The skills and keystone assessment for regional anesthesia (SanKARA) scoring system for evaluating competency in peribulbar anesthesia

Abstract

PURPOSE:

The purpose of this study was to introduce a standardized tool, developed through expert consensus with face and content validation, that integrates a comprehensive rubric with a scoring system for evaluating the ophthalmology residents’ competency in peribulbar anesthesia: The Skills and Keystone Assessment for Regional Anesthesia (SanKARA) Scoring System.

MATERIALS AND METHODS:

A multidisciplinary expert panel from Sankara Eye Hospital, Jaipur, India, each with experience of ≥2000 peribulbar anesthesia blocks, was established to develop a tool that combined a comprehensive rubric outlining essential competency criteria with a scoring system designed to assign numerical values to performance. The explicit behavioral descriptors for each crucial step of the peribulbar block were scored using a modified four-point Dreyfus scale of skill acquisition.

RESULTS:

The SanKARA Scoring System encompassed 20 crucial steps for evaluating competency in peribulbar anesthesia. These steps were further subgrouped into specific categories (pre-procedural-related, procedural-related, and post-procedural-related) to summarize the specific stages of the whole procedure. Key procedural aspects included needle positioning, drug administration, patient monitoring, and adverse event management.

CONCLUSIONS:

The SanKARA Scoring System integrates a structured rubric and scoring system to standardize peribulbar anesthesia training. This system can be globally adopted to assess and improve the training of ophthalmology residents, guide them in learning this paramount skill, and set a global competency benchmark.

Introduction

Peribulbar anesthesia is the most common regional anesthetic procedure performed worldwide in patients undergoing ocular surgery that require concomitant akinesia and analgesia.[1] Compared to retrobulbar anesthesia, it has a lower rate of complications and a higher safety profile.[2] Indeed, peribulbar anesthesia is performed using shorter and smaller needles that do not reach the intraconal space, reducing the risk of inadvertently hitting the optic nerve or other periocular structures, thus reducing life-threatening complications such as respiratory arrest or brainstem anesthesia.[3]

Nowadays, despite anesthesiologists routinely performing different kinds of ophthalmic blocks, regional ophthalmic anesthesia is one of the earliest skills learned by the ophthalmology residents before approaching the operating room and representing a paramount skill in the armamentarium of any ophthalmologist. As with any other medical procedure, the neophytes face a mandatory “learning curve” eased by hands-on supervised exposure and knowledge of orbital anatomy, ophthalmic physiology, and pharmacology.[4] Despite representing the most commonly used technique, neither rubrics, assessment tools, nor scoring systems have been developed to evaluate the ophthalmologists’ competency in performing this procedure.

The International Council of Ophthalmology (ICO) has developed surgical rubrics to instruct, evaluate, and track the advancement of ophthalmic residents during their training for specific “must-know” procedures such as extracapsular cataract extraction, phacoemulsification, small incision cataract surgery, pediatric cataract, vitrectomy, ptosis correction surgery, trabeculectomy, intravitreal injections, external dacryocystorhinostomy, strabismus surgery, and also for extraocular procedures such as laser photocoagulation.[5,6,7,8,9,10,11] Beyond the ICO efforts in developing the ophthalmology surgical competency assessment rubrics (OSCARs), different authors have published their tools, some of which have undergone validation, to assess competency in specific ophthalmology procedures. Indeed, in 2019, Zarei-Ghanavati et al. published their rubric for pterygium surgery.[12]

Notwithstanding the high importance of peribulbar block in ophthalmic surgery, to the best of our knowledge, no standardized tools for assessing ophthalmology residents’ skills in peribulbar anesthesia have been published. Therefore, inspired by the OSCAR framework for surgical skill evaluation, our objective was to create a standardized tool, developed through expert consensus with face and content validation, that integrates a comprehensive rubric delineating essential competency criteria with a scoring system designed to assign numerical values to performance to ease the teaching, assessment, and evaluation of ophthalmologist residents’ competency in peribulbar anesthesia: The Skills and Keystone Assessment for Regional Anesthesia (SanKARA) Scoring System.

Materials and Methods

All the activities related to our study adhered to the tenets of the Declaration of Helsinki. The Ethics Committee reviewed the study and determined that formal ethical approval was not required.

A team of ophthalmologists and anesthesiologists from Sankara Eye Hospital, Jaipur, India, each with experience of ≥2000 peribulbar anesthesia blocks, worked together to develop the explicit behavioral descriptors for each crucial step of the peribulbar block scored using a modified four-point Dreyfus scale of skill acquisition (novice = two points, beginner = three points, advanced beginner = four points, competent = five points).[13] In the SanKARA Scoring System development, the expert panel aimed to develop a tool that combined a comprehensive rubric outlining essential competency criteria with a scoring system designed to assign numerical values to performance. This combined strategy could facilitate qualitative feedback alongside objective assessment of residents’ skills in peribulbar anesthesia.

The previously published OSCAR rubrics that successfully adopted the five-point Dreyfus scale represented the baseline for developing this rubric.[5,6,7,8,9,10,11] The panel decided not to employ the expert category because, given their learning curve, the trainees could not be considered experts. This approach is consistent with all previously published rubrics, which uniformly omit the expert category, as this level of proficiency is not expected during residency.[5,6,7,8,9,10,11] Therefore, the exclusion of the expert category does not compromise the applicability or performance of the tool in practice. In addition, the rubric was designed not to cover assessments of clinical knowledge, decision-making, or communication that were beyond the scope of the assessment tool.

At the earliest stages, each expert panel member was asked to submit 20 crucial points, defined as critical procedural actions (“sentinel steps”) of the peribulbar technique, which were considered essential for mastering the procedure.

Therefore, each member independently proposed 20 crucial points of peribulbar anesthesia to be included in the rubric to obtain a final maximum score of 100 points. After an initial screening of the proposed essential points, the experts analyzed all the submitted crucial points to identify the 20 most vital “sentinel steps.” Specifically, all the submitted “sentinel steps” were collected into a comprehensive list, and redundant or overlapping steps were merged, resulting in unique steps, which were further reviewed and refined through a modified Delphi process involving two rounds of consensus discussions. During the analysis, if consensus could not be achieved among two or three components, another expert with higher experience was employed. After the initial screening, the experts chose the final 20 crucial steps and further subgrouped them into specific categories (preprocedural-related, procedural-related, and postprocedural-related). Afterward, for each essential step of the peribulbar block, they were asked to submit the explicit behavioral descriptors that differentiated the components of skill acquisition needed for each specified category, from novice to competent. These narrative behavioral descriptors were then compared, analyzed, and discussed to identify those that best enhanced the learning process and to develop a structured scoring system ensuring that each crucial step of the peribulbar block consistently matched the four-point Dreyfus scale of skill acquisition, where zero was assigned for not applicable or performed by the preceptor (i.e., the trainee is deemed ineligible for a stage or cannot complete it even with verbal commands) two for novice (i.e., the trainee requires constant supervision and verbal commands at every stage), three for beginner (i.e., the trainee requires minimal instruction or supervisor input), four for advanced beginner (i.e., the trainee completes that stage with minor issues that do not require the supervisor to revise), and five for competent (i.e., the trainee has full competency without supervisor intervention). After the last round of discussions to assess the degree of relevancy and representativeness of the rubric, the panel of experts unanimously agreed to the final rubric version.

Results

Table 1 displays the SanKARA Scoring System for assessing ophthalmologist skills in peribulbar anesthesia. This tool combines a structured rubric with an objective scoring system to improve the reliability of competency evaluation in peribulbar anesthesia.

Table 1.

The skills and keystone assessment for regional anesthesia scoring system for evaluating competency in peribulbar anesthesia

	Novice (score=2)	Beginner (score=3)	Advanced beginner (score=4)	Competent (score=5)	Not applicable/performed by preceptor (score=0)
Preprocedural
1. Equipment and drugs preparation	Does not organize equipment and medications appropriately	Does not organize equipment and medications appropriately	Organizes equipment and medications appropriately	Organizes equipment and medications appropriately
	Not aware of the concentration and volume of the mixture	Prepares the anesthetic mixture with verbal instruction	Requires minimal instruction when preparing the anesthetic mixture	Efficiently checks drug name and expiry date
	Unable to start preparing the anesthetic mixture without instruction		Incomplete check or unsure about aliquot amount or needle diameter	Aliquots the appropriate amount into syringe and uses correct needle diameter
2. Patient communication	Does not explain the procedure to the patient	Inaccurately explains the procedure to the patient	Concisely explains the procedure to the patient	Appropriately explains the procedure to the patient
	Does not provide instructions to follow during the procedure to the patient	Provides inaccurate instructions to follow during the procedure to the patient	Provides incomplete instructions to follow during the procedure to the patient	Provides clear instructions to follow during the procedure to the patient
	Does not provide reassurance before the procedure	Does not provide reassurance before the procedure	Provides inconsistent reassurance before the procedure	Provides adequate reassurance before the procedure
3. Checklist	Fails to identify the patient	Identifies the patient	Identifies the patient	Identifies the patient
	Fails to confirm the site of the surgical procedure	Confirms the site of the surgical procedure	Confirms the site of the surgical procedure	Confirms the site of the surgical procedure
	Does not review the patient’s current systemic status before the procedure (hypertension, use of anticoagulant and antiplatelet medications, allergies)	Partially reviews the patient’s current systemic status before the procedure (hypertension, use of anticoagulant and antiplatelet medications, allergies)	Reviews the patient’s current systemic status before the procedure (hypertension, use of anticoagulant and antiplatelet medications, allergies)	Reviews the patient’s current systemic status before the procedure (hypertension, use of anticoagulant and antiplatelet medications, allergies)
	Does not review the patient’s fitness for anesthesia	Reviews the patient’s fitness for anesthesia	Reviews the patient’s fitness for anesthesia	Reviews the patient’s fitness for anesthesia
	Does not check if the patient has provided and understood the informed consent	Does not check if the patient has provided and understood the informed consent	Partially checks if the patient has provided and understood the informed consent	Adequately checks if the patient has provided and understood the informed consent
	Does not check, monitor and record the vital parameters (blood pressure, heart rate, and oxygen saturation) as per protocol	Checks, monitors, and records the vital parameters (blood pressure, heart rate, and oxygen saturation) as per protocol	Checks, monitors, and records the vital parameters (blood pressure, heart rate, and oxygen saturation) as per protocol	Checks, monitors, and records the vital parameters (blood pressure, heart rate, and oxygen saturation) as per protocol
	Does not check biometrical data, intraocular lens power and/or ocular findings (e.g., axial length, anterior chamber depth, intraocular pressure)	Partially checks biometrical data, intraocular lens power and/or ocular findings (e.g., axial length, anterior chamber depth, intraocular pressure)	Partially checks biometrical data, intraocular lens power and/or ocular findings (e.g., axial length, anterior chamber depth, intraocular pressure)	Adequately checks biometrical data, intraocular lens power and/or ocular findings (e.g., axial length, anterior chamber depth, intraocular pressure)
4. Positioning	Not aware of the optimal position of the patient	Aware of the correct patient’s position despite the patient being evenly positioned	Patient and Doctor positioned in a comfortable position with an adequate bed height, but the doctor is not able to perform the block if the optimal patient’s head position is not totally achieved	Patient and Doctor positioned in a comfortable position with an adequate bed height. If the optimal head positioning is not achievable, the trainee can perform the procedure competently, regardless of the head position
	The patient is poorly positioned	Aware of the correct patient’s position despite being positioned in an uncomfortable position for placing the peribulbar block
	Not aware of the optimal doctor’s position for placement of the peribulbar block	Aware of the optimal bed height despite the height being not appropriate
	Doctor’s position is not optimal for placement of the peribulbar block	Not able to perform the block if optimal head position is not achieved
	Not aware of the optimal bed height
	The bed height is not appropriate
	Not able to perform the block if optimal head position is not achieved
5. Patient examination	Unaware of the importance of ocular and periocular area inspection before the procedure	Aware of the importance of ocular and periocular area inspection before the procedure, but inspect the ocular surface and adnexa before the procedure to check alerting signs such as ongoing inflammatory, allergic, or infective processes after the supervisor input	Aware of the importance of ocular and periocular area inspection before the procedure, and partially inspect the ocular surface and adnexa before the procedure to check alerting signs such as ongoing inflammatory, allergic, or infective processes	Aware of the importance of ocular and periocular area inspection before the procedure, and adequately inspect the ocular surface and adnexa before the procedure to check alerting signs such as ongoing inflammatory, allergic, or infective processes
	Does not inspect the ocular surface and adnexa before the procedure to check alerting signs such as ongoing inflammatory, allergic or infective processes
Procedure
6. Application of local anesthetic	Does not administer anesthetic without supervisor input	Does not require supervisor input to administer anesthetic to the operating eye	Does not require supervisor input to administer anesthetic to the operating eye	Adequately administers the correct amount of the local anesthetic agent to the operating eye without supervisor input
	Unaware of the correct amount of local anesthetic to be administered	Aware of the correct amount of local anesthetic to be administered but inadequate amount of local anesthetic administered	Adequate amount of local anesthetic administered after supervisor input
7. “Painting” the site	Unaware of the correct technique for site “painting”	Aware of the correct technique for site “painting”	Aware of the correct technique for site “painting”	Aware of the correct technique for site “painting”
	Unable to start the site “painting” without the supervisor input	Site “painting” with minimal verbal instruction	Site “painting” is not properly performed (not all areas are covered)	Site “painting” is properly performed (e.g., medial to lateral side covering all areas), and the 5% povidone-iodine skin exposure is≥180 s
			Site “painting” is properly performed (e.g., medial to lateral side covering all areas), but the 5% povidone-iodine skin exposure is <180 s
8. Conjunctival preparation and asepsis	Unaware of the importance of conjunctival preparation and asepsis	Aware of the importance of conjunctival preparation and asepsis	Aware of the importance of conjunctival preparation and asepsis	Aware of the importance of conjunctival preparation and asepsis
	Fails to administer 5%–10% povidone-iodine to the conjunctival fornix	Administers 5%–10% povidone-iodine to the conjunctival fornix after the supervisor input	Administers 5%–10% povidone-iodine to the conjunctival fornix but the 5% povidone-iodine exposure is <180 s	Administers 5%–10% povidone-iodine to the conjunctival fornix and the 5% povidone-iodine exposure is ≥180 s
				Topical chlorhexidine solution used for patients with local irritation/allergy to povidone-iodine
9. Anatomy Identification, eye position, and stability	Unaware of the injection sites	Aware of the injection sites	Aware of the injection sites	Aware of the injection sites
	Not able to identify relevant anatomical landmarks	Not able to identify relevant anatomical landmarks	Not able to identify relevant anatomical landmarks	Accurately identifies relevant anatomical landmarks
	Unable to stabilize eye in primary position before the block	Achieves acceptable eye position and stability with some difficulty	Achieves good eye position and stability	Precisely and consistently stabilizes eye in good position
10. Safety measures before injection	Unaware of the safety measures before injection	Aware of the safety measures before injection	Aware of the safety measures before injection	Aware of the safety measures before injection
	Neither aspiration nor tethering test performed	Only aspiration performed	Only tethering test performed	Aspiration and tethering test performed
11. Needle position, angle, and direction	Unaware of the needle position, angle, and direction	Aware of the needle position, angle, and direction	Aware of the needle position, angle, and direction	Aware of the needle position, angle, and direction
	Unable to perform without instruction	Performs injection with minimal input from the supervisor	Performs injection without input from supervisor	Performs injection without input from supervisor
	Needle endangers the eyeball and/or extraocular structures	Some mistakes in technique in terms of needle angle, position, or direction that neither endanger the eyeball nor extraocular structures	Good technique, but patient distressed during the procedure	Performs injection smoothly with minimal pain with the correct needle angle, position, and direction
12. Drug administration	Unaware of the appropriate volume and concentration of local anesthetic that needs to be injected	Aware of the appropriate volume and concentration of local anesthetic that needs to be injected	Aware of the appropriate volume and concentration of local anesthetic that needs to be injected	Aware of the appropriate volume and concentration of local anesthetic that needs to be injected
	Unable to inject the correct amount of local anesthetic without supervisor instructions	Able to inject the correct amount of local anesthetic without supervisor instructions despite no total analgesia and/or akinesia achieved	Able to inject the correct amount of local anesthetic without supervisor instructions but further injections of anesthetic are required to achieve analgesia and/or akinesia	Administers the appropriate volume and concentration of local anesthetic
				No further injections of anesthetic required to achieve analgesia and/or akinesia
13. Motions and instruments handling	Several unnecessary and awkward movements with the instruments endangering ocular and periocular structures	Some unnecessary movements with the instruments that do not endanger ocular and periocular structures	Efficient movements with the instruments that do not endanger ocular and periocular structures	Clear economy of movement and high efficiency
	Unsure of the procedure and excessive pauses during the whole block to control the patient’s pain	Moderate pauses during the whole block to control the patient’s pain	Adequate pauses during the whole block to control the patient’s pain	Adequate pauses during the whole block to control the patient’s pain
14. Motor functions	No ptosis and no akinesia achieved	Mild ptosis and mild akinesia	Moderate ptosis and moderate akinesia	Complete ptosis and complete akinesia
	Further injections of local anesthetic required	Further injections of local anesthetic required	Further injections of anesthetic required	No further injections of anesthetic required
15. Sensory function	No analgesia achieved	Mild analgesia achieved	Moderate analgesia achieved	Complete analgesia achieved
	Further injections of local anesthetic required	Further injections of local anesthetic required	Further injections of local anesthetic required	No further injections of anesthetic required
16. Patient comfort and communication during the procedure	Does not provide instructions and reassurance throughout the procedure	Inaccurately provides instructions and reassurance throughout the procedure	Concisely provides instructions and reassurance throughout the procedure	Provides clear instructions and reassurance throughout the procedure
	Does not manage patient anxiety and discomfort during the procedure	Poorly manages patient anxiety and discomfort during the procedure	Partially manages patient anxiety and discomfort during the procedure	Manages patient anxiety and discomfort effectively during the procedure
17. Minor adverse events (chemosis, subconjunctival hemorrhage, swelling, injection site ecchymosis)	Unable to identify any of the minor adverse events (subconjunctival hemorrhage, swelling, injection site ecchymosis)	Three out of four Minor Adverse Events (subconjunctival hemorrhage, swelling, injection site ecchymosis) present or chemosis	One out of four Minor Adverse Events present (subconjunctival hemorrhage, swelling, injection site ecchymosis)	No Minor Adverse Events present
	Subconjunctival hemorrhage, swelling, injection site ecchymosis present	Subconjunctival hemorrhage present	Either chemosis or subconjunctival hemorrhage present
18. Major adverse events (retrobulbar or peribulbar hemorrhage, globe perforation or penetration, Oculocardiac reflex, brainstem anesthesia)	Unable to identify the major adverse events	Able to promptly identify but unable to manage the major adverse events	Identifies in time and manages without supervisor input	Efficient and competent without any major adverse events
	Unable to manage the major adverse events	Requires assistance from supervisor for Major Adverse Events management
Postprocedural
19. Postprocedure checklist	Fails to document procedure details, medications administered, and patient response	Poorly documents procedure details, medications administered, and patient response	Partially documents procedure details, medications administered, and patient response	Accurately documents procedure details, medications administered, and patient response
	Fails to provide postprocedure instructions to the patient	Provides inadequate postprocedure instructions to the patient	Provides sufficient postprocedure instructions to the patient	Provides clear postprocedure instructions to the patient
	Fails to monitor patient for signs of local anesthetic toxicity or other complications	Inefficiently monitors patient for signs of local anesthetic toxicity or other complications	Partially monitors patient for signs of local anesthetic toxicity or other complications	Monitors patient for signs of local anesthetic toxicity or other complications
				Documents the procedure accurately in patient records
20. Overall speed and fluidity of procedure	Hesitant, frequent starts and stops, not at all fluid	Occasional starts and stops, and occasional unnecessary movements	Occasional starts and stops, and occasional unnecessary movements	Neither starts and stops nor occasional unnecessary movements
	Peribulbar block duration is not appropriate for case difficulty	Peribulbar block duration is not appropriate for case difficulty	Peribulbar block duration is appropriate for case difficulty	Peribulbar block duration is appropriate for case difficulty

1: If the trainee is deemed ineligible for a stage or cannot complete it even with verbal commands, a score of 0 is assigned to that stage, 2: If the trainee requires constant supervision and verbal commands at every stage, a score of 2 is assigned to that stage, 3: If the supervisor only needs to make minor changes to each step or if the trainee requires minimal instruction, a score of 3 is assigned, 4: If the trainee completes that stage with minor issues that do not require the supervisor to revise, a score of 4 is assigned, 5: A score of 5 indicates competency when there are no issues and the supervisor has nothing to say or do

The SanKARA Scoring System breaks down peribulbar anesthesia into 20 agreed-upon points. The 20 points encompass preprocedural, procedural, and postprocedural relevant domains for peribulbar anesthesia. Specifically, the preprocedural points that are essential to carry out an uneventful block are summarized in rows one to five and encompass the following points: (1) Equipment and Drugs Preparation, (2) Patient Communication, (3) Checklist, (4) Positioning, and (5) Patient Examination for a maximum score of 25 points.

The procedural section focuses on the main steps of the peribulbar block technique. It includes the following 13 crucial agreed steps for a maximum score of 65 points: (1) Application of local anesthetic, (2) Painting the site, (3) Conjunctival preparation and asepsis, (4) Anatomy Identification, eye position, and stability, (5) Safety measures before injection, (6) Needle position, angle, and direction, (7) Drug Administration, (8) Motions and instruments handling, (9) Motor functions, (10) Sensory Function, (11) Patient comfort and communication during the procedure, (12) Minor Adverse Events (Chemosis, Subconjunctival hemorrhage, swelling, injection site ecchymosis), and (13) Major Adverse Events (Retrobulbar or Peribulbar hemorrhage, Globe perforation or penetration, Oculocardiac reflex, brainstem anesthesia). The last section includes the postprocedural points, including the postprocedure checklist and the evaluation of the overall speed and fluidity of the procedure for a maximum score of 10 points.

Discussion

The SanKARA Scoring System represents a distinctive integration of a scoring system that assigns numerical values to trainees’ competence and a structured rubric that delineates essential competency criteria for qualitative assessment, and, to the best of our knowledge, this is the first proposed tool for assessing the ophthalmology residents’ skills in peribulbar anesthesia. The dual methodology improves the reliability of competency evaluation in peribulbar anesthesia by providing both objective, standardized assessments and systematic feedback.

The present tool is designed to address potential critical gaps in peribulbar anesthesia, given that it is the most frequently utilized anesthesiological technique in numerous anterior and posterior ocular surgical procedures and serves as one of the earliest practical skills acquired by residents before engaging in the operating room. By explicitly delineating the skills that the assessor must observe for each proficiency level, this assessment tool aims to minimize subjectivity. Furthermore, the rubric effectively communicates to the learner the expectations necessary to achieve competence, rendering it appropriate for both instructional and evaluative purposes. In addition, documented procedures enhance reflective practice, as trainees can utilize the rubric to assess their performance while reviewing the recorded material and juxtapose their evaluations with the feedback received.

Despite being safer compared to other anesthesiological techniques, such as retrobulbar blocks, peribulbar anesthesia requires a specific learning curve to avoid its sight-threatening and life-threatening complications, such as globe perforation, penetration, and cardiorespiratory arrest related to an inadvertent local anesthetic spread into the central nervous system. Therefore, it is paramount to master this skill to avoid avoidable complications.[2,3]

Despite several established global surgical rating tools for ophthalmic procedures, no consensus exists regarding a standard tool that guides and assesses competency in peribulbar anesthesia. Previous rubrics and scoring systems, many of which were content-validated through expert consensus, such as those developed to guide and evaluate residents’ surgical competency, improved training and instruction quality, accelerated learning curve advancement, recognized strengths and imperfections, encouraged reflective practice, and provided feedback opportunities.[5,6,7,8,9,10,11] Accordingly, we aimed to design a tool combining a scoring system and a structured rubric to bring consistency to training and evaluation in peribulbar anesthesia, offering objective criteria to help assess residents’ performance fairly and effectively.

The SanKARA Scoring System purely and objectively focuses on evaluating peribulbar-specific technical skills. The checklist encompasses 20 critical steps grouped into pre-procedural, procedural, and post-procedural categories, allowing educators to highlight improvement opportunities while guiding the resident through a well-defined learning experience. Regarding the assessment, a revised four-point Dreyfus scale is employed, with the expert level excluded, as it is deemed irrelevant to a trainee. However, a significant benefit of this tool is that it can be used as a formative and summative assessment. Indeed, the rubric comprises a collection of specific behavioral descriptors for each domain, enabling trainers to deliver constructive feedback. Therefore, this approach facilitates trainees’ understanding of their competencies and identifies additional areas requiring further development. Moreover, it facilitates objective and standardized evaluations, reducing differences among observers in competency assessment. Integrating a specific tool for assessing competency within ophthalmology residency training programs can improve patient safety and enhance clinical outcomes. Furthermore, it could reduce the complication rate associated with peribulbar anesthesia among junior and less experienced trainees by facilitating the acquisition of these skills through a structured approach. The tool may also be beneficial in research settings to assess comparative effectiveness of different training methodologies, thus offering insightful analysis on performing ocular anesthesia, potentially improving the quality of ophthalmic training worldwide.

Despite these strengths, our study has some limitations. First, although local experts contributed to face and content validation of the tool, further studies are necessary to assess its reliability and reproducibility in various training centers. Thus, further prospective studies on interrater reliability and the association of scoring performance with clinical outcomes may help highlight the tool’s utility in daily clinical practice. Second, the rubric includes multiple points, which could make it lengthy and cumbersome, possibly hindering the tool’s adoption. However, the tool is intentionally comprehensive to facilitate the authors’ objective of both teaching and assessment utilizing the same tool. Third, while the tool aims to align with internationally accepted competency assessment principles, it has not yet undergone external, international validation to confirm its applicability beyond the current local training setting. Finally, although the tool underwent face and content validation through expert consensus during development, no formal statistical validation (such as inter-rater reliability, construct validity, or correlation with clinical outcomes) was performed in the present study. These aspects will need to be addressed in future prospective and multicenter research.

Nevertheless, despite its limitations, the most significant strength of the SanKARA Scoring System lies in its dual nature that combines a scoring system and a structured rubric to bring consistency to training and evaluation in peribulbar anesthesia, offering objective criteria to help assess residents’ performance fairly and effectively. Furthermore, although the SanKARA Scoring System was primarily developed for ophthalmologists, it can also be utilized by anesthesiologists to assess and enhance their peribulbar anesthesia competencies. Moreover, the tool can be a foundation for developing comparable evaluation instruments applicable to other ocular block methodologies. This, in turn, could enhance the quality of training globally.

Conclusions

The SanKARA Scoring System provides a structured and objective method for evaluating ophthalmology trainees’ proficiency in peribulbar anesthesia, with its primary strength lying in the integration of a detailed rubric and a numerical scoring system. By incorporating this tool into training curricula, instructors may enhance patient safety, improve the quality of residency education, and promote higher standards in peribulbar anesthesia teaching. Future directions include formal validation at our center – assessing inter-rater reliability, construct validity, and correlation with clinical outcomes – as well as external and multicenter validation to establish broader applicability. Such efforts will be essential to confirm its impact on training outcomes and clinical practice. Ultimately, the SanKARA Scoring System has the potential to serve as a model for competency assessment in ocular block techniques, thereby contributing to the advancement of ophthalmic education worldwide.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.