The Impact of Simulation-Based Trabeculectomy Training on Resident Core Surgical Skill Competency.

PRCIS: Simulation-based surgical education shows a positive, immediate, and sustained impact on core surgical skill competency in trabeculectomy among resident ophthalmologists in training. PURPOSE: To measure the impact of trabeculectomy, surgical simulation training on core surgical skill competency in resident ophthalmologists. MATERIALS AND METHODS: This is a post hoc analysis of the GLAucoma Simulated Surgery trial, which is a multicenter, multinational randomized controlled trial. Resident ophthalmologists from 6 training centers in sub-Saharan Africa (in Kenya, Uganda, Tanzania, Zimbabwe, and South Africa) were recruited according to the inclusion criteria of having performed zero surgical trabeculectomies and assisted in <5. Participants were randomly assigned to intervention and control arms using allocation concealment. The intervention was a 1-week intensive trabeculectomy surgical simulation course. Outcome measures were mean surgical competency scores in 8 key trabeculectomy surgical skills (scleral incision, scleral flap, releasable suturing, conjunctival suturing, sclerostomy, tissue handling, fluidity, and speed), using a validated scoring tool. RESULTS: Forty-nine residents were included in the intention-to-treat analysis. Baseline characteristics were balanced between arms. Median baseline surgical competency scores were 2.88/16 [interquartile range (IQR): 1.75-4.17] and 3.25/16 (IQR: 1.83-4.75) in the intervention and control arms, respectively. At primary intervention, median scores increased to 11.67/16 (IQR: 9.58-12.63) and this effect was maintained at 3 months and 1 year ( P =0.0001). Maximum competency scores at primary intervention were achieved in the core trabeculectomy skills of releasable suturing (n=17, 74%), scleral flap formation (n=16, 70%), and scleral incision (n=15, 65%) compared with scores at baseline. CONCLUSIONS: This study demonstrates the positive impact of intensive simulation-based surgical education on core trabeculectomy skill development. The rapid and sustained effect of resident skill acquisition pose strong arguments for its formal integration into ophthalmic surgical education.

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.

Simulation-based surgical education for glaucoma versus conventional training alone: the GLAucoma Simulated Surgery (GLASS) trial. A multicentre, multicountry, randomised controlled, investigator-masked educational intervention efficacy trial in Kenya, South Africa, Tanzania, Uganda and Zimbabwe.

BACKGROUND/AIM: Glaucoma accounts for 8% of global blindness and surgery remains an important treatment. We aimed to determine the impact of adding simulation-based surgical education for glaucoma. METHODS: We designed a randomised controlled, parallel-group trial. Those assessing outcomes were masked to group assignment. Fifty-one trainee ophthalmologists from six university training institutions in sub-Saharan Africa were enrolled by inclusion criteria of having performed no surgical trabeculectomies and were randomised. Those randomised to the control group received no placebo intervention, but received the training intervention after the initial 12-month follow-up period. The intervention was an intense simulation-based surgical training course over 1 week. The primary outcome measure was overall simulation surgical competency at 3 months. RESULTS: Twenty-five were assigned to the intervention group and 26 to the control group, with 2 dropouts from the intervention group. Forty-nine were included in the final intention-to-treat analysis. Surgical competence at baseline was comparable between the arms. This increased to 30.4 (76.1%) and 9.8 (24.4%) for the intervention and the control group, respectively, 3 months after the training intervention for the intervention group, a difference of 20.6 points (95% CI 18.3 to 22.9, p<0.001). At 1 year, the mean surgical competency score of the intervention arm participants was 28.6 (71.5%), compared with 11.6 (29.0%) for the control (difference 17.0, 95% CI 14.8 to 19.4, p<0.001). CONCLUSION: These results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable trainee glaucoma surgeons to engage in intense simulation training for glaucoma surgery. TRIAL REGISTRATION NUMBER: PACTR201803002159198.

How can we improve the quality of cataract services for all? A global scoping review.

BACKGROUND: Cataract is a leading cause of blindness and vision impairment globally. Cataract surgery is one of the most frequently performed operations worldwide, but good quality services are not universally available. This scoping review aims to summarise the nature and extent of published literature on interventions to improve the quality of services for age-related cataract globally. METHODS: We used the dimensions of quality adopted by WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we added planetary health. On 17 November 2019, we searched MEDLINE, Embase and Global Health for manuscripts published since 1990, without language or geographic restrictions. We included studies that reported quality-relevant interventions and excluded studies focused on technical aspects of surgery or that only involved children (younger than 18 years). Screening of titles/abstracts, full-text review and data extraction were performed by two reviewers independently. Studies were grouped thematically and results synthesised narratively. RESULTS: Most of the 143 included studies were undertaken in high-income countries (n = 93, 65%); 29 intervention groups were identified, most commonly preoperative education (n = 17, 12%) and pain/anxiety management (n = 16, 11%). Efficiency was the quality element most often assessed (n = 58, 41%) followed by people-centredness (n = 40, 28%), while integration (n = 4) and timeliness (n = 3) were infrequently reported, and no study reported outcomes related to planetary health. CONCLUSION: Evidence on interventions to improve quality of cataract services shows unequal regional distribution. There is an urgent need for more evidence relevant to low- and middle-income countries as well as across all quality elements, including planetary health.

Experiences and Perceptions of Ophthalmic Simulation-Based Surgical Education in Sub-Saharan Africa.

BACKGROUND: Simulation-based surgical education (SBSE) can positively impact trainee surgical competence. However, a detailed qualitative study of the role of simulation in ophthalmic surgical education has not previously been conducted. OBJECTIVE: To explore the experiences of trainee ophthalmologists and ophthalmic surgeon educators' use of simulation, and the perceived challenges in surgical training. METHODS: A multi-center, multi-country qualitative study was conducted between October 2017 and August 2020. Trainee ophthalmologists from six training centers in sub-Saharan Africa (SSA) (in Kenya, Uganda, Tanzania, Zimbabwe and South Africa) participated in semi-structured interviews, before and after an intense simulation training course in intraocular surgery. Semi-structured interviews were also conducted with experienced ophthalmic surgeon educators. Interviews were anonymized, recorded, transcribed and coded. An inductive, bottom-up, constant comparative method was used for thematic analysis. RESULTS: Twenty-seven trainee ophthalmologists and 12 ophthalmic surgeon educators were included in the study and interviewed. The benefits and challenges of conventional surgical teaching, attributes of surgical educators, value of simulation in training and barriers to implementing ophthalmic surgical simulation were identified as major themes. Almost all trainees and trainers reported patient safety, a calm environment, the possibility of repetitive practice, and facilitation of reflective learning as beneficial aspects of ophthalmic SBSE. Perceived barriers in surgical training included a lack of surgical cases, poor supervision and limited simulation facilities. CONCLUSIONS: Simulation is perceived as an important and valuable model for education amongst trainees and ophthalmic surgeon educators in SSA. Advocating for the expansion and integration of educationally robust simulation surgical skills centers may improve the delivery of ophthalmic surgical education throughout SSA.

Ophthalmology training in sub-Saharan Africa: a scoping review.

Sub-Saharan Africa is home to 12% of the global population, and 4.3 million are blind and over 15 million are visually impaired. There are only 2.5 ophthalmologists per million people in SSA. Training of ophthalmologists is critical. We designed a systematic literature review protocol, searched MEDLINE Ovid and Embase OVID on 1 August 2019 and limited these searches to the year 2000 onwards. We also searched Google Scholar and websites of ophthalmic institutions for additional information. We include a total of 49 references in this review and used a narrative approach to synthesise the results. There are 56 training institutions for ophthalmologists in eleven Anglophone, eleven Francophone, and two Lusophone SSA countries. The median duration of ophthalmology training programmes was 4 years. Most curricula have been regionally standardised. National, regional and international collaborations are a key feature to ophthalmology training in more than half of ophthalmology training programmes. There is a drive, although perhaps not always evidence-based, for sub-specialisation in the region. Available published scientific data on ophthalmic medical and surgical training in SSA is sparse, especially for Francophone and Lusophone countries. However, through a broad scoping review strategy it has been possible to obtain a valuable and detailed view of ophthalmology training in SSA. Training of ophthalmologists is a complex and multi-faceted task. There are challenges in appropriate selection, capacity, and funding of available training institutions. Numerous learning outcomes demand curriculum, time, faculty, support, and appropriate assessment. There are opportunities provided by modern training approaches. Partnership is key.

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

Importance: Cataracts account for 40% of cases of blindness globally, with surgery the only treatment. Objective: To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees. Design, Setting, and Participants: A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis. Interventions: The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period. Main Outcomes and Measures: The primary outcome measure was overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period. Results: Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95% CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95% CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8% (42 of 537) for the intervention group and 26.6% (54 of 203) for the control group (difference, 18.8%; 95% CI, 12.3%-25.3%; P < .001). Conclusions and Relevance: This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety. Trial Registration: Pan-African Clinical Trial Registry, number PACTR201803002159198.

Interventions to improve the quality of cataract services: protocol for a global scoping review.

INTRODUCTION: Cataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally. METHODS AND ANALYSIS: We will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (<18 years). Two reviewers will screen all titles/abstracts independently, followed by a full-text review of potentially relevant articles. For included articles, data regarding publication characteristics, study details and quality-related outcomes will be extracted by two reviewers independently. Results will be synthesised narratively and presented visually using a spider chart. ETHICS AND DISSEMINATION: Ethical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health. REGISTRATION DETAILS: Open Science Framework (https://osf.io/8gktz).

Ophthalmic Simulated Surgical Competency Assessment Rubric for manual small-incision cataract surgery.

PURPOSE: To develop and test the validity of a surgical competency assessment tool for simulated small-incision cataract surgery (SICS). SETTING: Participating ophthalmologists contributed from 8 countries. DESIGN: Qualitative and quantitative development and evaluation of face and content validity of an assessment rubric, and evaluation of construct validity and reliability. METHODS: The SICS Ophthalmic Simulated Surgical Competency Assessment Rubric (Sim-OSSCAR) was developed and assessed for face and content validity by an international group of experienced ophthalmologists. Groups of novice and competent surgeons from 4 countries were recorded performing surgery, and masked assessments were performed by 4 expert surgeons, to determine construct validity and reliability. RESULTS: The Sim-OSSCAR for SICS was assessed by a panel of 12 international experts from 8 countries. In response to the question, "Do you think the OSSCAR represents the surgical techniques and skills upon which trainees should be assessed?," all respondents either agreed or strongly agreed. Face validity was rated as 4.60 (out of 5.0). The content was iteratively agreed to by the panel of experts; final content validity was rated as 4.5. Interobserver reliability was assessed, and 17 of 20 items in the assessment matrix had a Krippendorff α correlation of more than 0.6. A Wilcoxon rank-sum test showed that competent surgeons perform better than novices (P = .02). CONCLUSIONS: This newly developed and validated assessment tool for simulation SICS, based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric, has good face and content validity. It can play a role in ophthalmic surgical education.

Ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) for trabeculectomy.

BACKGROUND/AIMS: To develop, test and determine whether a surgical-competency assessment tool for simulated glaucoma surgery is valid. METHODS: The trabeculectomy ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) was assessed for face and content validity with a large international group of expert eye surgeons. Cohorts of novice and competent surgeons were invited to perform anonymised simulation trabeculectomy surgery, which was marked using the Sim-OSSCAR in a masked fashion by a panel of four expert surgeons. Construct validity was assessed using a Wilcoxon rank-sum test. Krippendorff's alpha was calculated for interobserver reliability. RESULTS: For the Sim-OSSCAR for trabeculectomy, 58 of 67 surgeons (86.6%) either agreed or strongly agreed that the Sim-OSSCAR is an appropriate way to assess trainees' surgical skill. Face validity was rated as 4.04 (out of 5.00). Fifty-seven of 71 surgeons (80.3%) either agreed or strongly agreed that the Sim-OSSCAR contents represented the surgical technique of surgical trabeculectomy. Content validity was rated as 4.00. Wilcoxon rank-sum test showed that competent surgeons perform better than novices (p=0.02). Interobserver reliability was rated >0.60 (Krippendorff's alpha) in 19 of 20 steps of the Sim-OSSCAR. CONCLUSION: The Sim-OSSCAR for trabeculectomy, a newly developed and validated assessment tool for simulation glaucoma surgery, has validity and reliability. It has the potential to play a useful role in ophthalmic surgical education.

Ophthalmology specialist trainee survey in the United Kingdom.

BACKGROUND: Currently there are a total of 780 post-graduate ophthalmology trainees in the United Kingdom (UK). Post-graduate ophthalmology training in the UK is 7 years in duration, and follows a comprehensive competency-based curriculum. Changes to training have been proposed as part of the government's Shape of Training paper. METHODS: UK ophthalmic trainees and trainers, in partnership with the Royal College of Ophthalmologists, designed a national questionnaire to explore the confidence of trainees in different clinical and non-clinical aspects of ophthalmology. The questions and possible responses underwent a process of refinement through the Royal College of Ophthalmologists Training Committee and Trainee Group. An online survey platform was used for the questionnaire, which was sent to all ophthalmology trainees within the UK. Reminders were sent via the Royal College of Ophthalmologists and Regional Training Programme Directors. A 4-week period was allowed for responses. Quantitative data were analysed, and qualitative data analysis included collation and thematisation of free-text responses. RESULTS: A total of 188 trainees (24.1% response rate) replied. Ninety-four percent of trainees were in full-time training posts. The most popular career choice was oculoplastics (31.4%), followed by vitreo-retina (25.1%), glaucoma (24.6%) and cornea (24.0%). One-quarter had opted out of the European working time directive (EWTD), and 54.8% agreed that their work contract reflected the number of hours actually worked. In total, 34.4% of trainees thought that ophthalmic specialist training should be shortened from the current 7-year programme. Overall, 79.9% of respondents felt confident in performing phacoemulsification cataract surgery independently. For more senior trainees in years 4-7, 100% felt confident in phacoemulsification. However, overall, only 47.9% were confident in independently performing an anterior vitrectomy (91.1% of final-year trainees). Overall, 77.6% thought that all surgical ophthalmologists should be trained to perform cataract surgery. For non-clinical skills, trainees felt least confident in 'preparing a business case', with 64.5% disagreeing that they felt confident in this task. The most confidence was felt for communication with patients: 100% of trainees (all of whom have completed at least 2 years of medical work following qualification) reported feeling confident. CONCLUSIONS: Most doctors in post-graduate specialist training in ophthalmology in the UK aim to specialise in surgical sub-specialities. The subjective reports collected in this survey suggest targets for strengthening of the UK's highly rated training system. Further research is necessary to determine overall satisfaction with training, the effect of changing training within the recent Shape of Training review; and how recent newly imposed junior doctor contracts as well as Brexit affects training.

Factors affecting cataract surgical coverage and outcomes: a retrospective cross-sectional study of eye health systems in sub-Saharan Africa.

BACKGROUND: Recently there has been a great deal of new population based evidence on visual impairment generated in sub-Saharan Africa (SSA), thanks to the Rapid Assessment of Avoidable Blindness (RAAB) survey methodology. The survey provides information on the magnitude and causes of visual impairment for planning services and measuring their impact on eye health in administrative "districts" of 0.5-5 million people. The survey results describing the quantity and quality of cataract surgeries vary widely between study sites, often with no obvious explanation. The purpose of this study was to examine health system characteristics that may be associated with cataract surgical coverage and outcomes in SSA in order to better understand the determinants of reducing the burden of avoidable blindness due to cataract. METHODS: This was a descriptive study using secondary and primary data. The outcome variables were collected from existing surveys. Data on potential district level predictor variables were collected through a semi-structured tool using routine data and key informants where appropriate. Once collected the data were coded and analysed using statistical methods including t-tests, ANOVA and the Kruskal-Wallis analysis of variance test. RESULTS: Higher cataract surgical coverage was positively associated with having at least one fixed surgical facility in the area; availability of a dedicated operating theatre; the number of surgeons per million population; and having an eye department manager in the facility. Variables that were associated with better outcomes included having biometry and having an eye department manager in the facility. CONCLUSIONS: There are a number of health system factors at the district level that seem to be associated with both cataract surgical coverage and post-operative visual acuity outcomes. This study highlights the needs for better indicators and tools by which to measure and monitor the performance of eye health systems at the district level. It is unlikely that epidemiological data alone is sufficient for planning eye health services within a district and health managers and study coordinators need to consider collecting supplementary information in order to ensure appropriate planning can take place.

Ocular surface squamous neoplasia in HIV-positive and HIV-negative patients and response to 5-fluorouracil in Angola.

BACKGROUND: Ocular surface squamous neoplasia (OSSN) is becoming increasingly prevalent and aggressive in Sub-Saharan Africa. It is a phenomenon linked with human immunodeficiency virus (HIV) infection, although association rates in Angola are currently unknown. A topical treatment that is effective in HIV-positive and HIV-negative individuals may be preferable to surgery in some contexts. We aimed to estimate the proportion of OSSN associated with HIV in Angola and to report on the success of topical 5-fluorouracil as a primary treatment in HIV-positive and HIV-negative patients. METHODS: Photographs of OSSNs taken at presentation and following treatment with 5-fluorouracil in patients presenting to Boa Vista Eye Clinic, Angola, between October 2011 and July 2013 were grouped into HIV-positive and HIV-negative groups and analyzed to compare presenting features and treatment response. Eighty-one OSSNs were analyzed for clinical features and 24 met the inclusion criteria for analysis of treatment response. RESULTS: Eighty-two patients presented with OSSN between October 2011 and July 2013. Twenty-one (26%) were HIV-positive and typically had OSSNs that exhibited more pathological features than those in HIV-negative patients. Twenty-four (29%) patients met the inclusion criteria for analysis of treatment response; of these, 26 (91%) OSSNs in both groups displayed at least partial resolution after one treatment course. In the HIV-positive group, five of eight patients displayed complete resolution, two showed partial resolution, and one failed. In the HIV-negative group, five of 16 showed complete resolution, ten of 16 had partial resolution, and one failed. CONCLUSION: Individuals presenting with OSSN in Angola are more likely to have HIV infection compared with the general population. Regardless of HIV status, 5-fluorouracil drops can be an effective strategy for management of OSSN without incurring the costs and risks of surgery in the developing world setting.