandemic.

Predictors of Manual Dexterity in Simulation-Based Cataract Surgery

Introduction The aim of this study is to determine if prior experience with fine motor hobbies influences a surgeon-in-training's performance on a cataract surgical simulator.

Materials and Methods Medical students (n = 70) performed navigation, forceps, and capsulorhexis simulations using the Eyesi Ophthalmosurgical Simulator. Participants were surveyed regarding fine motor hobby experiences, including musical instruments, video games, sewing, knitting, origami, painting, crafting, jewelry making, drawing, and extracurricular dissection.

Results Medical students with extracurricular dissection experience, including work in research laboratories involving microscopic animal dissection, did significantly better on the forceps simulator task (p = 0.009). Medical students with drawing experience performed better on capsulorhexis (p = 0.031). No other fine motor hobbies were significant for improving simulator scores.

Conclusion Drawing and extracurricular dissection lend to improved technical ability on the cataract surgical simulator. This research continues the conversation regarding fine motor hobbies that correlate with microsurgical ability and adds to the growing area of research regarding the selection and training of ophthalmology residents.

Assessment of operative competency for thyroidectomy: Comparison of resident self-assessment vs attending surgeon assessment

BACKGROUND

Self-awareness of skill, essential for progression as a surgeon, has direct bearing on postresidency practice; however, studies have supported that residents achieve self-perceived competence later than believed by program directors. This study compares residents' self-perception of operative competency to attending surgeon's evaluation using Computer Enhanced Visual Learning, a validated online hemithyroidectomy-specific assessment tool.

METHODS

Eleven otolaryngology-Head and Neck Surgery (HNS) residents completed a preoperative module and postoperative survey, later reviewed by an attending surgeon. Eighty-three performances were assessed for inter-rater reliabilities of key surgical steps.

RESULTS

Almost perfect agreement (Kappa = 0.81-1.00) was shown in 11 of 18 parameters. Substantial agreement (Kappa = 0.61-0.80) was demonstrated in the remaining seven parameters.

CONCLUSIONS

Otolaryngology-HNS trainees have high self-awareness of their performance at each step in a hemithyroidectomy. Standardized assessment tools can allow for documentation of procedural performance and serve as guides for improvement. This is the only study to examine otolaryngology-HNS trainees' self-perceived skill compared to an attending surgeon's assessment for hemithyroidectomy.

Ophthalmology Training in Greece as Perceived by Resident Ophthalmologists in the Times of Crisis: A National, Questionnaire-based Survey

Purpose:

To assess the level of perceived satisfaction with the current level of ophthalmology training in Greece from the perspective of residents and to identify deficiencies in the training curriculum.

Methods:

This is a prospective, cross-sectional questionnaire-based study. An online, semi-structured questionnaire was designed to evaluate ophthalmology residents' extent of satisfaction with the quality of their postgraduate medical training. The survey was divided in two parts: demographics and evaluation of training. Resident ophthalmologists in all teaching hospitals in Greece were contacted and encouraged to complete it.

Results:

A response rate of 53.8% was achieved. Two out of three participants stated their disappointment with the quality of training they received and deemed the four-year residency training program as insufficient. Surgical training was also viewed as unsatisfactory by the majority of the respondents. An interest in subspecialty training, as well as a significant participation in research activities, was noted.

Conclusions:

Both training and overall satisfaction with working conditions must be improved to preserve the appeal of ophthalmology for young academics. A new, structured curriculum, reduction of unnecessary bureaucracy, and improved surgical training rank among the most essential priorities in order to improve postgraduate ophthalmology training.

Interventions to Mitigate Cognitive Biases in the Decision Making of Eye Care Professionals: A Systematic Review

SIGNIFICANCE

Cognitive biases, systematic errors in thinking that impact a person's choices and judgments, can influence decision making at various points during patient care provision. These biases can potentially result in misdiagnoses, delayed clinical care, and/or patient mismanagement. A range of interventions exists to mitigate cognitive biases. There is a need to understand the relative efficacy of these interventions within the context of eye care practice.

PURPOSE

The aim of this systematic review was to synthesize the evidence relating to interventions for mitigating cognitive biases associated with clinical decision making by eye care professionals.

DATA SOURCES

Electronic databases (including Ovid MEDLINE, Embase, Scopus, PsycINFO) were searched from inception to October 2017 for studies investigating interventions intended to mitigate cognitive biases in the clinical decision making of eye care professionals. This review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines.

STUDY ELIGIBILITY CRITERIA

To ensure inclusion of all relevant literature, a wide range of study designs was eligible for inclusion, such as randomized controlled trials, nonrandomized trials, interrupted time series and repeated measures, controlled before-after studies, and qualitative studies that were a component of any of these quantitative study designs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two review authors independently screened titles, abstracts, and full-text articles in duplicate, applying a priori eligibility criteria.

RESULTS

After screening 2759 nonduplicate records, including full-text screening of 201 articles, no relevant studies were identified.

CONCLUSIONS AND IMPLICATIONS OF FINDINGS

Given that cognitive biases can significantly impact the accuracy of clinical decision making and thus can have major effects on clinical care and patient health outcomes, the lack of studies identified in this systematic review indicates a critical need for research within the area of cognitive bias mitigation for decision making within eye care practice.

Decision-Making in the Catheter Laboratory: The Most Important Variable in Successful Outcomes

Increasingly the importance of how and why we make decisions in the medical arena has been questioned. Traditionally the aeronautical and business worlds have shed a light on this complex area of human decision-making. In this review we reflect on what we already know about the complexity of decision-making in addition to directing particular focus on the challenges to decision-making in the high-intensity environment of the pediatric cardiac catheterization laboratory. We propose that the most critical factor in outcomes for children in the catheterization lab may not be technical failures but rather human factors and the lack of preparation and robust shared decision-making process between the catheterization team. Key technical factors involved in the decision-making process include understanding the anatomy, the indications and objective to be achieved, equipment availability, procedural flow, having a back-up plan and post-procedural care plan. Increased awareness, pre-catheterization planning, use of standardized clinical assessment and management plans and artificial intelligence may provide solutions to pitfalls in decision-making. Further research and efforts should be directed towards studying the impact of human factors in the cardiac catheterization laboratory as well as the broader medical environment.

Survey of ophthalmologists-in-training in Eastern, Central and Southern Africa: A regional focus on ophthalmic surgical education

Background: There are 2.7 ophthalmologists per million population in sub-Saharan Africa, and a need to train more. We sought to analyse current surgical training practice and experience of ophthalmologists to inform planning of training in Eastern, Central and Southern Africa. Methods: This was a cross-sectional survey. Potential participants included all current trainee and recent graduate ophthalmologists in the Eastern, Central and Southern African region. A link to a web-based questionnaire was sent to all heads of eye departments and training programme directors of ophthalmology training institutions in Eastern, Central and Southern Africa, who forwarded to all their trainees and recent graduates. Main outcome measures were quantitative and qualitative survey responses. Results: Responses were obtained from 124 (52%) trainees in the region. Overall level of satisfaction with ophthalmology training programmes was rated as 'somewhat satisfied' or 'very satisfied' by 72%. Most frequent intended career choice was general ophthalmology, with >75% planning to work in their home country post-graduation. A quarter stated a desire to mainly work in private practice. Only 28% of junior (first and second year) trainees felt surgically confident in manual small incision cataract surgery (SICS); this increased to 84% among senior trainees and recent graduates. The median number of cataract surgeries performed by junior trainees was zero. 57% of senior trainees were confident in performing an anterior vitrectomy. Only 29% of senior trainees and 64% of recent graduates were confident in trabeculectomy. The mean number of cataract procedures performed by senior trainees was 84 SICS (median 58) and 101 phacoemulsification (median 0). Conclusion: Satisfaction with post-graduate ophthalmology training in the region was fair. Most junior trainees experience limited cataract surgical training in the first two years. Focused efforts on certain aspects of surgical education should be made to ensure adequate opportunities are offered earlier on in ophthalmology training.

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.

The impact of surgical training on the practice of recently graduated ophthalmologists at Riyadh’s ophthalmology residency program

Purpose

Methods

Results

Conclusion

Self-perceived preparedness and competence among ophthalmology residents for open globe repair

Purpose

To assess which surgical training resources residents find most useful for open globe repair.

Methods

A nationwide, survey-based, cross-sectional analysis of ophthalmology residents enrolled in accredited training programs in the United States was performed to determine the association of surgical training methods with self-perceived resident preparedness and competence for open globe repair. The survey was developed at the Wilmer Eye Institute, Johns Hopkins Hospital.

Results

The individual response rate in our study was 38.6% (118/306 participant responses from 24 programs). Pre-operative surgical planning, in the form of review of patient charts and case discussion with senior faculty, was associated with higher self-perceived levels of both preparedness and competence for several different steps of globe repair. Both supervised and independent lab practice on animal or synthetic eyes were also found to be significantly associated with increased levels of self-perceived competence, especially for steps that involved scleral and limbal reapproximation.

Conclusion

Open globe repair is an important skill that all ophthalmologists must learn to master. To improve surgical training, residency programs must focus on developing a structured surgical curriculum that incorporates training for managing ocular trauma and open globes. Possible components can include implementation of pre-operative briefings and case discussion with faculty as well as, encouraging regular utilization of practice labs in a distributed pattern to consolidate learning among residents.

Outcomes and Complications Rate of Resident versus Attending Performed Eye Muscle Surgeries

Purpose: to compare the type, complications rate, and success rate of eye muscle surgeries performed by residents to those performed by attending consultants. Methods: A retrospective review was done on the charts of all children who underwent an eye muscle surgery in Cairo University Hospital during the period from January 2015 to December 2017. Preoperative data including age, sex, and type of deviation were tabulated. Details of the operative procedure including the surgeon, the type of eye muscle surgery, the number of muscles operated upon, perioperative complications, and the final ocular alignment at the end of the third month after surgery were recorded. Results: A total of 319 patients were included; 143 patients (315 muscles) in the supervised resident group and 176 patients (387 muscles) in the attending group. More vertical and oblique muscles surgeries were done by the attending consultants than by residents. Surgical success after three months was higher in the attending group (n = 126, 72%) than the resident group (n = 91, 64%). However, the difference was not statistically significant (P = .129). The perioperative complications rate was significantly higher (P = .004) in the resident group (14%) than the attending group (6%). Accidental scleral perforation was the most commonly encountered complication in the resident group (n = 6, 1.9%) followed by extruded/exposed Tenon (n = 5, 1.6%), and muscle slippage (n = 4, 1.3%). Conclusions: Success rate is similar in eye muscle surgeries performed by residents and attending consultants. However, perioperative complications are still more common among residents.

Assessment of Automated Identification of Phases in Videos of Cataract Surgery Using Machine Learning and Deep Learning Techniques

IMPORTANCE

Competence in cataract surgery is a public health necessity, and videos of cataract surgery are routinely available to educators and trainees but currently are of limited use in training. Machine learning and deep learning techniques can yield tools that efficiently segment videos of cataract surgery into constituent phases for subsequent automated skill assessment and feedback.

OBJECTIVE

To evaluate machine learning and deep learning algorithms for automated phase classification of manually presegmented phases in videos of cataract surgery.

DESIGN, SETTING, AND PARTICIPANTS

This was a cross-sectional study using a data set of videos from a convenience sample of 100 cataract procedures performed by faculty and trainee surgeons in an ophthalmology residency program from July 2011 to December 2017. Demographic characteristics for surgeons and patients were not captured. Ten standard labels in the procedure and 14 instruments used during surgery were manually annotated, which served as the ground truth.

EXPOSURES

Five algorithms with different input data: (1) a support vector machine input with cross-sectional instrument label data; (2) a recurrent neural network (RNN) input with a time series of instrument labels; (3) a convolutional neural network (CNN) input with cross-sectional image data; (4) a CNN-RNN input with a time series of images; and (5) a CNN-RNN input with time series of images and instrument labels. Each algorithm was evaluated with 5-fold cross-validation.

MAIN OUTCOMES AND MEASURES

Accuracy, area under the receiver operating characteristic curve, sensitivity, specificity, and precision.

RESULTS

Unweighted accuracy for the 5 algorithms ranged between 0.915 and 0.959. Area under the receiver operating characteristic curve for the 5 algorithms ranged between 0.712 and 0.773, with small differences among them. The area under the receiver operating characteristic curve for the image-only CNN-RNN (0.752) was significantly greater than that of the CNN with cross-sectional image data (0.712) (difference, -0.040; 95% CI, -0.049 to -0.033) and the CNN-RNN with images and instrument labels (0.737) (difference, 0.016; 95% CI, 0.014 to 0.018). While specificity was uniformly high for all phases with all 5 algorithms (range, 0.877 to 0.999), sensitivity ranged between 0.005 (95% CI, 0.000 to 0.015) for the support vector machine for wound closure (corneal hydration) and 0.974 (95% CI, 0.957 to 0.991) for the RNN for main incision. Precision ranged between 0.283 and 0.963.

CONCLUSIONS AND RELEVANCE

Time series modeling of instrument labels and video images using deep learning techniques may yield potentially useful tools for the automated detection of phases in cataract surgery procedures.

Cataract surgery training using surgical simulators and wet-labs: Course description and literature review

Cataract surgery is the most common surgery to face the ophthalmology training resident. To facilitate achieving surgical competency and reduce complication rates, wet laboratories and surgical simulators are used in surgical disciplines worldwide. We developed a simulator and wet-lab course that aims to build the microsurgery skills of trainees and improve safety during real surgical procedures. Herewith, we describe the standardized hands-on course that incorporates these tools for advanced training. Additionally, we review the literature on wet-lab and surgical simulators in ophthalmology, focusing on their importance in training centers. The course is offered four times per year since it started in December 2015, and t total of 88 trainees participated to date. Feedback received from the trainees' supervising surgeons showed that this course addresses a major training challenge, and that a permanent version of this course should be established at each training center. We suggest incorporating fixed wet-lab and surgical simulator competencies in ophthalmology training programs. Additionally, we recommend that residents be allowed to operate on real patients only after passing the course. We believe that these steps would foster ophthalmologists with advanced training, decrease their learning curve, and empower them to safely conduct cataract surgery with low complication rates.

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.

Assessing and Promoting the Wellness of United States Ophthalmology Residents: A Survey of Program Directors

OBJECTIVE

To report on the status of residency-based wellness initiatives in ophthalmic graduate medical education and identify strategies for promoting ophthalmology resident wellness by surveying US ophthalmology program directors (PDs).

DESIGN

The PDs were each sent an e-mail containing a link to an anonymous online 15-question survey. The PDs also received a letter with the survey link and a $1 incentive. After 2 weeks, nonresponders received 2 weekly reminder e-mails and phone calls. Descriptive statistics were used to analyze the multiple choice responses and categorize the free response answers.

SETTING

National survey.

PARTICIPANTS

All 111 US ophthalmology PDs were invited to participate.

RESULTS

Of 111 PDs, 56 (50%) responded; 14 (26%) of 53 respondents reported that their programs faced an issue involving resident depression, burnout, or suicide within the last year; 25 (45%) of 56 reported that their department had a resident wellness program. Respondents without wellness programs reported a shortage of time (19/30; 63%) and lack of training and resources (19/30; 63%) as barriers to instituting these programs. Respondents reported that the Accreditation Council for Graduate Medical Education could better promote resident wellness by providing training resources for burnout and depression screening (35/53; 66%), resilience skills building (38/53; 72%), and wellness program development (36/53; 68%).

CONCLUSIONS

This survey suggests that there is a substantial burden of burnout and depression among residents in ophthalmic graduate medical education and that this burden can be addressed by promoting the training of educators to recognize the signs of burnout and depression, and providing resources to develop and expand formal wellness programs.

Is there inter-procedural transfer of skills in intraocular surgery? A randomized controlled trial

PURPOSE

To investigate how experience in simulated cataract surgery impacts and transfers to the learning curves for novices in vitreoretinal surgery.

METHODS

Twelve ophthalmology residents without previous experience in intraocular surgery were randomized to (1) intensive training in cataract surgery on a virtual-reality simulator until passing a test with predefined validity evidence (cataract trainees) or to (2) no cataract surgery training (novices). Possible skill transfer was assessed using a test consisting of all 11 vitreoretinal modules on the EyeSi virtual-reality simulator. All participants repeated the test of vitreoretinal surgical skills until their performance curve plateaued. Three experienced vitreoretinal surgeons also performed the test to establish validity evidence. Analysis with independent samples t-tests was performed.

RESULTS

The vitreoretinal test on the EyeSi simulator demonstrated evidence of validity, given statistically significant differences in mean test scores for the first repetition; experienced surgeons scored higher than novices (p = 0.023) and cataract trainees (p = 0.003). Internal consistency for the 11 modules of the test was acceptable (Cronbach's α = 0.73). Our findings did not indicate a transfer effect with no significant differences found between cataract trainees and novices in their starting scores (mean ± SD 381 ± 129 points versus 455 ± 82 points, p = 0.262), time to reach maximum performance level (10.7 ± 3.0 hr versus 8.7 ± 2.8 hr, p = 0.265), or maximum scores (785 ± 162 points versus 805 ± 73 points, p = 0.791).

CONCLUSION

Pretraining in cataract surgery did not demonstrate any measurable effect on vitreoretinal procedural performance. The results of this study indicate that we should not anticipate extensive transfer of surgical skills when planning training programmes in intraocular surgery.

Impact of a Strabismus Surgery Suture Course for First- and Second-Year Ophthalmology Residents

PURPOSE

To investigate the effectiveness of an eye muscle surgery course on first- and second-year postgraduate ophthalmology residents.

METHODS

This prospective cohort pilot study invited first- and second-year ophthalmology residents to participate in a 2-hour strabismus surgery course at Wills Eye Hospital. The course consisted of a didactic session followed by a wet laboratory session. The wet laboratory session simulated strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. A structured self-assessment evaluation form and a questionnaire in the validated Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) were used to assess the effectiveness of the course.

RESULTS

A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Following the course, most residents felt less anxious (73%). All residents responded that the course was helpful or somewhat helpful in preparation for strabismus surgery. Regarding the distribution of ratings on questions of subjective experience, knowledge of steps, and understanding of potential complications, the residents gave significantly higher ratings after the course (P < .029). The change in the modified ICO-OSCAR:strabismus assessment's mean score was statistically significant before and after training (P = .038).

CONCLUSIONS

A strabismus course can play an important role in preparing residents for strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2017;54(6):339-345.].

Residency evaluation and adherence design study: Young ophthalmologists' perception of their residency programs - Clinical and surgical skills

Background:

Residency training is the basis of good clinical and surgical practice.

Purpose:

The aim is to know the demographics, training experience, and perception of young ophthalmologists to improve the present residency programs in India.

Setting:

Young ophthalmologists trained in India.

Methods:

A survey was conducted by the Academic and Research Committee of the All India Ophthalmology Society, in 2014–2016 of young ophthalmologists (those trained between 2002 and 2012, with 2–10 years' postresidency experience) to gauge teaching of clinical and surgical skills during the postgraduate residency program.

Statistical Analysis:

Statistical Package for Social Sciences version 16.

Results:

Of the 1005 respondents, 531 fulfilled inclusion criteria. Average age was 32.6 years (standard deviation [SD] 4). On a scale of 0–10, clinical skills teaching was graded as (mean, SD): Slit lamp examination (7.2, SD 2.8), indirect ophthalmoscopy (6.2, SD 3.3), gonioscopy (5.7, SD 3.4), perimetry (6.2, SD 3.2), optical coherence tomography (4.6, SD 4), and orthoptic evaluation (4.3, SD 3.1). The mean (SD) and median of surgeries performed independently was intracapsular cataract extraction 3.0 (14.9), 0; extracapsular cataract extraction 39.9 (53.2), 18; small incision cataract surgery 75.3 (64.4), 55; phacoemulsification 30 (52.6), 1; pterygium excision 31.5 (43.5), 15; dacryocystectomy 20.3 (38.1), 4; dacryocystorhinostomy 11.7 (26.2), 2; chalazion 46.4 (48.3), 30; trabeculectomies 4 (14.9), 0; strabismus correction 1.4 (4.9), 0; laser-assisted in situ Keratomileusis 1.5 (12.2), 0; retinal detachment 1.5 (12.5), 0; vitrectomy 3.0 (17.0), 0; keratoplasty 5.2 (17.8), 0; eyelid surgery 8.6 (18.9), 2 and ocular emergencies 41.7 (52.4), 20. Observed and assisted surgeries were more common. However, the range of grading was 0–10 in all categories.

Conclusion:

Residency training in India varies considerably from program to program. Standardization is needed to assure all graduates are competent and render consistent quality of service.

Impact of Microscope-Integrated OCT on Ophthalmology Resident Performance of Anterior Segment Surgical Maneuvers in Model Eyes

Purpose

The integration of swept-source optical coherence tomography (SS-OCT) into the operating microscope enables real-time, tissue-level three-dimensional (3D) imaging to aid in ophthalmic microsurgery. In this prospective randomized controlled study, we evaluated the impact of SS microscope-integrated OCT (MI-OCT) on ophthalmology residents' performance of ophthalmic microsurgical maneuvers.

Methods

Fourteen ophthalmology residents from a single institution were stratified by year of training and randomized to perform four anterior segment surgical maneuvers on porcine eyes with (MI-OCT+) or without (MI-OCT−) direct intraoperative OCT guidance. Subsequently, both groups repeated the same maneuvers without MI-OCT feedback to test whether initial MI-OCT experience affected subsequent surgical performance. Finally, the MI-OCT− group was crossed over and allowed to repeat the same maneuvers with direct MI-OCT guidance. Each resident completed a survey at the completion of the study.

Results

With direct MI-OCT feedback, residents demonstrated enhanced performance in depth-based anterior segment maneuvers (corneal suture passes at 50% and 90% depth and corneal laceration repair) compared with the residents operating without MI-OCT. Microscope-integrated OCT+ residents continued to outperform the controls when both groups subsequently operated without MI-OCT. For clear corneal wound geometry, there was no statistically significant effect of MI-OCT as applied in this study. Overall, the resident surgeons rated their subjective experience of using MI-OCT very favorably.

Conclusions

Microscope-integrated OCT feedback enhances performance of ophthalmology residents in select anterior segment surgical maneuvers. Microscope-integrated OCT represents a valuable tool in the surgical education of ophthalmology residents.

Comparison of training effect on tremor using 2 training modules

PURPOSE

To compare training effect of 2 training models-a surgical simulator anti-tremor module and a paper version-on tremor and time-to-task completion.

SETTING

Ophthalmology Department, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA.

DESIGN

Prospective crossover study.

METHODS

Trainees completed simulator and paper training modules (baseline test, 3 training sessions, posttraining test, and final test) with their dominant and nondominant hands. The change in tremor, number of paper errors, and time-to-task completion in dominant and nondominant hands were compared. The 2 training modules were compared using nonparametric tests.

RESULTS

The study comprised 19 trainees. There was a moderate correlation between average tremor values (simulator, 3-dimensional module) and paper errors (paper, 2-dimensional module) (Spearman ⍴ = 0.35, P < .0001). Practice on the simulator or paper modules did not reduce tremor significantly from baseline to final tasks for both hands combined (P = .12, simulator; P = .2, paper). Practice on the training modules improved time-to-task completion in the simulator module and paper module (both P < .0001). The improvement in time from baseline to final tasks was greater in the nondominant hands in the simulator module (improvement 64.5% over baseline time) than in the paper module (53.6% over baseline time).

CONCLUSION

Practice might not reduce tremor but improved the outcome measure of time, and results suggest that trainees can learn to compensate for tremor in both hands, which is important in bimanual microsurgery.

Selection for Surgical Training: An Evidence-Based Review

PURPOSE

The predictive relationship between candidate selection criteria for surgical training programs and future performance during and at the completion of training has been investigated for several surgical specialties, however there is no interspecialty agreement regarding which selection criteria should be used. Better understanding the predictive reliability between factors at selection and future performance may help to optimize the process and lead to greater standardization of the surgical selection process.

METHODS

PubMed and Ovid MEDLINE databases were searched. Over 560 potentially relevant publications were identified using the search strategy and screened using the Cochrane Collaboration Data Extraction and Assessment Template.

RESULTS

57 studies met the inclusion criteria. Several selection criteria used in the traditional selection demonstrated inconsistent correlation with subsequent performance during and at the end of surgical training. The following selection criteria, however, demonstrated good predictive relationships with subsequent resident performance: USMLE examination scores, Letters of Recommendation (LOR) including the Medical Student Performance Evaluation (MSPE), academic performance during clinical clerkships, the interview process, displaying excellence in extracurricular activities, and the use of unadjusted rank lists.

CONCLUSIONS

This systematic review supports that the current selection process needs to be further evaluated and improved. Multicenter studies using standardized outcome measures of success are now required to improve the reliability of the selection process to select the best trainees.

Ophthalmic Surgical Simulation in Training Dexterity in Dominant and Nondominant Hands: Results From a Pilot Study

PURPOSE

To determine whether a structured training program using the validated EYESI surgical simulator improves dexterity in nondominant (ND) hands.

SETTING

Academic tertiary referral center.

DESIGN

Nonrandomized, prospective study.

METHODS

Subjects who chose to participate and provided informed consent completed a structured simulation training program, which included a baseline test, 3 sessions of repeated tasks, and a final test on capsulorhexis in dominant (D) and ND hands. Participants completed demographic and satisfaction questionnaires. Performances at each session were recorded. We compared overall scores at baseline and at the end of the study, and analyzed trends over time. Statistical analysis was performed using JMP by SAS.

RESULTS

Overall, 14 subjects completed the training program. In all, 3 (21.4%) were attending physicians and 11 (78.6%) were trainees. There was a significant improvement in the average overall scores (baseline vs. final) in both the D hand (33.4 vs. 46.5; p < 0.05) and the ND hand (28.9 vs. 47.7; p < 0.001). The structured training program demonstrated significantly faster performance times in both hands at the end of the study (D p< 0.001, ND p < 0.02). However, the learning curve was significantly steeper in the ND hand (p < 0.01). Participants agreed that simulation training improved the ND hand dexterity.

CONCLUSIONS

We found a significantly greater trend for improvement in the ND compared with the D hand. These results suggest that an elaborate, structured curriculum targeting teaching dexterity results in better simulated performance.

Perspective of ophthalmology residents in the United States about residency programs and competency in relation to the International Council of Ophthalmology guidelines

Purpose

To evaluate the perspective of ophthalmology residents in the US about their residency programs and compare the competency of residency programs to international competency levels set by the International Council of Ophthalmology (ICO).

Methods

A cross-sectional web-based survey extracted from the ICO published competency standards was sent to program directors of ophthalmology residency programs in the US to forward it to current PGY-3, 4 residents, and residency graduates from 2011 to 2014.

Results

Eighty-seven responses were received, comprising 61 residents and 26 graduates. Most respondents were highly satisfied with their programs (93.6%). Clinic-based training was rated satisfactorily. Insufficient exposure to low-vision rehabilitation (38.5%), refraction and contact lenses prescription (38.5%), and vitreo-retinal surgeries (38.5%) was reported. Respondents were satisfied with their overall surgical experiences, with the vast majority (>83%) rating case volume, complexity, and variety as satisfactory or better. A significant group stated they had insufficient exposure to extra-capsular cataract extraction (26.3%), refractive surgery (19.7%), and orbital surgery (64.5%). All graduates surveyed passed their Ophthalmic Knowledge Assessment Program (OKAP) examinations, and 72% felt their residency programs adequately prepared them for the examinations. All respondents reported insufficient training in certain nonclinical areas, such as practice management, staffing, and administration skills.

Conclusions

Ophthalmology residents in the US express high levels of satisfaction with their residency training programs. While most programs adequately address most ICO core objectives, certain curriculum modifications should be considered.

Influence of stereoscopic vision on task performance with an operating microscope

PURPOSE

To determine the extent to which stereoscopic depth perception influences the performance of tasks executed under an operating microscope.

SETTING

Laboratory of Experimental Ophthalmology, University Medical Center Groningen, the Netherlands.

DESIGN

Experimental study.

METHODS

Medical students were assigned (on the basis of their stereoacuity) to a stereo-sufficient group (depth perception ≤240 seconds of arc [arcsec]) or stereo-deficient group (≥480 arcsec). They performed a bead-stringing task (a mockup surgical test) under an operating microscope or a task on a cataract surgery simulator. The stereo-sufficient subjects also performed the bead-stringing task under artificial stereo-deficient conditions (binocular and monocular viewing).

RESULTS

The study comprised 77 medical students. The stereo-sufficient subjects performed both tasks faster than the stereo-deficient subjects and artificially stereo-deficient subjects (P ≤ .024). In addition, a within-group analysis established that the stereo-sufficient subjects were faster at the bead-stringing task with stereoscopic viewing than under artificial stereo-deficient conditions with binocular viewing (P ≤ .011).

CONCLUSIONS

Having stereovision resulted in better initial performance on certain tasks involving the use of an operating microscope or cataract surgery simulator. However, this study did not show that stereo deficiency necessarily results in an inability to perform such tasks properly. Hence, it was not evident that for admission to an ophthalmology residency program, stereovision should be judged more stringently than other traits.

FINANCIAL DISCLOSURE

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

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.

The effects of absence of stereopsis on performance of a simulated surgical task in two-dimensional and three-dimensional viewing conditions

BACKGROUND

Stereopsis is believed to be advantageous for surgical tasks that require precise hand-eye coordination. We investigated the effects of short-term and long-term absence of stereopsis on motor task performance in three-dimensional (3D) and two-dimensional (2D) viewing conditions.

METHODS

30 participants with normal stereopsis and 15 participants with absent stereopsis performed a simulated surgical task both in free space under direct vision (3D) and via a monitor (2D), with both eyes open and one eye covered in each condition.

RESULTS

The stereo-normal group scored higher, on average, than the stereo-absent group with both eyes open under direct vision (p<0.001). Both groups performed comparably in monocular and binocular monitor viewing conditions (p=0.579).

CONCLUSIONS

High-grade stereopsis confers an advantage when performing a fine motor task under direct vision. However, stereopsis does not appear advantageous to task performance under 2D viewing conditions, such as in video-assisted surgery.

Establishment of a validated training programme on the Eyesi cataract simulator. A prospective randomized study

PURPOSE

To establish and evaluate a systematic training programme to be included into the ophthalmologic resident curriculum.

METHODS

Medical students (n = 20) within a year from graduation and with no previous ophthalmic experience were included in this prospective study and randomized into two groups. Group A (n = 10) completed the Eyesi cataract simulator training programme once a week for 4 weeks, while Group B (n = 10) completed it once a week at the first and the last week. Two cataract surgeons were used to determine two different levels of reference scores. Score per analysed module [two different levels of Capsulorhexis (A and B), Hydromaneuver, Phaco divide and conquer], Overall score, Total time, Cornea injury, Capsule rupture and Capsule damage by ultrasound were recorded.

RESULTS

Group A outperformed Group B in several modules, reached a significant higher number of reference scores (p < 0.01) and caused fewer complications with regard to Capsule rupture (p = 0.01) and Capsule damage by ultrasound (p < 0.05). Both Groups A and B improved their performance and also became more time efficient (p < 0.01 for both groups). Group A showed positive learning curves for Overall score (p < 0.01), Capsulorhexis A (p < 0.01), Capsulorhexis B (p < 0.01) and Hydromaneuver (p = 0.01). Group B showed a significant improvement for Overall score (p < 0.01), Hydromaneuver (p = 0.02) and Phaco divide and conquer (p < 0.01).

CONCLUSION

Repetitive training with a systematic training programme, based on validated modules in the Eyesi simulator, was shown to improve simulated cataract surgery skills. Higher level of skills and more reference scores were reached with more training. Furthermore, the programme was optimized to be applied into the standard ophthalmological curriculum for cataract surgery training.

Ophthalmology residency training in Jordan: an evaluation of quality and comparison with international standards

AIM

To evaluate Jordanian ophthalmology residency programs in achieving competencies outlined by the International Council of Ophthalmology (ICO) and residents' satisfaction with available training programs in Jordan, and to highlight weakness points that may be improved and strengthened.

METHODS

A closed-ended questionnaire was circulated to all ophthalmologists who completed their training in Jordanian institutions between 2006 and 2011, to measure the quality of residency training and satisfaction level with regards to clinical conferences, journal clubs, scientific lectures, wet lab sessions, simulations, outpatient clinics and operating room training. Barriers to a successful board exam were cited. All ophthalmologists had official residency training in Jordanian Hospitals; this includes military, university, governmental and private sector hospitals.

RESULTS

Sixty-one questionnaires completed out of 69 circulated. Males (75.4%) were more than females. Mean age was 32.5±3.27y. A total 21 (34.4%) responders expressed an overall satisfaction, 38 (62.3%) were dissatisfied and 2 (3.3%) were equivocal. Respondents reported insufficient exposure to low-vision rehabilitation 57 (93.4%), or refraction and glasses prescription 34 (55.7%). Regarding operative experiences, the mean cataract extraction per-resident was 43 cataracts; the number of phacoemulsification surgery was 2.96 per-resident, 46 (75.4%) of responders never did a single phacoemulsification during residency. Nine (14.8%) had training in refractive surgery, and 15 (24.6%) assisted orbital surgery. Forty-four (72.1%) never assisted in vitreoretinal surgery. Among The graduates surveyed, 14 (23.0%) passed Jordanian licensing board exam at the first attempt, and felt that their residency programs adequately prepared them for the examinations.

CONCLUSION

Around two thirds (62.3%) of ophthalmologists expressed dissatisfaction with residency training at Jordanian programs, further study is required to assess each program separately and evaluate the system of accreditation in Jordanian residency programs.