A novel method for strabismus surgery education using an asynchronous video module

Abstract

Conjunctival closure is an important step in strabismus surgery and a fundamental surgical skill that requires dexterity and understanding of general surgical principles. Traditionally, ophthalmology residents have improved their surgical technique in supervised wet labs. Social distancing guidelines during the COVID-19 pandemic may have limited the ability for direct supervised surgical teaching. We developed a safe, reusable, low-cost teaching module that allows residents to train independently to develop skills necessary for conjunctival closure. This module uses stepwise teaching and video instruction to improve resident confidence and preparedness in conjunctival suturing.

Graphical Abstract

Methods and Materials

Participants in this study included faculty members in the Department of Ophthalmology and Visual Sciences at the University of Maryland, Baltimore. No participating faculty had prior virtual surgical education experience.

A surgical training module was designed for ophthalmology residents to independently practice skills necessary for strabismus surgery. The model representing conjunctival tissue was created using commercially available polyester-spandex (95% polyester, 5% spandex) fabric, which was cut into 6″ × 8″ rectangles. Picture frames (5″ × 7″) were disassembled by removing the glass inserts and cutting 2″ × 4″ rectangles from the cardboard backings (Figure 1A). The fabric was secured into the frames, and three 1” incisions were created (Figure 1B). The price per model was calculated to be $2.27 (fabric cost of $0.19 and picture frame cost of $2.08).

FIG 1.

The back (A) and front (B) of the model shows the fabric, frame, and three 1″ incisions. All instruments and supplies were provided in a kit (C). Residents were instructed to submit the fabric insert of completed trials (D).

Each resident was provided a kit including the model, instructions, and surgical instruments, including Fechtner conjunctiva forceps, Westcott 4–5/8” scissors, Barraquer curved delicate needle holders with lock, 8–0 polyglactin 910 suture with a spatulated needle, and a marking pen (Figure 1C).

Residents viewed instructions with instrument review (eSupplement 1, available at jaapos.org) and a video demonstrating suturing on the model with voiceover (Video 1, available at jaapos.org). Participants then performed the following surgical task: five single interrupted suture closure of the 1″ incision. The module was designed for completion in three formats: (1) at home (unsupervised), (2) via submission of recorded video of their attempts for faculty feedback (asynchronous supervision), and (3) in practice sessions with faculty (live virtual supervision). Our residents utilized all three formats and submitted completed fabric models (Figure 1D) for assessment, but this model can be used to support flexible program goals.

Video 1.

Download video file ^{(56.2MB, mp4)}

Survey Protocol

To assess the perceived quality of the model and video from educators’ perspectives, a six-item electronic survey was distributed to fellowship-trained faculty ophthalmologists at the University of Maryland (eSupplement 2, available at jaapos.org). The physicians reviewed the video (Video 1) and materials (Figure 1, e-Supplement 1) and evaluated the appropriateness of the material, suitability of the module, and the recommended target audience.

Five statements were evaluated for level of agreement on a modified-Likert scale of 1–10 (with 1 indicating strong disagreement and 10 indicating strong agreement). The statements were as follows: (1) “The video presented demonstrated the clinical relevance of this skill”; (2) “The video presented clearly explained how to perform interrupted suture”; (3) “This (module and practice model) is an appropriate teaching tool to practice suturing technique”; (4) “My trainees would benefit from practicing with this model before performing this technique on patients”; and (5) “The material of these models sufficiently mimics human tissue for educational purposes.” The final statement (6) provided options to select trainees of varying training levels: “The following trainees would benefit from this training module.”

Results

Five physicians reviewed the module and completed the survey. All attending physicians indicated strong agreement that the video demonstrated the clinical relevance of this suturing skill, that it clearly explained how to perform the interrupted suture, that the module was an appropriate teaching tool to practice conjunctival suturing, and that trainees would benefit from practicing with this model before performing the technique on patients (median score 10 for all 4 statements). The survey statement about adequacy of fabric material as a model for human conjunctiva for educational purposes received variable responses: 2 (40%) strongly agreed; 2 (40%) agreed, with a score of 8; and 1 (20%) disagreed, with a score of 4. The median score was 9.

All attendings felt this module would specifically benefit fourth-year medical students and first-year ophthalmology residents and all saw value in employing the tool in multiple years of training (Figure 2, statement 6).

FIG 2.

Distribution of responses to statement 6 of the survey from attending ophthalmologists regarding the benefit of the module to trainees of different training levels.

Discussion

The COVID-19 pandemic challenged our strabismus surgery training curriculum to maintain hands-on skill building while adhering to social-distancing guidelines. We sought to incorporate evidence-based techniques including stepwise teaching and video-based education.^1–4 Studies have shown that these approaches reduce complications and improve resident preparedness.^5,6 All attending physicians surveyed strongly agreed that this module is an excellent educational tool that can strengthen suturing techniques in trainees at various levels.

Other materials that have been used for suture training include latex skin pads,⁷ cadaveric animals,⁸ synthetic bench models^8,9 and surgical gloves. These materials are either too expensive, hard to obtain, or do not accurately simulate the thin, stretchy, and delicate nature of the conjunctiva.¹⁰ The ideal material would replicate the membranous conjunctival tissue, be readily available and inexpensive, and clean enough to use outside of wet labs. The polyester-spandex fabric offers an inexpensive and accessible option for repetitive, at-home training modules. Even in the absence of a perfect material, practicing loading and passing needles without a physical wet lab removes traditional barriers to practice. The convenience of practicing at home may also encourage adherence to self-directed training.

This study has several limitations. Our module cannot accurately replicate conjunctival positioning, friability, and stretch. Adequate tension is needed to generate effective closure, but conjunctival positioning maneuvers were beyond the scope of this surgical training model. Additionally, surrounding eye structures, including the sclera and cornea, which are important landmarks for placement of sutures, were not included in our model. Future versions could include an illustrated cornea approximately 8 mm from the incision to replicate this feature. Lastly, our study was purely descriptive and therefore lacked outcomes data and feedback from the trainees. This will be an area of future research.

Strengths of this study included an evidence-based teaching approach, evaluation of anonymous feedback from faculty ophthalmology educators, and use of a highly accessible low-cost model. The module is portable, reusable, has flexibility to mature with the expertise of trainees, as skills can progress from simple interrupted, to buried interrupted, simple running, and locking running suturing techniques, or be modified to teach principles of hand tying.

In conclusion, our novel method for conjunctival closure training effectively demonstrates and promotes practice for a key step of strabismus surgery by providing an affordable model to encourage at-home repetition of important surgical skills. Attending surveys confirmed that this module is an appropriate tool, using a suitable material. Polyester-spandex fabric offered an affordable option but does not perfectly mimic live conjunctival tissue; thus, additional fabric types and other materials should be explored in future studies, which will also directly evaluate the change in objective resident skills outcomes following completion of the module.