Embracing technology in cataract surgical training - The way forward.

While ophthalmology as a surgical branch itself has evolved technologically with newer instruments, techniques and procedures; ophthalmic surgical training appears to have stagnated in terms of how it is delivered and how trainees' learning and performance are assessed. This collaborative editorial attempts to identify the lacunae in ophthalmic residency training and highlight how technological tools such as surgical simulators can be incorporated into ophthalmic training even in limited-resource settings with good results.

Estimation of the Prevalence of Uncorrected Refractive Error and Other Ocular Morbid Conditions in School Children of Industrial Area in a Non-metro City in India.

Purpose This study aims to estimate the prevalence of uncorrected refractive error and ocular morbid conditions in school-going children of the Pimpri Chinchwad Municipal Corporation (PCMC) industrial belt. Methods Ocular examination was done in a well-equipped mobile clinic on school premises in the presence of a school teacher using visual acuity (VA) charts, autorefractometer, retinoscope, and handheld slit lamp. For the age group of 5-6 years, Lea symbols and HOTV charts were used, and for the age group of >7 years, Snellen's chart was used. A detailed anterior segment examination was done to see lid position, the presence of any lid swelling, conjunctival congestion, conjunctival xerosis, corneal opacity, and lens opacity, and findings of previous eye surgery were noted. Spectacle correction was given to these students if they were found to have a significant refractive error. Children requiring intervention other than refractive correction were referred to a tertiary hospital. Results A total of 3,054 school children were examined. Most were between the age group of 11-15 years (2,448 (80.2%)), with a mean age of 12.45 ± 2.022 years; 1,470 (48.1%) were male children. A total of 368 (12.04%) children had uncorrected refractive error. Myopia was seen in 204 (6.68%) children, hypermetropia in 16 (0.52%) children, and astigmatism in 148 (4.85%) children. On classification, simple myopic astigmatism (SMA) was found in 73 (2.39%) children, compound myopic astigmatism (CMA) in 38 (1.24%) children, simple hypermetropic astigmatism (SHA) in 13 (0.34%) children, and compound hypermetropic astigmatism (CHA) in 16 (0.52%) children. Moreover, 121 children had ocular morbid conditions. Ocular morbidity with decreased vision was seen in 52 (1.7%) children with preexisting refractive error and 12 (0.39%) with amblyopia, and strabismus was seen in eight (0.26%) children. Five (0.16%) children had lens disorder, and five (0.16%) had no improvement with glasses despite normal anterior segment. Conclusion There was a high prevalence of uncorrected refractive error. Early detection of uncorrected refractive error and ocular morbidity will improve overall performance in school-going children.

Eye screening can be used to perform anemia screening and treatment in adolescent girls using ToucHb.

Purpose: Anemia is common in adolescent girls. Apprehension while drawing blood to estimate hemoglobin concentration is a barrier for confirming anemia. ToucHb, a noninvasive instrument that estimates the hemoglobin by taking an image of the exposed conjunctiva, was used during eye screening to help diagnose and treat anemia. Methods: ToucHb was used during secondary school eye screening and during house-to-house eye screening to estimate the hemoglobin concentration in the body. Each of the girls was distributed a packet of 60 tablets of ferrous and folate and a tablet of albendazole. They were followed up after 3 months. Results: Exactly 1511 municipal school girls aged 10-19 years (mean 12.9; standard deviation [SD] 1.64) were examined. Of them, 949 (62.8%) had hemoglobin of ≤9 mg%. Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.1 (1.4) and 9.6 (1.03), respectively, by paired t-test (P < 0.001). Another 588 girls (average age 14.4 years, SD 1.2) had their eyes examined and hemoglobin estimated during a house-to-house eye screening. Of them, 116 (19.7%) had hemoglobin level of ≤9 mg%. Their pre-Hb was 7.9 (SD 1.05) on average and after 3 months, it was 9.6 (SD 1.02). Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.2 (1.4) and 7.9 (1.1), respectively, by paired t-test (P < 0.001). Conclusion: ToucHb was useful to diagnose anemia while doing eye screening and to ensure its treatment. Anemia diagnosis and management would enhance the health of adolescent girls.

Ophthalmology residency trainers' perspective on standardization of residency training in India.

Purpose: The aim of this study was to study the perception of residency trainers about an optimum residency program. Methods: A survey, using a pre-validated questionnaire, was conducted by the Academic and Research Committee of the All India Ophthalmological Society, in 2019-20 with questions directed to teachers in medical colleges and national board of examination's ophthalmology residency programs on demography, teaching experience, imparting clinical and surgical skills, ideal academic schedule and dissertation in the post-graduate residency program. Results: The response rate in the survey was 47.6%. Valid responses were obtained from 309 residency trainers. Of these, 132 of 309 (42.7%) were females. The mean age was 45.3 ± 9.5 years, range 26-68 years. The trainers believed that on a scale of 0-10, clinical skills teaching should be taught, mean ± SD: slit lamp 9.8 ± 0.7; indirect ophthalmoscopy 9.3 ± 1.3; gonioscopy 9.2 ± 1.5; perimetry 8.9 ± 1.5; OCT 8.4 ± 1.9; applanation tonometry 9.5 ± 1.2 and orthoptic evaluation 8.1 (±1.9). A resident should ideally perform independently surgeries (median, inter-quartile range IQR): SICS 50 (IQR 40-100); phaco 50 (20-60); pterygium excision 20 (10-40); DCR 10 (5-20); chalazion 20 (10-50), trabeculectomy 7 (5-15); strabismus 5 (2-10), LASIK and retinal detachment 0. Ideally there should be four lectures, four seminars, four case presentations, five journal clubs and four wet labs every month. Conclusion: Teachers expected their wards to become competent professionals. There was near unanimity about the content of clinical skills training, non-medical skills and academics, but there was a significant variation on extent of surgical training that should be imparted to the residents.

A new normal with cataract surgery during COVID-19 pandemic.

Cataract is the second leading cause of preventable blindness on the globe. Several programs across the country have been running efficiently to increase the cataract surgical rates and decrease blindness due to cataract. The current COVID-19 pandemic has led to a complete halt of these programs and thus accumulating all the elective cataract procedures. At present with the better understanding of the safety precautions among the health care workers and general population the Government of India (GoI) has given clearance for functioning of eye care facilities. In order to facilitate smooth functioning of every clinic, in this paper, we prepared preferred practice pattern based on consensus discussions between leading ophthalmologists in India including representatives from major governmental and private institutions as well as the All India Ophthalmological Society leadership. These guidelines will be applicable to all practice settings including tertiary institutions, corporate and group practices and individual eye clinics. The guidelines include triage, use of personal protective equipment, precautions to be taken in the OPD and operating room as well for elective cataract screening and surgery. These guidelines have been prepared based on current situation but are expected to evolve over a period of time based on the ongoing pandemic and guidelines from GoI.

The impact of COVID-19 related lockdown on ophthalmology training programs in India - Outcomes of a survey.

Purpose: In 2020, in response to the emergence and global spread of the disease COVID-19, caused by a new variant of coronavirus 2019-nCoV, the government of India ordered a nationwide lockdown for 21 days, which was then extended to a total of over 50 days. The aim of this study is to assess the effect of the lockdown on ophthalmic training programs across India. Methods: An online survey was sent across to trainee ophthalmologists across India through various social media platforms. Results: In all, 716 trainees responded; the average age was 29.1 years. Results showed that majority of the respondents were enrolled in residency programs (95.6%; 685/716) and the others were in fellowship programs. About 24.6% (176/716) of the trainees had been deployed on 'COVID-19 screening' duties. Nearly 80.7% (578/716) of the trainees felt that the COVID-19 lockdown had negatively impacted their surgical training. Furthermore, 54.8% (392/716) of the trainees perceived an increase in stress levels during the COVID-19 lockdown and 77.4% (554/716) reported that their family members had expressed an increased concern for their safety and wellbeing since the lockdown began. In all, 75.7% (542/716) of the respondents felt that online classes and webinars were useful during the lockdown period. Conclusion: Our survey showed that majority ophthalmology trainees across the country felt that the COVID-19 lockdown adversely affected their learning, especially surgical training. While most found online classes and webinars useful, the trainees' perceived stress levels were higher than normal during the lockdown. Training hospitals should take cognizance of this and reassure trainees; formulate guidelines to augment training to compensate for the lost time as well as mitigate the stress levels upon resumption of regular hospital services and training. Going ahead, permanent changes such as virtual classrooms and simulation-based training should be considered.

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.

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.

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.

Residency evaluation and adherence design study: Young ophthalmologists' perception of their residency programs II: Academics and Research dissertation.

PURPOSE: To know the perception of young ophthalmologists about their dissertation and academics during residency training in order to improve the research output during present residency programs in India. METHODS: A survey was conducted by Academic and Research Committee of the All India Ophthalmological Society, the world's second largest ophthalmic professional's organization, in 2014-2016 of young ophthalmologists (those who completed residency between 2005 and 2012) to gauge usefulness of dissertation or thesis during postgraduate residency. RESULTS: There were 1005 respondents, of whom 531 fulfilled inclusion criteria. On a scale of 0-10, residents rated level of supervision of their dissertation as adequate (mean 5.9/10, standard deviation [SD] = 3.1, median = 6). The level of infrastructure available was for dissertation rated as 5.9/10 (median = 7, SD = 3.1), and 6.2/10 was the score that residents said about value added by the dissertation (median = 7). The dissertation was presented at local (33.5%), state (28.1%), national (15.4%), and international (4%) levels. Students, not supervisors, did most of the local and state level presentations. It was published in some forms at local 210 (39.5%), state (140, 26.4%), national (94, 17.7%), and international (39, 7.3%) levels. On a scale of 0-4, seminars (3/4) and case presentations were (3/4) rated higher than didactic lectures (2.2/4), journal clubs (2.2/4), and wet laboratory (1.1/4). CONCLUSION: Peer-reviewed publications from Indian residency training dissertations were few. Residents felt dissertation added value to their training, but there was a huge range among the responses. Journal clubs and wet laboratories were not graded high in academic programs, unlike seminars and case presentations.

Outcomes of Pediatric Cataract Surgery in the Copperbelt Province of Zambia.

PURPOSE: To study the outcomes of pediatric cataract surgeries in children operated on in the Copperbelt Province of Zambia and the barriers to accessing surgery. METHODS: All children who had congenital, developmental, and traumatic cataracts operated on by lens aspiration, primary posterior capsulotomy, and anterior vitrectomy with posterior chamber intraocular lens implantation from 2012 to 2013 and followed up beyond 6 months were studied. Each child underwent a comprehensive preoperative evaluation. An active, assisted follow-up was done and parents were asked about reasons for delay between presentation and surgery. RESULTS: One hundred two eyes of 70 children met the inclusion criteria of the study. Preoperatively, 76 of 77 (98.7%) eyes in the congenital and developmental cataract group had presenting visual acuity of worse than 6/60. This improved postoperatively, with 19 (29.7%) eyes having best corrected visual acuity (BCVA) of better than 6/18, 23 (35.9%) having BCVA of 6/24 to 6/60, and 22 (34.4%) having BCVA of worse than 6/60. Older age (P = .005), better preoperative vision (P = .045) at presentation, unilaterality (P = .012), and delay between presentation and surgery (P = .004) were predictors of a better postoperative outcome. On multivariate analysis, only age was significant (P = .025). Distance and cost of travel and surgery were the causes of delay in presentation. In the patients with traumatic cataracts, 17 of 25 (68%) had BCVA of better than 6/18, 6 (24%) had BCVA between 6/24 and 6/60, and 2 (8%) had BCVA of worse than 6/60 at the 6-month follow-up. The most common causes of injury were being struck by sticks and stones (10 children, 25%). CONCLUSIONS: Visual outcomes after pediatric cataract surgery in Zambia were comparable and satisfactory. Cost of treatment was a barrier, but delay did not adversely affect outcome. [J Pediatr Ophthalmol Strabismus. 2016;53(5):311-317.].

Comparison of the Posterior Capsule Rupture Rates Associated with Conventional (Start to Finish) Versus Reverse Methods of Teaching Phacoemulsification.

PURPOSE: Comparison of the rates of posterior capsule rupture (PCR) associated with conventional versus a reverse method of teaching phacoemulsification. METHODS: Trainees were taught conventional (start-to-finish) phacoemulsification beginning with an incision (tunnel construction) to capsulorhexis, sculpting, nucleus cracking, segment removal, cortex aspiration, intraocular lens implantation, and viscoelastic removal. In the reverse method, after incision and capsulorhexis, the trainees were progressively taught viscoelastic wash, cortex aspiration, segment removal, nucleus cracking, sculpting, and intraocular lens implantation. Trainees from a Tertiary Eye Care Centre were classified as beginners, for their first 30 cases and then trainees for their next 70 surgeries. Data were collected on posterior capsular rent and vitreous loss during each step of training. RESULTS: Thirty-two ophthalmic surgeons learning phacoemulsification surgery on 609 cataracts cases were supervised by 3 trainers. Fifteen beginners performed 287 surgeries using the conventional method, and 17 beginners performed 322 surgeries with the reverse method. The incidence of PCR was 18/287 (6.2%) with the conventional method and 15/322 (4.6%) with the reverse method (P = 0.38). PCR occurred during cortex aspiration (8/287, 2.8%) and segment removal (5/287, 1.7%) in the conventional method. PCR occurred during nucleus cracking, segment removal, and cortex aspiration (4/322 surgeries for each step, 1.2%). In the follow, 70 cases (trainees) there was no difference in PCR with either method (4.7% vs. 4.3%, P = 0.705). CONCLUSION: Conventional and reverse method for training phacoemulsification were both safe in a supervised setting.