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 Table of Contents  
Year : 2022  |  Volume : 60  |  Issue : 2  |  Page : 171-174

Glauco skills for the millennial glaucoma specialist

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 Submission17-Feb-2022
Date of Decision04-Apr-2022
Date of Acceptance04-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Shweta Tripathi
Senior Consultant, Glaucoma Services, Indira Gandhi Eye Hospital and Research Centre, Lucknow - 226 001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_24_22

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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

How to cite this URL:
Tripathi S, Bhadauria M, Paul C, Ariga M. Glauco skills for the millennial glaucoma specialist. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Nov 27];60:171-4. Available from: https://www.tnoajosr.com/text.asp?2022/60/2/171/349520

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].[1]
Figure 1: [1]Drefus five-stage model of skill acquisition

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The term 'clinical skills' involves history-taking, physical examination, clinical investigations, using diagnostic reasoning, procedural perfection, effective communication, teamwork and professionalism [Figure 2].[2],[3],[4]
Figure 2: Skills learned in a clinical skills lab

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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].
Figure 3: Clinical skills trainers

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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].[5]
Table 1: Clinical pearls for history taking

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Table 2: Clinical pearls for slit-lamp examination

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Communication skills are also the prerequisite to counselling patients for glaucoma management to achieve improved adherence and increased compliance to medication. Hahn et al.[6] 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.[7]

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].
Table 3: Clinical pearls for Goldmann applanation tonometry

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Table 4: Clinical pearls for Gonioscopy

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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

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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].[7]
Table 5: Clinical pearls for ONH evaluation

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Table 6: Clinical pearls for perimetry

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Table 7: Clinical pearls for OCT.[8]

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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.[8],[9]

Modern surgical training has made attempts to move away from the Halstedian method of “see one, do one, teach one” when training surgical skills.[10],[11] Many curricula now involve the use of simulation-based training prior to undertaking live surgery on patients.[8],[12] 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.[13]

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.

  References Top

Peña A. The Dreyfus model of clinical problem-solving skills acquisition: A critical perspective. Med Educ Online 2010;15. doi: 10.3402/meo.v15i0.4846.  Back to cited text no. 1
Boulay CD, Medway C. The clinical skills resource: A review of current practice. Med Educ 1999;33:185-91.  Back to cited text no. 2
Bradley P, Postlethwaite K. Setting up a clinical skills learning facility. Med Educ 2003;37(Suppl. 1):6-13.  Back to cited text no. 3
Sebiany AM. New trends in medical education: The clinical skills laboratories. Saudi Med J 2003;24:1043-7.  Back to cited text no. 4
McMonnies CW. Glaucoma history and risk factors. J Optom 2017;10:71-8.  Back to cited text no. 5
Hahn SR, Friedman DS, Quigley HA, Kotak S, Kim E, Onofrey M, et al. Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma. Ophthalmology 2010;117:1339-47.  Back to cited text no. 6
Mazhar S. Nuggets in clinical approach to diagnosis of glaucoma. J Clin Ophthalmol Res 2013;1:175-81.  Back to cited text no. 7
  [Full text]  
Ophthalmologists TRCo. Simulation Information for Surgical Trainers. June, 2015. Available from: https://www.rcophth.ac.uk/wpcontent/uploads/2015/06/Web-doc-simulation-information.pdf. [Last accessed on 2017 Mar].  Back to cited text no. 8
DeanWH, Buchan J, Gichuhi S, Philippin H, Arunga S, Mukome A, et al. Simulation-based surgical education for glaucoma versus conventional training alone: The Glaucoma Simulated Surgery (GLASS) trial. A multicentre, multicountry, randomised controlled, investigator-masked educational intervention efficacy trial in Kenya, South Africa, Tanzania, Uganda and Zimbabwe.Br J Ophthalmol 2021:bjophthalmol-2020-318049. doi: 10.1136/bjophthalmol-2020-318049.  Back to cited text no. 9
Dean WH, Buchan J, Admassu F, Kim MJ, Golnik KC, McNaught A, et al. Ophthalmic simulated surgical competency assessment rubric (Sim-OSSCAR) for trabeculectomy. BMJ Open Ophthalmol 2019;4:e000313.  Back to cited text no. 10
Gonzalez-Gonzalez LA, Payal AR, Gonzalez-Monroy JE, Daly MK. Ophthalmic surgical simulation in training dexterity in dominant and nondominant hands: Results from a pilot study. J Surg Educ 2016;73:699-708.  Back to cited text no. 11
Ophthalmology AAo. Simulation in resident education. 2019. Available from: https://www.aao.org/simulation-in-residenteducation. [Last accessed 2019 Jun].  Back to cited text no. 12
Damagatla M, Krishnamurthy R, Senthil S. Surgical skill assessment rubric for Ahmed glaucoma valve implantation surgery. Indian J Ophthalmol 2021;69:1008-13.  Back to cited text no. 13
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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]


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