Competency in surgery of a resident has been described as the ability of the resident to perform a procedure in a reasonable amount of time while achieving the desired outcome without intervention by a supervisor or complications. Complications in strabismus surgery resulting from improper surgical technique include a slipped or lost muscle. Inadvertent tears in Tenon's capsule can result in the prolapse of orbital fat with fat adherence or restrictive strabismus postoperatively. Reattaching a muscle incorrectly may create unexpected torsion or horizontal or vertical deviation. Recognized scleral perforation (Figure 1) has an incidence of 1.42%1 and may result in vitreous hemorrhage, retinal detachment, endophthalmitis, or chorioretinal scarring. The risk of these complications lessens with the experience level of the surgeon.2–5
Fundus photograph showing scleral perforation a few days after muscle surgery on the lateral rectus muscle.
Many techniques have been employed to minimize the risk of complications for residents beginning surgery, including instructional videos of surgery, observation of surgery, assisting during surgery, and simulated surgery teaching courses.
Effective surgical training programs for residents prior to operating room experience may compensate for differences in the level of knowledge and skill of incoming residents. The development of wet laboratories and simulators for cataract and vitreoretinal surgery in ophthalmology has been widely adopted by residents.6–11 However, simulated programs for strabismus surgery are not widely available or used. In addition, objective measurements of surgical competency remain difficult. The current study investigated the efficacy of an eye muscle surgery course on first- and second-year ophthalmology residents.
Patients and Methods
This prospective cohort pilot study was conducted at Wills Eye Hospital in Philadelphia, Pennsylvania. This study was deemed to be exempt from institutional review board approval by the research committee of Wills Eye Hospital.
First- and second-year postgraduate ophthalmology residents were invited to participate in a 2-hour strabismus surgery practical course developed by several attending pediatric ophthalmologists at Wills Eye Hospital, which is offered annually in the fall. The course consists of a didactic session detailing the steps of strabismus surgery (approximately 50 minutes) followed by a wet laboratory session (approximately 70 minutes). The wet laboratory session simulates strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. The following equipment was provided for each resident: a No. 11 blade, a Castro-Viejo locking needle holder, 0.5 forceps, Westcott scissors (Westcott, Fairfield, CT), a large muscle hook, a 6-0 polyglactin 910 suture on a spatulated needle, surgical loupes, a desk lamp, gloves, the chicken breast model, and a pig eye. Surgical gloves were worn throughout. The raw chicken breast was placed on a stable platform and folded into an oval shape. Using the No. 11 blade, two parallel incisions approximately 10 mm apart were created in the chicken breast in either a horizontal or vertical orientation to simulate a rectus muscle. The area between the incisions was undermined with Westcott scissors to create a strip of muscle tissue still attached to the chicken breast at its distal and proximal ends (Figure 2). Using similar maneuvers to isolate a rectus muscle during strabismus surgery, the strip of chicken breast was hooked. The “muscle” was pulled up with the hook and the proximal end approached similar to the “insertion” of the muscle. A 6-0 polyglactin 910 suture was passed through the chicken strip simulating the muscle with locking bites at each pole. The chicken strip was then disinserted with Westcott scissors and reinserted onto the adjacent chicken breast with the 6-0 polyglactin 910 suture using the technique for scleral passes. The hand position, needle position, and manner of passing the suture can be carefully taught at this juncture. The curvature of the chicken breast can approximate the scleral curvature in each quadrant of the eye by repositioning the chicken breast. Tying the polyglactin 910 suture was also practiced using square knots. After several “muscles” had been detached and reattached in what would be each of the quadrants of an eye using both right- and left-handed passes as indicated, scleral passes with a spatulated needle on a 6-0 polyglactin 910 suture were placed in pig eyes, which were re-inflated with saline and secured to a polystyrene block.
Chicken breast was used to simulate a rectus muscle in the wet laboratory sessions. (A) The chicken strip is pulled up with the hook, (B) a 6-0 polyglactin 910 suture is passed through the “muscle,” and (C) the chicken strip is then disinserted with Westcott scissors.
To assess the effectiveness of the course, a structured self-assessment subjective evaluation form was developed. In addition, a questionnaire in the validated tool called Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) was used.12 The ICO-OSCAR:strabismus is a standardized, internationally valid tool to teach and assess competence in performing strabismus surgery. Ten of 17 steps in the ICO-OSCAR:strabismus were selected as relevant for this course. In particular, steps 5, 7, 8, 9, 10, 13, 14, 15, 16, and 17 were used. Each question had the following score scale rated by the attending ophthalmologist: 0 = unable to perform, 2 = novice, 3 = beginner, 4 = advanced beginner, and 5 = competent. The total score was calculated as the sum of the scores from the 10 selected questions. The questionnaire was administered prior to the course and again after completion of the course.
To compare the change in total score from the modified ICO-OSCAR:strabismus score before and after training, a paired t test was used. The demographics were summarized using mean and standard deviation (SD). Frequencies and percentage for continuous and categorical variables are reported separately. To assess any difference between first- and second-year residents' experience with the training course, Fisher's exact test was used to compare the responses for the three overall assessment questions. In contrast, for the questions regarding subjective experience, knowledge of steps, and understanding of potential complications, an ordinal logistic regression model with repeated measurements was used to test whether the distribution of rating before training differed from the distribution of the rating after training in the same subjects. All statistical tests used two-sided tests with a P value of .05. Analyses were performed using SAS software (version 9.4; SAS Institute, Cary, NC).
A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Eight (67%) residents were male and 4 (33%) were female. The average age was 28.3 ± 1.5 years (range: 27 to 32 years). Eight (67%) of the 12 residents had already performed complete strabismus surgery as a primary surgeon. In particular, 4 of the 8 (50%) first-year residents and all 4 (100%) of the second-year residents had already performed at least one strabismus surgery prior to this course. The mean number of prior eye muscle surgery procedures for each of those residents was 11 ± 9.3 (range: 1 to 25). Specifically, the mean number of prior surgery procedures performed by first- and second-year residents was 5.25 ± 4.9 (range: 1 to 12) and 17 ± 9.2 (range: 8 to 25), respectively. Characteristics of the study population are summarized in Table 1.
Characteristics of the Study Population
Prior to participating in this strabismus surgery course, 8.3% of the residents felt very confident regarding strabismus surgery, 25% felt more or less confident, 25% felt somewhat insecure, and 41.6% felt insecure. There were no significant differences between first- and second-year residents (P = .4950). In contrast, 41.6% of first-year residents had some basic knowledge of the steps for strabismus surgery, whereas 100% of second-year residents had a good understanding of the steps. This difference was statistically significantly different between the two years of residency (P = .0016). Seventy-five percent of the residents reported basic knowledge of the potential complications of strabismus surgery, with no statistically significant difference between first- and second-year residents (P = .4039).
Following the course, most residents (73%) felt less anxious. All residents responded that the course was helpful in preparation for strabismus surgery. Overall, the residents agreed that this training was somewhat helpful, even those residents with prior strabismus surgery experience (Table 2). There was no statistically significant difference in the response to these three assessments between first- and second-year residents. (Table 3).
Subjective Evaluation of the Eye Muscle Surgery Course
Comparison of Overall Assessment for the Eye Muscle Surgery Course
The distribution of ratings regarding questions of subjective experience, knowledge of steps, and understanding of potential complications are listed in Table 4. For all three questions, the residents gave significantly higher ratings after the course (P = .0051, .0050, and .029, respectively). Using the modified ICO-OSCAR:strabismus assessment to evaluate the resident surgical competency, we observed that the mean score before and after training was 28.2 ± 7.76 (median: 32) and 35.4 ± 4.98 (median: 34), respectively. This difference is statistically significant (P = .038) (Table 5).
Response Profile for Questions Before and After the Eye Muscle Surgery Course
First-year residents may have significant variability in clinical knowledge at the start of their surgical training.13 The American Board of Ophthalmology has added “surgery” as the seventh competency to the six core competencies identified by the Accreditation Council for Graduate Medical Education (ACGME).14–16 Effective and validated surgical training programs should be offered for residents prior to operating room experience to compensate for differences in the level of knowledge and skill of incoming residents.13
This study assessed both the effectiveness of a strabismus surgery practical course and first- and second-year residents' perceptions of that course. Acquiring surgical competency is a common concern among residents.17 In fact, there is potential for significant gaps in the basic surgical training between residents, particularly in relation to wet laboratory experience and the opportunity to perform strabismus procedures.18 Typically, surgical training for extraocular muscle surgery occurs through assisting in the operating room,11 but this may not be the best method for residents to learn.19 The environment in an operating room can be perceived as stressful and hostile by residents.20 In addition, this type of teaching session cannot be designed to address a particular resident's needs.17
Both residents and program directors acknowledge the importance of the practice of surgical skills outside of the operating room,21 which may become mandated by the ACGME regarding surgical competence. Indeed, the ACGME's requirements are shifting from the acquisition of medical knowledge to a system that measures actual performance (“show how”) to thus infer professional competence (“do it”).15,16 Although 98% of programs have surgical practice facilities, Binenbaum and Volpe17 showed that fewer programs (64%) have a formal microsurgery teaching course and only 36% of programs mandate practice time in the wet laboratory.
In our study, it is interesting to note that both the first- and second-year residents felt equally insecure about strabismus surgery. Insecurity remained regardless of the year of training, number of prior strabismus cases performed, or knowledge of the steps of surgery and potential complications. The mean number of cases performed was only 11 in this group. Therefore, it is possible that with a greater number of strabismus cases performed, the confidence may have risen. Kim et al.22 found that approximately 50 cases are required for an ophthalmologist to feel confident in strabismus surgery. The first-year residents may have underreported their confidence level or underestimated the difficulty of acquiring the skills needed because their experience was considerably less than that of their second-year colleagues.
Following the strabismus surgery practical course, most residents felt less anxious and reported that the course was helpful in preparation for strabismus surgery. The concentrated teaching during the course may lower the number of surgical cases needed to reach a confidence level, but more studies would be needed to prove this concept. Moreover, the residents agreed that this training was somewhat helpful, even in those residents with prior strabismus surgery experience.
Previous seminars and web-based or interactive presentations have resulted in increased academic performance and sustained retention over traditional teaching alone,23–32 with the added benefits of less inconvenience and discomfort to patients.33 Increasing the training in wet-laboratory types of courses might result in a reduction in surgical time.34–36 Longer resident operating time may translate into greater financial costs for anesthesia and operating room personnel.37,38 However, the validity, efficacy, and cost-effectiveness of various surgical training modalities in ophthalmology seem to be inadequate.39
Learning curve experience in strabismus surgery is similar to that reported in studies of cataract surgery training.35,40,41 However, unlike cataract surgery, for which wet laboratory training has become more common, most strabismus surgery training occurs without a widely accepted, standardized strabismus surgery curriculum and instead occurs intraoperatively.34
Gertsch et al.11 described a Web-based structured simulation curriculum of strabismus surgery using non-cadaveric eye models and reported an improvement in knowledge and comfort level in residents undergoing the course. Similarly, Crespi-Flores et al.42 showed that more practice opportunities and greater supervision of resident procedures may improve the teaching of strabismus surgery.
In attempting to find a readily available and inexpensive tissue, White et al.43 developed a wet laboratory to practice strabismus surgery using bacon as an extraocular muscle substitute.
We recognize that our study has limitations relating to our small sample size. Assessment of the effectiveness of a course is difficult. The ICO-OSCAR:strabismus was created to assess strabismus skills and an ophthalmologist's competence in performing surgery. A validated tool specifically designed to assess skills in an eye muscle surgery course would be desirable. Separating the results by the number of prior strabismus cases performed may have led to a more dramatic improvement recorded in knowledge and skill level. This would influence the timing of such courses in the future. Unfortunately, the small number of participants makes this difficult. Caution should be taken in the interpretation of the data.
This study describes the effectiveness of this eye muscle surgery course to facilitate better preparation in strabismus surgery in first- and second-year postgraduate ophthalmology residents. To the best of our knowledge, a systematic literature review revealed no articles describing analogous courses for strabismus surgery. Given its relatively low expense, the subjective responses of the participating residents, and the objective improvement in skills level, there is confirmation of the efficacy of this approach. Although further studies are essential for testing these findings, our strabismus course may play an important role in strabismus surgical residency training.
- Taherian K, Sharma P, Prakash P, Azad R. Scleral perforations in strabismus surgery: incidence and role of prophylactic cryotherapy: a clinical and experimental study. Strabismus. 2004;12:17–25. doi:10.1076/stra.184.108.40.206014 [CrossRef]
- Noel LP, Bloom JN, Clarke WN, Bawazeer A. Retinal perforation in strabismus surgery. J Pediatr Ophthalmol Strabismus. 1997;34:115–117.
- Morris RJ, Rosen PH, Fells P. Incidence of inadvertent globe perforation during strabismus surgery. Br J Ophthalmol. 1990;74:490–493. doi:10.1136/bjo.74.8.490 [CrossRef]
- Bradbury JA, Taylor RH. Severe complications of strabismus surgery. J AAPOS. 2013;17:59–63. doi:10.1016/j.jaapos.2012.10.016 [CrossRef]
- Rathod D, Goyal R, Watts P. A survey of the management of globe perforation during strabismus surgery in the United Kingdom. Strabismus. 2011;19:63–66. doi:10.3109/09273972.2011.578298 [CrossRef]
- Thomsen AS, Kiilgaard JF, Kjaerbo H, Ia Cour M, Konge L. Simulation-based certification for cataract surgery. Acta Ophthalmol. 2015;93:416–421. doi:10.1111/aos.12691 [CrossRef]
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- Spiteri AV, Aggarwal R, Kersey TL, et al. Development of a virtual reality training curriculum for phacoemulsification surgery. Eye (Lond). 2014;28:78–84. doi:10.1038/eye.2013.211 [CrossRef]
- Rossi JV, Verma D, Fujii GY, et al. Virtual vitreoretinal surgical simulator as a training tool. Retina. 2004;24:231–236. doi:10.1097/00006982-200404000-00007 [CrossRef]
- Spiteri A, Aggarwal R, Kersey T, Benjamin L, Darzi A, Bloom P. Phacoemulsification skills training and assessment. Br J Ophthalmol. 2010;94:536–541. doi:10.1136/bjo.2009.159715 [CrossRef]
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- Golnik KC, Motley WW, Atilla H, et al. The ophthalmology surgical competency assessment rubric for strabismus surgery. J AAPOS. 2012;16:318–321. doi:10.1016/j.jaapos.2012.04.005 [CrossRef]
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- Accreditation Council for Graduate Medical Education. Common program requirements. Accreditation Council for Graduate Medical Education Web site. https://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements. Updated: 2017.
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Characteristics of the Study Population
| Male||8 (67%)|
| Female||4 (33%)|
| First-year||8 (67%)|
| Second-year||4 (33%)|
|Prior strabismus surgery experience|
| Yes||8 (66.7%)|
| No||4 (33.3%)|
| Mean ± standard deviation||28.25 ± 1.48|
| Range||27 to 32|
Subjective Evaluation of the Eye Muscle Surgery Course
|Anxiety after course|
| Equally anxious||3 (25%)|
| Less anxious||8 (67%)|
| Not reported||1 (8%)|
| Completely||5 (42%)|
| Partially||6 (50%)|
| Not reported||1 (8%)|
| More or less useful||4 (33.3%)|
| Very useful||7 (58.3%)|
| Not reported||1 (8.3%)|
Comparison of Overall Assessment for the Eye Muscle Surgery Course
|Evaluated Theme||First-Year Resident Group||Second-Year Resident Group||Pa|
|Anxiety post course||.491|
| Equally anxious||1 (33.3%)||2 (66.6%)|
| Less anxious||6 (75%)||2 (25%)|
| Completely||2 (40%)||3 (60%)|
| Partially||5 (83.3%)||1 (16.6%)|
| More or less useful||2 (50%)||2 (50%)|
| Very useful||5 (71.4%)||2 (28.5%)|
Response Profile for Questions Before and After the Eye Muscle Surgery Course
|Category||Before Course||After Course|
| (1) Insecure||5 (41.6%)||1 (8.3%)|
| (2) Somewhat insecure||3 (25%)||2 (16.6%)|
| (3) More or less confident||3 (25%)||7 (58.3%)|
| (4) Very confident||1 (8.3%)||2 (16.6%)|
| (1) “I don't know any information.”||2 (16.6%)||0 (0%)|
| (2) “I have some basic knowledge of the steps.”||5 (41.6%)||3 (25%)|
| (3) “I have good understanding of the steps.”||5 (41.6%)||9 (75%)|
| (1) “I do not know any information.”||1 (8.3%)||1 (8.3%)|
| (2) “I have some basic knowledge of the complications.”||9 (75%)||3 (25%)|
| (3) “I have good understanding of the complications”||1 (8.3%)||7 (58.3%)|
| (4) “I feel confident to handle basic complications in strabismus surgery.”||1 (8.3%)||1 (8.3%)|
|Measurement||Before Course (n = 5)||After Course (n = 5)||Pa|
| Mean ± standard deviation||28.2 ± 7.76||35.4 ± 4.98|