Is time really of the essence? Timeliness of narrative feedback in ophthalmology CBME assessments.

PURPOSE: Competency-based medical education relies on a strong program of assessment, and quality comments play a vital role in ensuring its success. The goal of this study is to determine the effect of the timeliness of assessment completion on the quality of the feedback. MATERIALS AND METHODS: Using the Quality of Assessment for Learning (QuAL) score 2478 assessments were evaluated. The assessments included those completed between July 2017 and December 2020 for 18 ophthalmology residents. Spearman correlation, Mann-Whitney U and Kruskal-Wallis tests were used to assess variations in QuAL scores based on the timeliness of assessment completion. RESULTS: The timeliness of assessment completion ranged from 0 to 299 d with the mean time for completion being 3 d. As the delay increased, the QuAL score decreased. Feedback provided 4, 5, and 14 d post-encounter demonstrated statistically significant differences in the QuAL score. Additionally, there was a significant difference in the timeliness of feedback when there is no written comment. CONCLUSIONS: This study demonstrates that the timeliness of assessment completion might have an effect on the quality of written feedback. Written feedback should be completed within 14 d of the encounter to optimize quantity and quality.

Using a rapid-cycle approach to evaluate implementation of competency-based medical education in ophthalmology.

OBJECTIVE: As competency-based medical education is being implemented across Canada, there is an increasing need to evaluate the progress to date, including identification of strengths and weaknesses, to inform program development. Ophthalmology is preparing for a national launch in coming years. The purpose of this study was to describe key stakeholders' lived experiences in the competency-based medical education foundation-of-discipline stage in one ophthalmology department. DESIGN: Using a case-study approach, a qualitative rapid-cycle evaluation was conducted during the 2018-2019 academic year. PARTICIPANTS: Residents, faculty, academic advisors, competence committee members, the program director, the program administrator, and the educational consultant were invited to participate in the program evaluation. METHODS: The rapid-cycle evaluation consisted of 2 evaluation cycles, with the first round of interviews and focus groups occurring in October 2018 and the second round in March 2019. Recommendations were implemented in November 2019 and June 2019. All data were analyzed thematically using NVivo. RESULTS: Three main themes emerged across all data sets: developing a shared understanding (e.g., role expectations and changes to assessment), refining assessment processes and tools (e.g., the need for streamlining and clarification), and feedback (e.g., perceived benefits and value of narrative comments). CONCLUSIONS: Exploring lived experiences in this study resulted in positive and immediate improvements to the residency program. The recommendations and approach will be useful to other Canadian departments and institutions as they prepare for Competence by Design.

Smartphone Compatible versus Conventional Ophthalmoscope: A Randomized Crossover Educational Trial.

Objective The aim of the study is to compare performance and ease-of-use (EOU) of optic disk assessment using a smartphone direct ophthalmoscope attachment (D-EYE) to the gold standard direct ophthalmoscope (DO). Design The type of study involved is prospective, randomized, crossover, and educational trial. Participants The participants involved were first year medical students inexperienced in ophthalmoscopy. Methods Optic disks of standardized and volunteer patients were examined using the D-EYE and a conventional DO. Optic disk identification, EOU ratings of the devices, self-reported confidence level in their examination with the devices, and estimation of vertical cup-to-disk ratio (VCDR) were compared. Analyses included Chi-square tests, independent samples t -tests, correlations, and multivariable linear regression. Results Forty-four medical students voluntarily participated in the study. Students using the DO required more attempts (3.57 vs. 2.69, p = 0.010) and time (197.00 vs. 168.02 seconds, p = 0.043) to match the patient's fundus to the correct photograph. Overall EOU between the devices (6.40 vs. 4.79, p < 0.001) and overall confidence in examination (5.65 vs. 4.49, p = 0.003) were greater when using the D-EYE. There were no statistically significant differences in accuracy of VCDR estimations between the two ophthalmoscopes. Conclusion Smartphone ophthalmoscopy could offer additional learning opportunities in medical education and may be considered in clinical practice by non-specialist physicians given its greater EOU and increased success in visualizing the optic disk.

Involving ophthalmology departmental stakeholders in developing workplace-based assessment tools.

OBJECTIVE: As competency-based medical education (CBME) rolls out across Canada, the assessment process is changing. Our purpose was to involve stakeholders in the selection and modification of workplace-based assessment (WBA) tools for use in an ophthalmology residency program. DESIGN: This is a qualitative case study conducted in one ophthalmology department at a midsized teaching hospital in eastern Ontario. PARTICIPANTS: Ophthalmology faculty and residents within the Emergency Eye Clinic participated in the study. METHODS: Phase 1 consisted of faculty piloting the tools and providing written feedback. Phase 2 consisted of 2 focus groups, 1 for residents (n = 9) and 1 for faculty (n = 6), to explore their experiences with the 4 piloted adapted WBA tools. RESULTS: Residents and faculty discussed ongoing issues with buy-in and formalizing feedback through the new assessment process. Residents also reiterated the need for more constructive feedback delivered in a timely and sensitive manner. Generally, residents did not value numerical scales on the tools and preferred written comments. Both residents and faculty valued oral over written feedback given the interactive nature of oral feedback. CONCLUSIONS: This study provides insight into faculty and resident perspectives about WBA tools within one ophthalmology department. These results informed the development of WBA tools within the department and highlighted the importance of shifting the assessment culture to accommodate programmatic approaches to assessment in CBME. Involving key stakeholders in the change process has been a valuable strategy. Future research should examine whether or not these perspectives change after CBME implementation.

Use of a fundus photograph matching program in imparting proficiency in ophthalmoscopy.

OBJECTIVE: To determine whether practice using an online fundus photograph program results in a long-term increase in proficiency with direct ophthalmoscopy skills in medical students. DESIGN: This study was a prospective medical education trial. Students were enrolled to participate in a voluntary Objective Structured Clinical Examination (OSCE) using 5 patients with ocular findings. Students who matched a minimum of 6 discs 16 months before the study were assigned to the intervention group and were compared with students who did not participate in the exercise. PARTICIPANTS: Forty-six second-year medical students at Queen's University: 15 in the intervention group and 31 in the control group. METHODS: Students were evaluated using the Queen's University Ophthalmoscopy OSCE Checklist (QUOOC). Students were asked to calculate the cup-to-disc ratio, comment on disc margins, and whether there was any macular pathology. Students participated in a summative OSCE as part of the curriculum in which all students attempted to match fundus photographs. RESULTS: Students in the intervention group performed significantly better on the QUOOC, with a mean score of 78.3% (± 4.2), compared with the control, who had a mean score of 69.4% (± 4.2) (p = 0.005). The intervention group was significantly more accurate at matching optic nerve photographs, with 100% (15/15) of the students correctly identifying the correct optic nerve on first attempt compared with 53.3% (16/30) in the control group (p = 0.0014). CONCLUSIONS: The use of an online peer fundus photograph program leads to a long-term increase in examination technique, proficiency in ophthalmoscopy, and accuracy at matching optic nerve photographs.

YouTube videos in the English language as a patient education resource for cataract surgery.

PURPOSE: To assess the quality of the content of YouTube videos for cataract surgery patient education. SETTING: Hotel Dieu Hospital, Kingston, Ontario, Canada. DESIGN: Observational study. METHODS: "Cataract surgery," "cataract surgery for patients," and "cataract surgery patient education" were used as search terms. The first two pages of search results were reviewed. Descriptive statistics such as video length and view count were obtained. Two cataract surgeons devised 14 criteria important for educating patients about the procedure. Videos were analyzed based on the presence or absence of these criteria. Videos were also assessed for whether they had a primary commercial intent. RESULTS: Seventy-two videos were analyzed after excluding 48 videos that were duplicate, irrelevant, or not in English. The majority of videos came from a medical professional (71%) and many depicted a real cataract surgery procedure (43%). Twenty-one percent of the videos had a primary commercial intent to promote a practice or product. Out of a total possible 14 points, the mean number of usefulness criteria satisfied was only 2.28 ± 1.80. There was no significant difference in view count between the most useful videos and other videos (p = 0.94). Videos from medical organizations such as the National Health Service were more useful (p < 0.0001). CONCLUSIONS: Cataract surgery videos are popular on YouTube, but most are not adequately educational. Patients may be receiving biased information from videos created with primary commercial intent. Physicians should be aware of the type of information patients may be accessing on YouTube.

Evaluation of an online peer fundus photograph matching program in teaching direct ophthalmoscopy to medical students.

OBJECTIVE: Direct ophthalmoscopy is an important clinical skill that is often poorly performed by medical professionals and students. This is attributable to a declining emphasis on ophthalmology in medical school. We present and evaluate a self-directed approach of teaching ophthalmoscopy to medical students that is suitable for the current medical curriculum. DESIGN: Prospective medical education trial. PARTICIPANTS: Ninety-five second-year medical students at Queen's University: 32 in the experimental group and 63 in the control group. METHODS: The experimental group consisted of medical students who practised ophthalmoscopy with one another using an online peer fundus photograph matching exercise created by the Department of Ophthalmology at Queen's University. To use the program, students first examined a peer with an ophthalmoscope and then selected an online photograph of a fundus corresponding to that of the examinee. The program notifies students if a correct selection is made. To encourage use of the program, students participated in a 2-week ophthalmoscopy competition during their ophthalmology rotation. The control group consisted of students who did not participate in the learning exercise. RESULTS: On assessment at the end of the ophthalmology rotation, the experimental group (n = 32) was more accurate in matching fundus photographs compared with the control group (n = 63) (p = 0.02). Participants were faster at performing ophthalmoscopy at the end of the learning exercise (p < 0.01). All students in the experimental group reported increased confidence levels in ophthalmoscopy after participation in the learning exercise. CONCLUSIONS: Matching online peer fundus photographs in a self-directed manner appeared to increase the skill and confidence of medical students in ophthalmoscopy.

Creation and validation of a simulator for corneal rust ring removal.

OBJECTIVE: To create and validate a simulation model for corneal rust ring removal. METHODS: Rust rings were created on cadaveric eyes with the use of small particles of metal. The eyes were mounted on suction plates at slit lamps and the trainees practiced rust ring removal. An inexperienced cohort of medical students and first year ophthalmology residents (n=11), and an experienced cohort of senior residents and faculty (n=11) removed the rust rings from the eyes with the use of a burr. Rust ring removal was evaluated based on removal time, percentage of rust removed and incidence of corneal perforation. A survey was administered to participants to determine face validity. RESULTS: Time for rust ring removal was longer in the inexperienced group at 187±93 seconds (range of 66-408 seconds), compared to the experienced group at 117±54 seconds (range of 55-240 seconds) (p=0.046). Removal speed was similar between groups, at 4847±4355 pixels/minute and 7206±5181 pixels/minute in the inexperienced and experienced groups, respectively (p=0.26). Removal percentage values were similar between groups, at 61±15% and 69±18% (p=0.38). There were no corneal perforations. 100% (22/22) of survey respondents believed the simulator would be a valuable practice tool, and 89% (17/19) felt the simulation was a valid representation of the clinical correlate. CONCLUSION: The corneal rust ring simulator presented here is a valid training tool that could be used by early trainees to gain greater comfort level before attempting rust ring removal on a live patient.

Bone strength estimates relative to vertical ground reaction force discriminates women runners with stress fracture history.

PURPOSE: To determine differences in bone geometry, estimates of bone strength, muscle size and bone strength relative to load, in women runners with and without a history of stress fracture. METHODS: We recruited 32 competitive distance runners aged 18-35, with (SFX, n=16) or without (NSFX, n=16) a history of stress fracture for this case-control study. Peripheral quantitative computed tomography (pQCT) was used to assess volumetric bone mineral density (vBMD, mg/mm3), total (ToA) and cortical (CtA) bone areas (mm2), and estimated compressive bone strength (bone strength index; BSI, mg/mm4) at the distal tibia. ToA, CtA, cortical vBMD, and estimated strength (section modulus; Zp, mm3 and strength strain index; SSIp, mm3) were measured at six cortical sites along the tibia. Mean active peak vertical (pkZ) ground reaction forces (GRFs), assessed from a fatigue run on an instrumented treadmill, were used in conjunction with pQCT measurements to estimate bone strength relative to load (mm2/N∗kg-1) at all cortical sites. RESULTS: SSIp and Zp were 9-11% lower in the SFX group at mid-shaft of the tibia, while ToA and vBMD did not differ between groups at any measurement site. The SFX group had 11-17% lower bone strength relative to mean pkZ GRFs (p<0.05). CONCLUSION: These findings indicate that estimated bone strength at the mid-tibia and mean pkZ GRFs are lower in runners with a history of stress fracture. Bone strength relative to load is also lower in this same region suggesting that strength deficits in the middle 1/3 of the tibia and altered gait biomechanics may predispose an individual to stress fracture.

Drug-prescribing patterns among optometrists and nonophthalmologist physicians at a tertiary care centre in Kingston, Ontario.

OBJECTIVE: To report on patterns of optometry prescribing and adherence to prescribing regulations at a tertiary care ophthalmology centre. DESIGN: Prospective cohort study. PARTICIPANTS: All new referrals from optometrists and other health care professionals to the emergency eye care service (n = 1965) between July 2011 and June 2012, as well as optometry referrals to 2 subspecialty services (glaucoma [n = 71] and cornea [n = 212]). METHODS: In our primary analysis, the frequency of prescribing and classes of medications prescribed were reported and compared amongst various referral sources to the emergency eye care service. As a secondary analysis, we reported frequency of prescribing in optometry referrals to 2 subspecialty clinics. Adherence to prescribing guidelines was reported for all optometry referrals. RESULTS: Of 296 referrals from optometrists to the emergency eye care service, 20 (6.8%) had received a prescription medication; this was significantly less compared to emergency and family physicians (p < 0.001). Topical antibiotics were the most frequently prescribed medication class. The frequency of prescribing by optometrists was 5.2% (11/212) and 4.2% (3/71) for patients referred to the cornea and glaucoma services, respectively. Among those patients referred after being given a prescription for a glaucoma medication by an optometrist, 89% cases (8/9) did not adhere to prescribing regulations. CONCLUSIONS: After the introduction of prescribing privileges, optometrists prescribe a variety of medications in their practices. Current prescribing guidelines are not always followed in practice, suggesting that continued study and collaboration is necessary to create an optimal model of interdisciplinary care that provides access to the highest quality of care.

Punctal Plug Retention Rates for the Treatment of Moderate to Severe Dry Eye: A Randomized, Double-Masked, Controlled Clinical Trial.

PURPOSE: To compare retention rates of Super Flex (Eagle Vision, Memphis, Tennessee, USA; Softplug-Oasis Medical Inc, Glendora, California, USA) vs Parasol (Odyssey Medical, Memphis, Tennessee, USA; Beaver Visitec International, Waltham, Massachusetts, USA) punctal plugs. DESIGN: Randomized, double-masked, interventional controlled clinical trial. METHODS: Institutional study at Hotel Dieu Hospital (Queen's University) of 50 eyes, from patients with moderate to severe dry eye. Each eye from eligible patients was separately randomized to receive Super Flex or Parasol punctal plugs. The main outcome measure was plug retention at 6 months. Secondary outcome measures included objective tests of Schirmer I (mm), tear meniscus height (mm), tear break-up time (s), inferior fluorescein corneal staining (National Eye Institute [NEI] scale), and average lissamine green conjunctival staining (NEI scale). RESULTS: Punctal plug retention was significantly different at 6 months (P = .011). Sixty-eight percent of Parasol plugs were retained compared to 32% of Super Flex plugs. Parasol plugs required less frequent artificial tear use at 6 months (P = .024). There was a statistically significant improvement in all secondary outcome measures (Schirmer, tear meniscus height, tear break-up time, fluorescein corneal staining) at 6 months within plug groups except conjunctival staining. There were no additional significant differences between groups and no plug complications reported. CONCLUSIONS: Punctal plugs improve symptoms of moderate to severe dry eye; however, retention rates differ significantly. These data will allow us to guide patient decision making for the safe and effective treatment of punctal plugs for moderate to severe dry eye.

Relative importance of the components of the Canadian Residency Matching Service application.

OBJECTIVE: The primary goal of this project was to investigate Canadian ophthalmology residency program directors' and department heads' perceptions about the relative importance of the various components of the Canadian Residency Matching Service (CaRMS) application package. Secondary goals were: (i) to investigate the perceptions of all program directors and department heads at Queen's University's residency programs; and (ii) to compare faculty's perceptions with the perceptions of medical students at Queen's University. DESIGN: Survey. PARTICIPANTS: Queen's University medical students, Queen's University faculty, and Canadian Ophthalmology faculty participated in this survey. METHODS: A validated survey was administered to faculty and students. The study targeted program directors and department heads of 15 Canadian ophthalmology residency programs, 18 residency programs at Queen's University, as well as 404 medical students at Queen's University. Qualitative questions were included in the faculty survey. Quantitative data were analyzed with nonparametric tests. Qualitative data were organized according to primary themes. RESULTS: Response rates ranged from 64% to 87%. On a scale of 1 to 4 in order of increasing importance, faculty and students respectively assigned the highest scores to the following components: interview performance (3.73, 3.89), electives (3.64, 3.83), reference letters (3.53, 3.74), and personal letter (3.27, 3.58). For all 4 components, student scores were significantly higher than faculty scores. First- and fourth-year medical students' scores differed significantly in eight areas including research experience and volunteer experience. In both of these components, there were statistical differences between fourth-year student scores and faculty scores, whereas the first-year class had scores that were comparable with faculty scores. Queen's University faculty and Ophthalmology faculty did not differ significantly. Faculty scores also did not differ significantly based on age or sex. CONCLUSIONS: Faculty and students agreed on the most important components of the application, but significant differences were found in their perceptions of the relative importance of other components.

Evaluating the need for close follow-up after removal of a noncomplicated corneal foreign body.

PURPOSE: The purpose of this study was to evaluate the need for close follow-up after removal of noncomplicated corneal foreign bodies. METHODS: This is an observational prospective cohort study of 60 eyes in noncontact lens wearers with corneal foreign bodies outside the visual axis. Foreign bodies were removed and patients were followed as per the Wills Eye Manual guideline for 1 to 3 days after foreign body extraction, and every 3 to 5 days until resolution of the epithelial defect. Patients were asked to record their symptoms of eye pain, eye irritation, eye redness, and visual acuity on a visual analog scale to monitor symptoms related to development of infectious keratitis. The primary endpoint was resolution of the epithelial defect. RESULTS: The average time to resolution of the epithelial defect was 4.34 ± 1.56 days, with an average of 2.2 ± 1.23 follow-up visits after removal. One patient developed infectious keratitis (1.67%). Symptoms showed a statistically significant improvement in patients who had healed epithelial defects, and a statistically significant worsening in the 1 patient who developed infectious keratitis (sensitivity = 1 and specificity = 0.915). CONCLUSIONS: Few noncomplicated injuries develop infectious keratitis. We recommend fewer follow-ups for these injuries. However, if patients develop any worsening in eye pain, irritation, redness, or decrease in their visual acuity, they should return promptly for reassessment.

Orbital compartment syndrome in a burn patient without aggressive fluid resuscitation.

INTRODUCTION: Orbital compartment syndrome may rarely occur in the setting of burns where therapy includes aggressive fluid resuscitation. CASE: We report a case of bilateral orbital compartment syndrome in a 13-year-old male, with superficial facial burns secondary to hydrobromic acid, who did not receive aggressive fluid resuscitation. The patient was treated successfully with bilateral lateral canthotomy and cantholysis. COMMENT: Facial burns may lead to orbital compartment syndrome without aggressive fluid resuscitation, likely due to excessive leakage of fluid and protein into the orbit combined with an inflammatory reaction.

Electromyographic analysis of the rotator cuff in postoperative shoulder patients during passive rehabilitation exercises.

BACKGROUND: Numerous rehabilitation protocols exist for postoperative rotator cuff repairs. Because the goal of early rehabilitation is to prevent postoperative adhesions while protecting the repaired tendons, it would be advantageous to know which range-of-motion exercises allow the rotator cuff to remain the most passive in a painful, guarded, postsurgical shoulder. METHODS: Twenty-six subjects who had undergone subacromial decompression, distal clavicle resection, or a combination of both procedures volunteered to participate within the first 4 days after surgery. Fine-wire electrodes were inserted into the subject's supraspinatus (SS) and infraspinatus (IS). Muscle activity was recorded at resting baseline (BL) and during 14 exercises that have been found in the passive phase of rotator cuff protocols and tested in healthy subjects. Each exercise was compared with BL activity as well as with other exercises in the same movement group. RESULTS: The SS remained as passive as BL during therapist- and self-assisted external rotation, therapist-assisted elevation, pendulums, and isometric internal rotation and adduction. The IS was activated greater than BL for all 14 exercises studied. CONCLUSION: Of the 14 exercises studied, 6 allowed the SS and 0 allowed the IS to remain as passive as quiet-stance BL in postsurgical subacromial decompression/distal clavicle resection patients.

Influence of Donor Tissue Factors on Detachment Rate in DSAEK Patients.

Purpose. To determine whether the rate of graft detachment in patients undergoing the DSAEK procedure is influenced by the time elapsed between donor death and tissue implantation. Methods. Data on procedure outcome and donor tissue for patients undergoing the DSAEK procedure were reviewed. Data on time elapsed between harvest, processing, storage, and implantation of the tissue, as well as donor tissue endothelial cell count were obtained from reports made available from the Eye Bank of Canada. The adverse outcome of interest was graft detachment. Results. 71 cases were reviewed, with 14% resulting in detachment. The following time periods were compared between detachment and nondetachment groups: donor death to enucleation; enucleation to processing; duration of storage at the Eye Bank to implantation. No statistically significant differences were found (Student's t-test, P > 0.05). Endothelial cell counts of donor tissue were compared between the two groups, and no statistically significant difference was found (Student's t-test, P > 0.05). Conclusion. The range of processing times and endothelial cell counts in donor tissue available from the Eye Bank did not predict a change in the rate of graft dislocation in one surgeon's practice.

Effect of prophylactic nonsteroidal antiinflammatory drugs on cystoid macular edema assessed using optical coherence tomography quantification of total macular volume after cataract surgery.

PURPOSE: To evaluate the efficacy of prophylactic administration of the topical nonsteroidal antiinflammatory drug (NSAID) ketorolac tromethamine 0.5% on acute (within 4 weeks of surgery) cystoid macular edema (CME) and total macular volume (TMV) in patients having phacoemulsification cataract surgery. SETTING: Department of Ophthalmology, Queen's University, Hotel Dieu Hospital, Kingston, Ontario, Canada. METHODS: This open-label nonmasked randomized (random number assignment) study comprised 106 eyes of 98 patients. Exclusion criteria included hypersensitivity to the NSAID drug class, aspirin/NSAID-induced asthma, and pregnancy in the third trimester. Ketorolac tromethamine 0.5% was administered starting 2 days before surgery and for 29 days after surgery for a total of 31 days. The outcome measure was macular swelling, which was quantified by the optical coherence tomography. RESULTS: At 1 month, there was a statistically significant difference in TMV between the control group (0.4420 mm3) and the ketorolac group (0.2392 mm3), with the ketorolac group having 45.8% less macular swelling (P = .009). Multiple linear regression with backward selection indicated a 44.3% (P = .013) and 46.1% (P = .030) reduction in macular swelling in the ketorolac group at 1 week and 1 month, respectively. CONCLUSION: Used prophylactically after cataract surgery, ketorolac 0.5% was efficacious in decreasing postoperative macular edema.