The Ophthalmology Surgical Competency Assessment Rubric for External Dacryocystorhinostomy Surgery.

PURPOSE: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tool for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for external dacryocystorhinostomy (ExDCR). METHODS: An international panel of content experts, representing Argentina, India, U.A.E., United Kingdom, and the U.S.A. was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardized OSCAR template as a baseline, developing explicit behavioral descriptors (the behavior and performance expected for each step) that were reviewed and modified with successive models. Learners were scored on a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain. The tool was then reviewed by a secondary panel of international content experts, representing Brazil, India, Iran, Singapore, United Kingdom, and the U.S.A. RESULTS: The final OSCAR ExDCR tool was developed in alignment with the ICO-OSCAR standard. Nineteen agreed and weighted stems were produced. Specific comments with regards to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity. CONCLUSIONS: The OSCAR ExDCR is skill and behavior based, has ICO agreed standards for assessment, and provides learners with specific targets for improvement. Although the OSCAR tool has face and content validity, further development could better elucidate its precise role.

External versus endonasal dacryocystorhinostomy in a specialized lacrimal surgery center.

PURPOSE: To study the duration of surgery, outcomes, adverse events and success rates of external versus endonasal dacryocystorhinostomy (DCR) surgery in a specialized lacrimal surgery center. METHODS: Prospective, interventional case series. Standard external DCR technique was performed. Mechanical endonasal DCR was performed with enlargement of the ostium and full length opening of the lacrimal sac. Surgical time, duration of intubation, incidence of hemorrhage, infection, wound dehiscence; follow-up duration and functional success at the end of follow up were recorded. RESULTS: Functional success and symptomatic relief were equivalent in both procedures. Endonasal DCR surgery was found to be quicker to perform than external DCR surgery. The follow-up duration was comparable in both groups (mean 9 months). Patient satisfaction was significantly higher in the endonasal DCR group (9.3 versus 8.6). CONCLUSION: Endonasal DCR surgery offers a very attractive alternative to the well established technique of external DCR surgery for the treatment of primary acquired nasolacrimal duct obstruction with equivalent success rates, shorter surgical time and higher patient satisfaction.

Sleep position and the ocular surface in a high airflow environment.

PURPOSE: To study the relationship between sleep position and ocular surface symptoms and signs in an high air flow environment. METHODS: Prospective observational study of new patients attending the dry eye clinic was performed. Patients with pre-existing ocular history, relevant systemic history (e.g. Sjogren's syndrome) or who were using topical or systemic therapy for dry eye were not included. Data were collected from the patient to document their dry eye symptoms; preferred dependent sleeping side and their bedroom airflow. All patients were examined by a clinician blind to the patient's responses where Schirmer's test and slit lamp examination were performed looking for the presence of lagophthalmos and corneal epitheliopathy. RESULTS: 48 patients enrolled into the study of which 23 were males and 25 were females with a normal and comparable age distribution. The study found a strong association between patients' preferred sleeping side and the incidence of corneal epitheliopathy in the contralateral eye particularly in patients with evidence of lagophthalmos. Dry eye symptoms were found to be worse and tear production lower on the contralateral side to the preferred sleeping side particularly in patients who sleep in a high airflow environment. CONCLUSION: In patients sleeping in a high airflow environment with nocturnal lagophthalmos, this study observed an association between preferred dependent sleep position and increased dry eye symptoms, lower Schirmer's scores and increased corneal epitheliopathy in the contralateral eye.

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

PURPOSE: To test the validity and reliability of a new tool for assessing residents' competence in ophthalmic surgery. Changing paradigms of ophthalmic education in the United States have influenced worldwide ophthalmic education and necessitated new methods of assessing resident competence. Accordingly, a new tool for assessing residents' competence in ophthalmic surgery (phacoemulsification) that could be applicable internationally was developed. We hypothesize that this instrument is valid and reliable. METHODS: A panel of six international content experts adapted a previously published tool for assessing phacoemulsification. The tool (called the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric, or ICO-OSCAR:phaco) was reviewed by 12 international content experts for their constructive comments, which were incorporated to ensure content validity. Ten expert cataract surgery teachers then graded six recorded phacoemulsification surgeries with the ICO-OSCAR:phaco to investigate inter-rater reliability. RESULTS: The coefficient alpha statistic (a measure of reliability/internal consistency) for the ICO-OSCAR:phaco as a whole was 0.92, and 17 of its 20 dimensions had alpha coefficients greater than 0.70. CONCLUSIONS: The ICO-OSCAR:phaco is a valid and reliable assessment tool that could be applied internationally to satisfy the global need of new instruments to comply with emerging trends in ophthalmic education. A toolbox of similar surgical competency assessment tools is being developed.

Kinematic analysis in oculoplastic reconstructive surgery: measuring manual control and fluidity of movement.

OBJECTIVE: To evaluate higher-order kinematic analysis, a technique not previously applied to surgical skills assessment, as a tool for elucidating patterns of movement. METHODS: An observational cohort study of 27 subjects, divided into 3 equal groups based on surgical experience consisting of novice (performed <5 prior procedures), intermediate (performed 5-100 prior procedures), and expert (performed >100 prior procedures) subjects. The subjects placed a deep 3-1-1 suture onto a shielded hook on a standardized surgical skills practice board. Detailed 3-dimensional motion data were obtained using a motion capture system. Two novel parameters were used to analyze movement patterns: the frequency distribution (cumulative histogram), describing the distribution of movement sizes used, and the probability density function (normalization of frequency distribution data), evaluating the distribution of motion against the magnitude of movement. The α risk for statistical significance was set at .05. RESULTS: We found significant differences among the 3 groups for frequency distribution (P = .02; Kruskal-Wallis test) and probability density function (P = .03). CONCLUSIONS: These 2 indices, derived from kinematic analysis, appear to distinguish between groups of test subjects with known differences in surgical experience. The evaluation of higher-order motion patterns appears to be of value in the objective evaluation of surgical skills. This method for assessment of manual skills is likely to provide a better guide as to which patterns of movement have the greatest efficiency for specific tasks.

The ophthalmology surgical competency assessment rubric for lateral tarsal strip surgery.

PURPOSE: To produce an internationally valid tool to assess skill in performing lateral tarsal strip surgery. METHODS: A panel of 7 content experts adapted a previously published tool for assessing lateral tarsal strip surgery by using a modified Dreyfus scale of skill acquisition and providing behavioral descriptors for each level of skill in each category. The tools were then reviewed by 11 international content experts for their constructive comments. RESULTS: Experts' comments were incorporated, establishing face and content validity. CONCLUSIONS: The tool International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubric for Lateral Tarsal Strip Surgery has face and content validity. It can be used globally to assess lateral tarsal strip surgical skill. Reliability and predictive validity still need to be determined.

Monocanalicular versus bicanalicular intubation in external dacryocystorhinostomy for primary acquired nasolacrimal duct obstruction.

PURPOSE: Monocanalicular intubation offers potential advantages over bicanalicular intubation including ease of removal and use of only one canaliculus. Recent reports suggest equal outcomes with both types of tubes for nasolacrimal intubation. This study aimed to evaluate the outcome of monocanalicular intubation during external dacryocystorhinostomy. METHODS: Fifty-seven lacrimal systems of 54 adults with primary acquired nasolacrimal duct obstruction were prospectively randomized into two cohorts for either bicanalicular intubation (n = 29) or monocanalicular intubation (n = 28) during external dacryocystorhinostomy. All subjects had their symptoms evaluated subjectively according to a modified Munk scale and objectively by the dye disappearance test along with probing and irrigation, pre- and post-operatively. Complete success was defined as a total disappearance of symptoms, partial success as an improvement with some residual symptoms, and failure as an absence of improvement or worsening of symptoms at the last follow-up. Patients with concurrent lid or ocular pathology were excluded. RESULTS: Bicanalicular subjects had a significantly higher complete success rate (21/29, 72.4%) compared to the monocanalicular group (12/28, 42.9%) (p = 0.03). Complications included 3 slit punctuae and 2 early tube removals with bicanalicular intubation; 6 temporary superficial punctate keratopathies, 1 punctal stenosis and 4 premature tube losses occurred with monocanalicular intubation. CONCLUSIONS: Patients with monocanalicular intubation during external dacryocystorhinostomy had a significantly lower success rate than patients with bicanalicular intubation in the treatment of nasolacrimal duct obstruction.

Kinematic analysis of surgical dexterity in intraocular surgery.

OBJECTIVE: To evaluate the potential of motion analysis as a discriminator of surgical skill during intraocular surgery. METHODS: Twenty-four subjects were divided into 3 groups (n = 8 each) based on the number of completed phacoemulsification procedures: novice (n < 10), intermediate (n = 10-150), and expert (n > 150). The Qualisys motion-capture system obtained data from the surgeons performing (1) corneal wound construction (incision), (2) continuous curvilinear capsulorrhexis (CCC), and (3) phacoemulsification lens extraction on artificial eyes. The main outcome measures were time, overall path length, and total number of movements. Statistical significance was set at P < .05. RESULTS: For the incision task, significant differences between the levels of experience were found for time (P = .001), number of movements (P = .001), and path length (P = .05). For the CCC task, significant differences were found between groups for time (P = .03) and number of movements (P = .03), but not for path length (P = .08). For the phacoemulsification task, significant differences were found between the 3 groups for time (P = .04), path length (P = .02), and number of movements (P = .04). CONCLUSIONS: Motion analysis differentiated between surgeons with varying levels of experience performing phacoemulsification tasks, thus demonstrating construct validity. This technique may be useful in the objective quantitative measurement of microsurgical skill with potential applications for training and research.

The practice of dacryocystorhinostomy (DCR) surgery by ophthalmologists in the United Kingdom (UK).

PURPOSE: To study the practice of dacryocystorhinostomy (DCR) surgery by ophthalmologists in the United Kingdom (UK) looking at the evaluation techniques used, surgical variations, and follow-up management of DCR cases. METHODS: A mail-shot questionnaire was designed and distributed to every UK consultant ophthalmologist on the specialist register held by the Royal College of Ophthalmologists. The questionnaire consisted of eight questions and an image of a typical DCR candidate so respondents could illustrate details of their surgical incision. The data received was entered into a database and analyzed with the SPSS statistical package. The variation in incisions was divided into various sub-types and quantified accordingly. The chi-square test and analysis of variance (ANOVA) were used to calculate significance, which was set at p < 0.05. RESULTS: A response rate of over 75% was achieved amongst the 800 questionnaires dispatched, almost one-third of which perform DCR surgery. Of these, almost 50% were non-lacrimal specialists. The majority never use the endonasal approach, with 59% never performing preoperative nasal endoscopy. Most respondents use a standard incision 10-15 mm long with routine silicone intubation. Lacrimal specialists tended to remove tubes earlier (week 4 to 8) and suture posterior flaps more often than non-specialists. Significant differences in practice were found between lacrimal and non-lacrimal specialists in most parameters, in addition to differences between members and non-members of the National Oculoplastic Surgery Society. CONCLUSIONS: A minimum of 200 DCR surgeons are practicing in the UK where almost 50% are non-lacrimal specialists. Marked variations exist in the perioperative DCR practice.

Povidone iodine causes opacification of silicone intraocular lens implants.

PURPOSE: Four cases of silicone intraocular lens (IOL) opacifications presented at a routine cataract service at a UK district general hospital. A systematic investigation was performed to identify and eliminate the causative factor. METHODS: An experiment was set up to determine the role of a chemically induced IOL injury. Silicone IOLs were exposed to the various chemical agents used during cataract surgery. One IOL was not exposed to any chemicals and was used as a control. The samples were then photographed with the same camera settings against the same background in a medical photography studio. RESULTS: All samples photographed using this technique were clear as the unexposed control IOL, except the IOLs that had come into contact with povidone iodine (PI). Exposure to higher concentrations of PI appears to give a greater opacification and staining--a graded effect. CONCLUSION: While the toxic effects of PI on corneal endothelial health is well recognized, as far as the authors are aware no reports exists on the possible harmful effects of PI on IOLs. The results from the current study suggest that exposure of silicone IOLs to even small volumes of 5% PI can lead to IOL opacifying effects. Further studies are needed to determine the toxic effects of PI on all IOL materials. However, based on the results of our study, we strongly recommend extreme caution in the use of PI as prophylaxis against infection at the conclusion of cataract surgery and recommend great care to ensure complete wound closure.

Human Reliability Analysis of Cataract Surgery.

OBJECTIVE: To evaluate the use of the Human Reliability Analysis of Cataract Surgery tool to identify the frequency and pattern of technical errors observed during phacoemulsification cataract extraction by surgeons with varying levels of experience. DESIGN: Observational cohort study. Thirty-three consecutive phacoemulsification cataract operations were performed by 33 different ophthalmic surgeons with varying levels of operative experience: group 1, fewer than 50 procedures; group 2, between 50 and 250 procedures; and group 3, more than 250 procedures. Face and content validity were surveyed by a panel of senior cataract surgeons. The tool was applied to the 33 randomized and anonymous videos by 2 independent assessors trained in error identification and correct tool use. Task analysis using 10 well-defined end points and error identification using 10 external error modes were performed for each case. The main outcome measures were number of errors performed per task, nature of performed errors (executional or procedural), and surgical experience of operating surgeon. RESULTS: Analysis of 330 constituent steps of 33 operations identified 228 errors, of which 151 (66.2%) were executional and 77 (33.8%) were procedural. The overall highest error probability was associated with sculpting, followed by fragmentation of the nucleus; this was most evident in group 1. Surgeons in group 3 proportionally performed more errors during removal of soft lens matter than those in group 1 or 2. Surgical experience had a significant effect on the number of errors, with a statistically significant difference among the 3 groups (P < .001). CONCLUSIONS: The Human Reliability Analysis of Cataract Surgery tool is useful for identifying where technical errors occur during phacoemulsification cataract surgery. The study findings, including the high executional error rate, could be used to enhance and structure resident surgical training and future assessment tools. Face, content, and construct validity of the tool were demonstrated.

Motion analysis as a tool for the evaluation of oculoplastic surgical skill: evaluation of oculoplastic surgical skill.

OBJECTIVE: To evaluate motion analysis as a discriminator of ophthalmic plastic surgical skill between surgeons of varying experience. METHODS: Thirty subjects were divided into 3 groups based on surgical experience: novice (< 5 performed procedures; n = 10), intermediate (5-100 procedures; n = 10), and expert (> 100 procedures; n = 10). Detailed 3-dimensional motion data from surgeons performing 2 oculoplastic surgical tasks on a wet laboratory skills board were obtained using the Qualisys motion capture system. The first task was a deep 3-1-1 suture. The second was skin closure with a continuous suture. The main outcome measures were time, overall path length, and total number of movements. Kruskal-Wallis analysis was performed to evaluate statistical significance. RESULTS: Highly significant differences were found during the skin closure task between all groups for mean time (P = .002), overall path length (P = .002), and number of movements (P = .001). For the deep stitch, highly significant differences were also found for time (P < .001), path length (P < .001), and number of movements (P < .001). CONCLUSIONS: Motion analysis, using this technology, was able to differentiate between surgeons of varying experience performing oculoplastic tasks, thus demonstrating construct validity. This technique may be useful in the objective quantitative measurement of oculoplastic skill, with potential applications for training and research.

Ophthalmic plastic surgical skills assessment tool.

PURPOSE: To present a structured tool to assess ophthalmic plastic surgical skill and to determine its face and content validity. METHODS: A 1-page structured subjective evaluation form was developed to evaluate a resident's oculoplastic surgical skill while performing lateral tarsal strip surgery. The tool consisted of generic task components and global indices evaluated using a 5-point Likert scale. A survey was conducted among a panel of highly experienced oculoplastic surgeons to establish face and content validity of the tool. All feedback was considered and, if feasible, was used to amend the tool. RESULTS: There was more than 90% agreement among the highly experienced oculoplastic surgeons regarding the content and weighting of each assessment component. The final format of the tool is divided in 9 task-specific indices, based on the lateral tarsal strip procedure, and 9 global indices which, after assessment, appraisal, and amendment by our expert panel, demonstrates face and content validity. CONCLUSIONS: The Ophthalmic Plastic Surgical Skills Assessment Tool is a structured, quantitative instrument designed to aid in the oculoplastic surgical evaluation and training of residents.

Modified Ruiz procedure for reducing high astigmatism after penetrating keratoplasty.

PURPOSE: To evaluate the refractive, keratometric, and visual outcomes of a modified Ruiz procedure in patients with high astigmatism after penetrating keratoplasty (PKP). METHODS: Retrospective cohort study with 26 eyes of 24 patients. A modified Ruiz incision pattern was used. Two paired arcuate incisions, centered on the preoperative cylinder axis, were performed over 2 o'clock hours (60 degrees) within the graft. The median optical zone was 4.5 mm (range, 3-5 mm). Subsequently, 4 radial cuts were made. The depth of all cuts was 90%-95% of the central corneal thickness. The follow-up time was 3 months. RESULTS: The mean preoperative subjective cylinder was 8.75 +/- 3.05 D, decreasing to 5.31 +/- 3.12 D postoperatively. Three months after the procedure, 53.8% of the eyes had <5.0 D of refractive astigmatism and 47% of eyes had <5.0 D of keratometric astigmatism. For the refractive data, the mean correction index was 1.95; the mean index of success was 1.27. The mean reduction in spherical equivalent was 1.95 D (60.5%). The mean best-corrected visual acuity (BCVA) was 0.61 and did not change significantly. Three eyes gained 2 or more lines of BCVA, and 1 eye lost 2 or more lines of BCVA. There was no difference in subgroup analysis of eyes treated with 4- (13 eyes) or 5-mm (12 eyes) optical zones. CONCLUSIONS: The modified Ruiz procedure is an effective method to reduce high astigmatism after PKP. However, the results were widely scattered, and the patients need to be informed about the unpredictable outcome and its consequences.

Objective structured assessment of cataract surgical skill.

OBJECTIVE: To evaluate the Objective Structured Assessment of Cataract Surgical Skill scoring system. METHODS: An objective performance rating tool was devised. This instrument is comprised of standardized criteria with global rating and operation-specific components, each rated on a 5-point Likert scale. The total potential score was 100. Complete phacoemulsification cataract extraction operations were recorded through the operating microscope of surgeons with a range of experience (group A, <50 procedures; group B, 50-249 procedures; group C, 250-500 procedures, and group D, >500 procedures). These were then scored by independent expert reviewers masked to the grades of the surgeons. The U test was used to evaluate statistical significance. RESULTS: We evaluated 38 surgical videotapes of 38 surgeons (group A, 11 surgeons; group B, 10 surgeons; group C, 5 surgeons; and group D, 12 surgeons). Mean +/- SD overall scores were as follows: group A, 32.0 +/- 5.3; group B, 55.0 +/- 12.6; group C, 89.0 +/- 4.7; and group D, 90.0 +/- 11.1. Statistically significant differences were found between groups A and B (P = .002) and groups B and C (P = .003), but not between groups C and D (P>.99). CONCLUSION: The Objective Structured Assessment of Cataract Surgical Skill scoring system seems to have construct validity with cataract surgery and, thus, may be valuable for assessing the surgical skills of junior trainees.