Impact of COVID-19 pandemic on ophthalmology medical student teaching: educational innovations,challenges, and future directions

Graduate medical education (GME) in ophthalmology has faced and overcome many challenges over the past years, and 2020 has been a game-changer. Although the severe acute respiratory syndrome coronavirus pandemic disrupted medical education globally, ophthalmic educators rapidly transformed their curricula to novel and effective virtual learning formats. Thus, while the COVID-19 outbreak has been one of the most significant challenges faced in the history of medical education, it has also provided an impetus to develop innovative teaching practices, bringing with it unprecedented success in allowing medical students to continue their education in ophthalmology despite these challenges. We review and appraise novel educational interventions implemented by various institutions in response to the COVID-19 pandemic, highlighting their effectiveness, challenges and proposing future directions beyond the pandemic. Many of these innovations will persist even after the end of the pandemic because they have proven that face-to-face learning is not required for all aspects of the ophthalmic GME curriculum. As ophthalmic educators harness the power of educational technology it is critical that their novel educational initiatives are incorporated into competency-based curricula with assessments mapped to the competencies. Future research should focus on evaluating the impact of this transformation to virtual learning environments on student performances as well as implementing longitudinal assessment strategies for clinical competence in workplace-based practice.     

The Impact of the First Peak of the COVID-19 Pandemic on a Paediatric Ophthalmology Service in the United Kingdom: Experience from Alder Hey Children’s Hospital

Objective:The COVID-19 pandemic has led to significant service loss across the NHS, and ophthalmology is one of the greatest affected specialties. We attempt to quantify the impact of the first peak of the COVID-19 pandemic on a paediatric ophthalmology unit in a children’s hospital in the United Kingdom (UK) and report lessons learnt to aid in the recovery of the service.Methods and Analysis:Two eight-week periods of clinical activity were compared; one during the first UK peak of the COVID-19 pandemic and the other during a similar period the previous year. Four areas of clinical activity were included in the study: outpatient clinic appointments, theatre activity, outpatient referrals to ophthalmology and ward reviews. Appointment data was collected from departmental databases.Results:During the first peak of the pandemic, outpatient clinic appointments were reduced by 87.2%, ophthalmic surgery by 90.9%, outpatient referrals to ophthalmology by 50.2% and ward reviews by 50%. The number of actual cancelled appointments was 1377, of which 6.8% were triaged as suitable for teleophthalmology.Conclusion:The COVID-19 pandemic has dramatically restricted clinical activity in the ophthalmology service. Paediatric ophthalmology is vulnerable to capacity issues and the consequences of delayed or cancelled appointments. Departments must adapt quickly and maximise capacity to help reduce the backlog and treat patients effectively and safely. Solutions such as teleophthalmology have potential although can be difficult in the paediatric population.     

Adoption of newer teaching methods to overcome challenges of training in ophthalmology residency during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has disrupted training programs across all specialties. Surgical specialties, such as ophthalmology, that need continued microsurgical training are affected the most. The pandemic has resulted in ophthalmology residents being taken off their regular duties in ophthalmology and inducted into COVID duties. The focus on COVID care has de-emphasized training in ophthalmology. We highlight the challenges that teachers face in continuing the training programs of theory, clinical skill, and surgical skill transfer. Embracing technology is the need of the hour. We discuss the multiple options available to enable continued training programs and emphasize the need for all training institutes to include technology as an additional component of their training curricula.     

Prevalence and effectiveness of innovative techniques in ophthalmic surgical training during COVID-19 pandemic in India

Purpose:This study aimed to determine the various innovative surgical training techniques prevalent among ophthalmology residents in India during the COVID-19 pandemic.Methods:This was a prospective cross-sectional study. An online survey questionnaire was completed by ophthalmology residents from different parts of the country. The survey consisted of questions related to the impact of the pandemic on training, innovative training techniques adapted during the pandemic and their effectiveness, and COVID-19 duty-related information.Results:A total of 147 responses were obtained. The mean age was 29.3 years (range: 24–40 years, SD: ±3.82). Of which, 87 (59.2%) respondents were females. A total of 61 (41.5%) respondents reported practicing steps of ocular surgeries on goat eye, 69 (46.9%) on model eye/vegetables/fruits, 30 (20.4%) on surgical simulators, and 26 (17.7%) utilized 3-D virtual images and videos. In addition, 22 (15%) respondents reported never using any such techniques. Furthermore, 130 (88.4%) respondents reported practicing steps of cataract surgery, 52 (35.4%) practiced steps of open globe repair, and steps of trabeculectomy were reported by 24 (16.3%). The steps that were reported to be practiced most are incision or tunnel construction by 108 (73.5%), suturing by 92 (62.6%), capsulorrhexis by 91 (61.9%), primary wound repair by 82 (55.8%), and conjunctival peritomy by 75 (51%).Conclusion:The present study demonstrates that residents across the country are adapting to the present scenario by utilizing several innovative methods to sharpen their surgical acumen. The current pandemic situation can serve as an impetus to emphasize upon the institutes and medical regulatory bodies to appropriately remodel the residency curriculum.     

Retrospective analysis of ophthalmology referrals during the COVID-19 pandemic compared to prepandemic

ObjectiveThis study was conducted to analyse emergency ophthalmology referrals to a Canadian tertiary academic centre during the current coronavirus disease 2019 (COVID-19) pandemic in comparison to prepandemic referrals.DesignThis was a retrospective chart review looking at emergency referrals seen by the ophthalmology service between March 18 to April 17, 2020 (representing the COVID-19 period), and March 18 to April 17, 2019 (representing the pre-COVID-19 period).MethodsData gathered from referral records included patient demographics, timing and site of referral, and ophthalmic diagnosis. Referrals were categorized as urgent or nonurgent, with urgent indicating the need for ophthalmic assessment within 24 hours.ResultsThe total number of referrals decreased by 54.2% in the COVID-19 period versus the pre-COVID-19 period. There was a similar bimodal age distribution in both periods, with fewer patients over 65 years of age presenting during the pandemic. Tertiary hospital referrals decreased by 62% in the pandemic period, while nontertiary emergency department referral trends varied and outpatient clinic referrals increased by 16%. Overall, there was a significant shift in the distribution of referral sites (p = 0.04). The proportion of urgent referrals increased by 14% during the pandemic; this was not statistically significant. There was no significant change in the timing of referrals or in the distribution of diagnostic segments.ConclusionsThis study offers insight into the impact of the COVID-19 pandemic on ophthalmology referral patterns in a Canadian context. Moving forward, it helps to guide resource allocation and public education on the importance of seeking necessary eye care.     

Status of Canadian undergraduate medical education in ophthalmology

Objective

To use the perspectives of undergraduate program directors to assess the current structure and adequacy of undergraduate ophthalmology curricula at Canadian medical schools.

Neuro-ophthalmology as a career

This essay was written to discuss the reasoning behind the personal decisions made by 2 current neuro-ophthalmology fellows to pursue neuro-ophthalmology as a career. It is meant to enlighten the reader about what role neuro-ophthalmologists play in clinical practice, what makes neuro-ophthalmology unique to all other sub-specialties, and how this contributes to making neuro-ophthalmology not only one of the most medically interesting, yet rewarding sub-specialties in ophthalmology.     

新型冠状病毒肺炎疫情期间眼科急诊及手术的防控策略

新型冠状病毒(SARS-CoV-2)感染的肺炎,新型冠状病毒肺炎(COVID-19)已被中国列为按照甲类传染病管理的乙类传染病,由医院相关性传播导致的COVID-19并不少见,给临床医护人员和住院患者造成严重威胁。本文介绍眼科医生应掌握COVID-19的流行病学特点和临床表现,眼科医生如何应对眼科急诊患者,围绕眼科急诊及手术的感染防控要点和加强具体防控措施,为战疫在一线的眼科医护感染防控提供参考。     

Online survey on practice patterns in the treatment of corneal ulcer during COVID-19 pandemic

Purpose:To evaluate practice patterns in the treatment of corneal ulcer by ophthalmologists during COVID-19 pandemic in the Indian subcontinent.Methods:This was an online questionnaire-based survey circulated via google form to reach ophthalmologists practising cornea as a subspeciality between January 4, 2021 and February 3, 2021. The survey comprised of 21 questions to evaluate the prevailing practice patterns in corneal ulcer management during pandemic.Results:In total, 39.3% of government ophthalmology clinics and 41.5% of private ophthalmology clinics reported an average delay of 2 weeks in presenting to the hospital after the onset of symptoms. Totally, 60.5% of participants reported that the clinical outcomes of infectious keratitis cases during the COVID-19 pandemic were worse than before. In total, 61.3 and 41.1% of ophthalmologists in private and government sectors, respectively, were routinely performing corneal scrapings for corneal ulcer patients. The procedures were performed with adequate protective measures. In total, 68.5% participants mentioned decreased availability of donor cornea during the pandemic, and 44.4% reported compromised cornea practice due to the limited availability of essentials (tissue adhesives, BCLs, medications, etc.). A statistically significant difference of effect of pandemic on cost of services was noted between government and private hospitals. In total, 51% participants from private hospitals reported hike in outpatient department services and surgical charges, and 78.6% from government hospitals mentioned no hike in the charges (P value <0.001).Conclusion:This study provides an overview on modified strategies in corneal ulcer management during pandemic without compromising patient safety and quality care.     

Optometric education in the post-COVID-19 era: A time of forced change!

There is a massive disruption of the global economy and education due to the coronavirus disease-2019 (COVID-19) pandemic. This has posed significant challenges and threats to the academic community, especially in health care where the learning and assessment are patient centered. Though blended learning had its emphasis in the pre-COVID-19 era, innovations are required to meet up to the increased demands on learning and assessment. This article uses an inductive approach and outlines the existing challenges, impact of COVID-19 era, the need for a mindset reframe, and the potential opportunities for innovations that underlie during these challenging times.     

Perception among ophthalmologists about webinars as a method of continued medical education during COVID-19 pandemic

Purpose:To ascertain ophthalmologist‘s perceptions about webinars as a method of continued medical education during the COVID-19 pandemic.Methods:In a cross-sectional study, a 21-question survey was circulated using digital media platform to approximately 1400 ophthalmologists in India between 16^th August 2020 to 31^st August 2020. The questionnaire focussed on the quality and usefulness of webinars based on the Bloom‘s taxonomy. The responses (on 4- or 5-point Likert scale) were analyzed among three professional groups- ophthalmologists in-training, consultants in public sector, and private practitioners.Results:393 ophthalmologists participated in the survey, with a response rate of 28%. The mean age was 34.6 ± 9.7 years, and males constituted 49.6% (199/393) of the respondents. Forty-seven percent of the respondents perceived the quality of webinars as good or excellent (185/393), 72.8% reported knowledge gain from webinars (286/393), and 63.9% felt that webinars are important in clinical practice and should continue post-COVID-19 pandemic (251/393), with distinct responses among the professional groups. The drawbacks perceived were overt number of webinars (371; 94.4%), confusion regarding which webinars to attend (313; 79.6%), repetition of the information (296; 75.3%), limited opportunity for participant interaction (146; 37.2%) and disparate weightage to the core disciplines of Ophthalmology.Conclusion:Most respondents had favorable perceptions of Ophthalmology webinars happening during the COVID-19 pandemic. However, there is need for improvisation in the volume of webinars, target-audience-based delivery, and participant interaction to add value to this new dimension of teaching-learning.     

Teaching of ophthalmology in undergraduate curricula: a survey of Australasian and Asian medical schools

BACKGROUND: Despite established international guidelines on preferred teaching components for ophthalmology in undergraduate curricula, with increasingly less specialty-based undergraduate teaching within curricula, teaching of core ophthalmology knowledge and skills may become marginalized. This survey aims to evaluate the current state of undergraduate ophthalmology teaching in Australasia and proximate Asian medical schools. METHODS: A questionnaire was developed to determine the content and extent of ophthalmology teaching in the undergraduate medical curriculum. The questionnaire was sent to 25 medical schools throughout Australasia and Asia. RESULTS: Nineteen of the 25 questionnaires were returned (76% response rate). Ophthalmology teaching programmes ranged from 2 to 20 days: five (26%) medical schools having one ophthalmology attachment; six schools (32%) two attachments; and the remainder three or more. Only seven of the schools taught all 13 ophthalmology topics recommended in current curriculum guidelines. Ocular examination (100%), lens and cataract (95%) and ocular manifestations of systemic disease (95%) were the most commonly taught topics, with intraocular tumours only covered by 10 schools (53%). Students in 14 schools (74%) attended ophthalmology operating theatre, but only two schools (11%) offered attendance at optometry clinics. Ten schools (53%) required a pass in ophthalmology to complete the academic year. CONCLUSION: Ophthalmology may increasingly be a small, or even absent, component of undergraduate medical curricula. Despite established international ophthalmology curriculum guidelines, this survey highlights significant lack of uniformity in their implementation.     

Flipped classroom approach to global outreach: cross-cultural teaching of horizontal strabismus to Chinese ophthalmology residents

AIM: To evaluate the flipped classroom model for teaching horizontal strabismus didactics in an ophthalmology residency program in China as part of a visiting professorship from the United States. METHODS: Residents from an ophthalmology residency program in China were invited to participate in flipped classroom sessions taught by an experienced American ophthalmology faculty in 2018. Residents were instructed to watch a pre-class video lecture prior to the in-class-case-based activity. Content tests (5 Ophthalmic Knowledge Assessment Program style questions) and surveys were administered before and after the classroom sessions (100% response rate). These results were compared to that of an American cohort who were taught the same content. RESULTS: The Chinese cohort of 12 residents preferred the flipped classroom to the traditional classroom at higher rates than the American cohort of 40 residents (92% vs 55%, P=0.04) and felt that all ophthalmology topics would be appropriate for the flipped classroom teaching style (P-values between 0.008 and <0.001). In both Chinese and American cohorts, we found that the exotropia curriculum saw a small but significant improvement in performance following the flipped classroom session (P=0.025 for Chinese residents; P=0.001 for US residents), whereas scores in both groups for the esotropia course did not significantly improve. CONCLUSION: This is the first study to evaluate the flipped classroom model implemented by a visiting ophthalmology professor in a global outreach setting. The flipped classroom sessions are viewed favorably by the Chinese residents relative to the US cohort with a modest impact on knowledge. Decreased in-person interpreter requirement and increased student engagement make this model valuable in cross-cultural visiting professorship settings. Finally, the flipped classroom may lend itself well to a virtual format to prevent the transmission of COVID-19, although such a format requires further study.     

新型冠状病毒感染疫情下眼科诊疗工作的困难和应对措施

新型冠状病毒感染（COVID-19）是一种新发的传染性很强的乙类传染病。由于疫情突发及对新发疾病特点不熟悉,眼科医护人员在诊疗过程中与患者近距离接触存在交叉感染的风险,且面临诸多困惑。本文从疫情对医院及患者的影响、眼科医护人员的防护对策等方面探讨如何在疫情下合理、安全地开展眼科诊疗工作及相应的应对措施。（眼科, 2020, 29: 81-83）     

Ophthalmology practice during COVID-19 pandemic: A survey of Indian ophthalmologists

Purpose:To assess the ophthalmic practice pattern among ophthalmologists in India amidst the COVID-19 pandemic.Methods:An online questionnaire-based analysis was performed among members of the All India Ophthalmological Society (AIOS) and results were analyzed using SPSS software version 20.Results:A total of 2253 responses were received. The majority of the participants (72.6%) were between 30 and 60 years of age and were into private practice (64.7%). During the lockdown, over one-third of participant ophthalmologists reported not attending any OPD patients, whereas a majority (64%) provided only emergency ophthalmic services. During the COVID-19 pandemic, <15% surgeries were performed compared to the pre-COVID-19 era by 81% of participants, whereas elective surgeries were performed by only 4.3%. The proportion of participants utilizing telemedicine in ophthalmology showed a two-fold rise from the pre-COVID-19 era (21.9%) to the COVID-19 pandemic (46%). Over half of the participants reported following the AIOS guidelines, reducing clinic hours, use of screening questionnaires, minimizing staff, and use of breath shield on a slit lamp as precautionary measures to reduce the exposure. Over 95% of ophthalmologists were satisfied (score > 5/10) by the AIOS guidelines for ophthalmic practice during COVID-19.Conclusion:COVID-19 pandemic has adversely affected the ophthalmic care services across India with telemedicine emerging as a major rescue. The majority of practicing ophthalmologists are satisfied with guidelines provided by AIOS for ophthalmic care during the COVID-19 pandemic and have implemented the same in their setup.     

Effects of COVID-19 pandemic on stress level of residents and fellows during ophthalmology training

Purpose:To evaluate the impact of coronavirus disease 2019 (COVID-19) on the mental health of residents and fellows in ophthalmology.Methods:A questionnaire composed of 42 questions was applied to Brazilian residents and fellows in Ophthalmology. The questionnaire addressed the demographics of participants, their working conditions before and during the COVID-19 pandemic, and the Perceived Stress Scale (PSS-10).Results:The study had a total of 271 participants in Ophthalmology training, from which 100 were fellows and 171 were residents. Before the pandemic, Ophthalmology residents and fellows had a higher workload (P < 0.001), and residents worked more hours than fellows (P = 0.001). During the pandemic, the workload of both residents and fellows decreased and equalized (P = 0.195). No correlation was found between the working hours during the pandemic and their stress level were observed (P = 0.760). Higher stress scores were identified in women ophthalmologists (P = 0.001) as well as in residents and fellows that had their surgical training interrupted during the pandemic (P < 0.001).Conclusion:The stress level of residents and fellows during the COVID-19 pandemic was similar, however, those that had their surgical training interrupted during the pandemic presented higher level of stress. Female physicians also presented higher level of stress compared to male physicians.     

Impact of COVID-19 on Indian optometrists: A student,educator, and practitioner‘s perspective

Purpose:The optometry profession has experienced massive changes amid lockdown in COVID 19 pandemic. This study gauges the impact of COVID-19 on optometry education and practices in India.Methods:The impact of COVID-19 among key stakeholders of Indian optometry that included educators, students, and practitioners was surveyed. The content validity of the survey tool was achieved through a focused group discussion with experts.Results:Of the 1408 responses, 118 were educators, 845 were students and 445 were practitioners. Post COVID-19 lock-down, a high percentage of students (96%) and educators (94%) were now using online mode of education to learn and teach. The blended learning methods were reported to be used by 81% of educators. Practical skills were the most difficult to teach by educators and to learn by students. Almost a third of the students were concerned about their internships and job opportunities amid the pandemic. Practitioners felt confident in performing routine eye examinations with personal protective equipment (PPE). Telemedicine was found to be adopted by 55% of the private practitioners and 49% of the eye hospitals.Conclusion:The COVID-19 pandemic has provided an opportunity to reform Indian optometry education through blended learning methods. Optometry practices changed and adapted instantly to the new hygiene norms that have raised the standard of care provided to patients. Telemedicine emerged as a mode of providing care by optometrists. Overall, all key stakeholders of optometry in India were found to have adapted well to the sudden changes due to COVID 19 pandemic.     

关注和重视小儿神经眼科学

小儿神经眼科学是综合眼科学、神经科学、儿科学的边缘学科,具有神经科学的逻辑性、眼科学的精确性、儿科学的精巧性等。由于儿童不善于或不能准确发现和叙述症状,因此小儿神经眼科学有不同于普通神经眼科学的特点、临床诊治技巧以及疾病谱;同时,由于儿童眼和神经均处于生长发育阶段,因此早期快速地发现、诊断和治疗,尽早恢复和建立患儿视功能的发育和重塑过程,才能最大限度的避免永久性盲和低视力的出现。因此需要广大眼科、神经科、儿科医生特别地关注和重视。