|Year : 2022 | Volume
| Issue : 2 | Page : 171-174
Glauco skills for the millennial glaucoma specialist
Shweta Tripathi1, Madhu Bhadauria2, Chandrima Paul3, Murali Ariga4
1 Department of Glaucoma Services, Indira Gandhi Eye Hospital and Research Centre, Lucknow, Uttar Pradesh, India
2 Director, Regional Institute of Ophthalmology and Chief Medical Officer, Sitapur Eye Hospital, Sitapur, Uttar Pradesh, India
3 Director, BB Eye Foundation, Kolkata, West Bengal, India
4 Senior Consultant and Glaucoma Specialist M. N. Eye Hospital, Chennai, Tamil Nadu, India
|Date of Submission||17-Feb-2022|
|Date of Decision||04-Apr-2022|
|Date of Acceptance||04-Apr-2022|
|Date of Web Publication||30-Jun-2022|
Senior Consultant, Glaucoma Services, Indira Gandhi Eye Hospital and Research Centre, Lucknow - 226 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Clinical skills training in Glaucoma is an intergral for the Glaucoma specialist of tomorrow. We discuss the various modalities and resources for glaucoma skills training.
Keywords: Glaucoma,Clinical skills, Millennial specialist
|How to cite this article:|
Tripathi S, Bhadauria M, Paul C, Ariga M. Glauco skills for the millennial glaucoma specialist. TNOA J Ophthalmic Sci Res 2022;60:171-4
With our goal of preparing the glaucoma specialist of tomorrow, it is imperative we lay more emphasis on clinical skills training for the glaucoma trainee.
The enhanced clinical skills training (CSL) will help us lower the burden of the disease by timely intervention with an early diagnosis and prompt management of the disease.
For glaucoma management, not only is a clinical diagnosis of paramount importance, but patient evaluation with its detailed history-taking is an important step-by-step structured building of clinical skills training accomplishment. The journey of the trainee from the novice to the expert can be facilitated with structured clinical training [Figure 1].
The term 'clinical skills' involves history-taking, physical examination, clinical investigations, using diagnostic reasoning, procedural perfection, effective communication, teamwork and professionalism [Figure 2].,,
The CSL can be imparted in the safe environment of clinical skills labs which ensures increased safety for the patient, and more confidence to the trainees with easy access to the repeatability of performance of skills under supervision. The clinical skills lab can be part of training institutes and can be recreated during continued medical, educational activities [Figure 3].
The prerequisites of the training programme are trained motivated facilitators, and a structured training programme encompassing communication, psychomotor, and teamwork skills training. This can be achieved by the use of simulators [Figure 3].
A structured history-taking and slit-lamp examination can be accomplished with clinical pearls for which session can be conducted with a simulated patient. (visual complaints. ocular symptoms, past ocular history, past medical history, past family history, past history of topical and systemic medications, and history of allergy) [Table 1] and [Table 2].
Communication skills are also the prerequisite to counselling patients for glaucoma management to achieve improved adherence and increased compliance to medication. Hahn et al. conducted a study that demonstrated that experienced community physicians significantly improved their communication strategies and ability to detect and address nonadherence after a 3-hour educational program.
Glaucoma is the most important cause of irreversible blindness worldwide. Intraocular pressure (IOP) is the only modifiable significant risk factor in the development of the disease. Accuracy of IOP measurement, therefore, is critical to predicting and monitoring the course of the disease Assessment of angle via gonioscopy plays a key role in diagnosis and management.
Thus the two skills which form the early part of the curve are Applanation tonometry and Gonioscopy by Goldman applanation tonometry (GAT), currently the gold standard. GAT involves a slit-lamp-mounted device with a prism on the tip of the tonometer. This tip is placed against the central cornea, which is anesthetised and stained with topical fluorescein dye. The tonometer head is gently advanced to apply force to the cornea until the inner edges of the two half-circle mires make contact as viewed with a cobalt blue filter through the slit-lamp. Challenges with Applanation and gonioscopy interpretation [Table 3] and [Table 4].
To overcome the challenges of increased practice sessions for postgraduates, an L-shaped bar [Figure 4] was designed in collaboration with Madhu Enterprises. One limb of the attachment was designed to attach to the slit-lamp, and the other circular attachment to allow to fixate the practice eye for the resident, which acts as a simulator for the human eye. The simulated eye that was conceptualized and executed was the goat's eye. This part of the animal body is wasted and can be utilised for educational purposes.
|Figure 4: L-shaped attachment to slit lamp for mounting demonstration eye|
Click here to view
A module was prepared for the skills of applanation tonometry and gonioscopy. The learning objectives were defined. The steps to be demonstrated by the mentor were written step-wise. The pre-reading material is to be shared with the students before the skills session. Each postgraduate is to be mentored by the facilitator and skill demonstrated by the video, followed by the demonstration on the eye. Practice sessions under observance of the facilitator by the mentor advantages are:
- Repeated practice sessions under observance of facilitator
- Increased confidence in students without inhibition to injure the cornea on the human eye while acquiring the skills
- Attainment of competence with feedback and upgradation of skill acquisition
- Patient safety
- With low cost and attachment, the glaucoma companion can be used with various models of slit lamps.
The interpretation of field OCT and disc examination can be imparted with training modules on the basics of interpretation and hands-on activity with case-based scenarios [Table 5],[Table 6], [Table 7].
Trabeculectomy remains the gold standard and cost-effective surgical management for glaucoma. Surgical treatment of glaucoma may be a first-line management strategy in moderate cases and is essential for treating advanced and severe glaucoma. Same can be trained by the use of the simulated animal eye with steps demonstrated by the facilitator and observance by the trainee, the practice as observed by the facilitator, and feedback given for the same.
The need of the hour is to incorporate training modules in the skills training programmes of the postgraduates and fellowship programs.
Dean et al have carried out a study to determine the impact of adding simulation based surgical education for glaucoma. Results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable glaucoma surgeons to engage in intense simulation training for glaucoma surgery. The Sim-OSSCAR for trabeculectomy, a newly developed and validated assessment tool for simulation glaucoma surgery which has validity and reliability can be used for training in trabeculectomy. It has the potential to play a useful role in ophthalmic surgical education.,
Modern surgical training has made attempts to move away from the Halstedian method of “see one, do one, teach one” when training surgical skills., Many curricula now involve the use of simulation-based training prior to undertaking live surgery on patients., This will result in safer surgery and better patient outcomes. These can be accomplished by the use of virtual reality simulators, simulators as the animal eye fixed with the attachment on the mannequin.
A similar module can be incorporated for surgical training for glaucoma valves on the simulated goat's eye. Damagatla et al. have described a method of developing a rubric for Ahmed Glaucoma Valve (AGV) implantation surgery.
For increasing proficiency the use of surgical video and its resources can be shared as prereading material.
The millennial glaucoma specialist needs holistic glaucoma skills training which can be imparted as a part of the residency programme and advanced during the fellowship years. This will help to achieve the goal of reducing the burden of glaucoma with early diagnosis and appropriate management.
Two authors, Dr. Shweta Tripathi and Col (Dr) Madhu Bhadauria, are co innovators with Madhu Enterprises for the L-shaped bar to be attached to the slit lamp. The innovators are in the process of agreement and filing for a patent.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]