Keywords corneal suture - training - education - assessment - residents
Corneal suturing is a fundamental step in ophthalmic surgery. While being part of
regular elective surgeries (i.e., keratoplasties, amniotic membrane transplantations,
and pterygium surgeries), it is also a key step in many urgent procedures, such as
traumatic corneal wound closure. Since both of these situations might be encountered
by novice surgeons, anticipatory training for corneal suturing during residency is
mandatory to improve surgical outcomes and reduce the risk of complications in these
procedures.[1 ]
[2 ]
The widespread use of surgical skills training on simulated tissue instead of actual
patients has been thought to improve the learning curve of residents. Indeed, residents'
evaluation during one specific procedure in the operating room (OR) might vary according
to the intrinsic difficulty of the procedure and the degree of stress affecting either
the resident or the supervisor hampering a smooth procedure. Thus, reproducibility
of the assessments in these conditions might be difficult.[3 ]
[4 ] Many studies have reported the outcomes of penetrating keratoplasty procedures performed
by residents during elective surgery in the OR.[5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ] However, a large diversity of assessment parameters has been proposed (i.e., details
on surgery times, graft clarity, postoperative astigmatism, best corrected visual
acuity, and graft survival), reflecting the difficulty of finding widely accepted
and reproducible assessments for the quality of a given surgical procedure. Defining
the optimal parameters for assessing good surgical procedures remains difficult,[12 ] and the corresponding objective scores for their assessment in corneal suturing
still need to be determined.
It is acknowledged that the repetition of one particular technique is key to acquiring
and maintaining a high level of skill for surgeons.[13 ] This evidence supports training programs. There is, however, a lack of data on how
courses should be structured to promote the acquisition of skills.[2 ] It remains difficult to design a dedicated training program that presents both relevant
conditions and the right evaluation of specific surgical skills,[14 ] such as corneal suturing. In addition, evaluations should indicate which specific
task needs improvement,[15 ]
[16 ] without indicating whether the given improvement will impact performance in the
OR.
This study aims to conduct a comprehensive review of all publications proposing educational
programs and assessment scores for ophthalmology residents dealing specifically with
corneal suturing.
Methods
Outcome
The aim of this study was to review all available papers concerning the assessment
of corneal suturing in residents during specific training sessions with the objective
of improving their surgical skills. The surgical model, assessment tool, and training
conditions proposed were defined.
Search Strategy and Data Extraction
A comprehensive search strategy was designed to retrieve all articles published up
to March 2021 by combining (corneal suture OR corneal suturing OR corneal transplantation
AND training OR residents OR novice surgeons OR assessment OR skill assessment OR
quality assessment) in the electronic bibliographic database of PubMed and following
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting
guidelines. All studies proposing an English abstract were reviewed. Inclusion criteria
involved the study design (i.e., prospective comparative studies with two or more
groups or prospective studies with before/after comparison [simple or crossover] in
one single group), the type of population studied (i.e., ophthalmology residents or
novice surgeons), and the study outcome (i.e., assessment of residents' surgical performance
in corneal suturing during specific training sessions). All studies presenting with
the following criteria were excluded from this review: inappropriate study type (i.e.,
retrospective studies, observational studies, clinical guidelines, consensus documents,
reviews, systematic reviews, and conference proceedings), studies dealing with surgical
procedures other than corneal suturing or with populations other than residents or
novice surgeons or with another condition than training session (i.e., OR assessments)
and, finally, studies reporting molecular aspects (i.e., artificial cornea design).
The search results were compiled using EndNote X9.3.3 software. Two experienced reviewers
screened the retrieved articles and extracted data from each eligible study using
a standardized data extraction sheet following presence or absence of inclusion and
exclusion criteria.
Relevant Studies Analyses
For each selected study, first author, publication date, study type, and country were
retrieved. The following information on the methods was reported: defined groups,
number of participants per group, eye support and type of sutures used, type of exercise
assessed, assessment tool selected for the objective evaluation, surgical skills assessed,
and training conditions. The outcomes for each study were also reported for further
discussion.
Results
The database identified 175 articles. After removing 23 duplicates, 152 articles were
reviewed based on the title and abstract. Of these, 148 were excluded based on study
type (i.e., retrospective, observational, clinical guidelines, consensus documents,
reviews, systematic reviews, and conference proceedings), surgical procedures other
than corneal suturing, participants other than residents, surgical conditions other
than training, and studies only reporting molecular aspects of corneal models. Four
articles were assessed for the systematic review ([Fig. 1 ]). One was excluded after a full-text review as it reported the same training session
from the same team as another already included article, the difference being the results
focused exclusively on ophthalmic surgeries other than corneal suturing.[17 ]
[Table 1 ] gives an overview of the methods and results of the three remaining studies.
Table 1
Main characteristics, methods and results of the reviewed studies
Source
Publication year
Study type
Country
Groups with no.
Eye support
Type of sutures
Exercise assessed
Assessment tool
Skills assessed
Training conditions
Outcome
Saleh et al[16 ]
2006
PCS
The United Kingdom
Novice (n = 10)
Trainee (n = 10)
Expert (n = 10)
Artificial eye
10–0 nylon
3–1-1 pattern on a corneal wound
ICSAD (3D record from an electromagnetic tracker attached to the surgeon's index fingers)
Number of movements, path length of the movements, duration time
Simple performance of the exercise under silent supervision
Highly significant difference between the three groups: the more experienced are faster
and make fewer hand movements with shorter path length
Ezra et al[15 ]
2009
PBAS
The United Kingdom
Residents (n = 20)
Model eye for the assessment; porcine eye for training
10–0 nylon
1 corneal stitch
ICSAD and OSATS (video-based assessment score system)
Same as study 1 + economy and confidence of movement, limiting tissue damage and precision
of operative technique from the OSATS
One-day surgical course including practice on porcine eyes
Improvement of the ICSAD and OSATS scores after the training course
Significant correlation between both assessments (ICSAD and OSATS)
Pasricha et al[18 ]
2020
PCS
The United States
Remote (+) residents (n = 5)
Remote (−) residents (n = 5)
Porcine eye
10–0 nylon
4 cardinal keratoplasty stitches after corneal trephination
Modified rubric from Mayo Clinic corneal trauma curriculum
Stitch length in host and graft, stitch depth in host and graft, stitch radiality,
stitch tension
Remote (+) with direct attendings' remoted feedback
Remote (−) without feedback
No difference in the assessment score between both groups
Increased confidence with corneal suturing after the remote training course reported
by residents
Abbreviations: 3D, three-dimensional; ICSAD, Imperial College Surgical Assessment
Device; No, Number of participants per group; OSATS, Objective Structured Assessment
of Technical Skill; PBAS, Prospective before/after study; PCS, Prospective comparative
study.
Fig. 1 Flow chart representing study selection.
Study 1
Study 1 was conducted in 2006 by Saleh et al.[16 ] This prospective and comparative study included 30 surgeons assigned to three different
groups according to their level of experience in corneal suturing (defined by the
number of stitches previously performed). The surgeons were asked to perform a 10–0
nylon suture pass using a 3–1-1 pattern to close a wound on an artificial cornea under
a microscope. Evaluation of the suture pass was performed using the Imperial College
Surgical Assessment Device (ICSAD). Briefly, this method uses a 10-mm electromagnetic
tracker attached to the surgeon's index finger of each hand from which three-dimensional
records are created using a magnetic field. The data were then analyzed using a custom-made
computer software program which assessed the number of movements, the path length
of these movements, and the time taken to complete the procedure.
The study showed that all three collected data points (i.e., number of finger movements,
path length of these movements, and time taken to complete the task) significantly
differed between groups. For each comparison, the more experienced group demonstrated
fewer hand movements, shorter path length, and shorter time to perform the task, compared
with the less experienced groups. Moreover, as experience increased during training,
there was a reduction in the variability between the individuals within the cohort.
Study 2
Study 2 was conducted by Ezra et al in 2009.[15 ] This prospective study included 20 residents assessed using ICSAD for one unique
10–0 nylon corneal stitch on a model eye with a microscope. All participants had to
perform a stitch 1 week before and 1 week after a 1-day surgical course, with the
aim of measuring the impact of the course on corneal suturing. Also, a video-based
system (i.e., the modified Objective Structured Assessment of Technical Skill [OSATS])
was evaluated and compared with ICSAD as a supplementary assessment tool. The OSATS
videos were scored by two masked independent observers for economy of movement, confidence
of movement, limiting tissue damage, and precision of operative technique on a 5-point
Likert's scale. The 1-day course was precisely scheduled and included different teaching
techniques, such as lectures for basic techniques on knot tying and instrument handling,
along with practicing diverse surgical procedures including corneal suturing on porcine
eyes.
This study showed that the three ICSAD parameters drastically improved after the 1-day
course. When participants were divided into two experience-based groups, the improvement
was more significant in the “senior group” than the “junior group.” OSATS had good
interrater reliability and was significantly better after training. There was significant
correlation between two scores.
Study 3
Study 3 was conducted in 2020 by Pasricha et al.[18 ] This prospective and comparative study included 10 residents randomly assigned to
two groups and stratified by their postgraduate year. Participants were asked to perform
four cardinal corneal stitches using 10–0 nylon on porcine eyes under a microscope
just after a full-thickness trephination. All had a prewet laboratory virtual lecture
reviewing proper corneal suturing technique. This exercise was then performed under
two different conditions. During one remote training exercise, residents' hand and
body positioning, as well as their microscopic view were both remotely transmitted
to a virtual whiteboard conference with three attending surgeons using Zoom. The attendings
could give direct oral and gestural feedback to the residents. One other training
condition consisted of performing the same task without any feedback. The porcine
eyes were scored at the end of the session by two masked graders using the modified
rubric from the Mayo Clinic corneal trauma curriculum to provide a maximum score of
6 points per suture pass (24 points per trial). The six items evaluated were as follows:
(1) stitch length in the graft, (2) stitch length in the host, (3) stitch depth in
the graft, (4) stitch depth in the host, (5) stitch radiality, and (6) stitch tension.
During the first evaluation, one group (remote [+]) used remote training while the
other (remote [−]) used training without feedback. Both groups then performed one
training exercise without feedback and, finally, the remote (−) group underwent remote
training and the remote (+) group the training exercise without feedback. Additionally,
pre- and postwet laboratory surveys were completed by the residents to assess their
confidence with corneal suturing and postwet laboratory surveys were completed by
both the residents and attendings to assess the effectiveness of the remote wet laboratory.
Both groups had similar scores for corneal suturing during all evaluations. Only the
depth of the stitch was better in the remote (+) group after the first trial. First-year
residents performed similarly to other residents. All residents' rates for comfort
with corneal suturing increased significantly after the remote wet laboratory. The
remote wet laboratory was considered highly effective and at least as effective as
previous in-person wet laboratories by residents and attendings. Attendings rated
the remote wet laboratory as highly effective in evaluating all six components, with
suture depth being the lowest rated. Finally, the prewet laboratory virtual lecture
was rated highly effective by all residents and the virtual whiteboard during the
remote wet laboratory considered highly effective by the residents and attendings.
Discussion
General Considerations
This study aimed to review the parameters proposed for residents' assessment in corneal
suturing during devoted training sessions. In this review, only three studies, from
two countries, were relevant considering our inclusion criteria. In these studies,
only three different assessment tools were reported. Even if our inclusion criteria
might have been restrictive, we believe that a prospective comparative study (either
with group comparison or before/after comparison) is a mandatory design for the evaluation
of such assessment tools. This small number of studies is not in line with the substantial
need for training in the field of ophthalmic surgery, as many ophthalmology residents
still struggle with surgical procedures.[19 ]
Video Assessment by Attendings
In study 2,[15 ] the authors describe a video-recorded assessment, the OSATS, scored by two masked
independent observers for economy of movement, confidence of movement, limiting tissue
damage, and precision of operative technique on a 5-point Likert's scale. This tool
was efficient in showing an improvement of these skills after a 1-day training course,
using the performance of one corneal stitch as the assessment exercise. Video-recorded
assessment affords the possibility of reviewing the video at the assessor's convenience
and ensures masked evaluation. However, some aspects of the “live” surgical procedure
might be missed, such as whole-body coordination (for instance, head movements out
of the microscope to be combined with needle loss). Moreover, OSATS focuses on the
ergonomic performance of the surgeon, which does play a great part in the quality
of the procedure,[20 ] yet limited focus is thus paid to the quality of the stitch (depth and tension of
the stitch, for instance, are not assessed). Also, one could wonder if one corneal
stitch is enough to assess surgical skill improvement after training. Indeed, more
elaborate tasks might be needed for this assessment. Interestingly, the improvement
of corneal suturing was more significant in the “senior group” than in the “junior
group” which could suggest either that basic experience in surgery gives more possibilities
for improvement, or that the assessment tool was not realistic enough to differentiate
novices' improvement from that of more experienced trainees.[15 ]
Remote assessment is possible using video-recorded evaluations. In study 3, for example,
real-time remote assessment and teaching was performed by attendings while visualizing
residents' performance on four cardinal corneal sutures in porcine eyes.[18 ] Such training was conducted using everyday equipment (i.e., laptop and smartphone)
and the Zoom program which makes it easy to reproduce. Moreover, the residents and
attendings rated the remote training program as highly effective for real-time teaching.
The use of a virtual white board might have actually provided ergonomic and comprehensive
viewing of the exercise. However, objective assessments of stitch quality (i.e., by
depth, length, tension, and radiality) were similar between the residents with remote
feedback and those without. Also, when comparing residents according to their postgraduate
years, stitch quality remained similar. While proposing a longer exercise for suturing
than study 2, this study nevertheless failed to demonstrate the effectiveness of remote
training in skill improvement. Of note, no evaluation of residents' ergonomic and
posture was proposed which might have been helpful either for a before/after comparison
or for a comparison according to the level of experience. An evaluation via Zoom may
also be limited as transmission of the microscope autofocus was not possible, thus
constraining the remote evaluation.[18 ] For both study 2 and study 3, time to perform suture pass and additional orientations
(i.e., within 1 clock hour) may have added value to the assessment as these are important
in clinical practice.[15 ]
[18 ]
Computerized Assessment with Automated Feedback
Another type of assessment tool was described in study 1.[16 ] The ICSAD motion analysis system was used to evaluate participants practicing a
3–1-1 pattern corneal suture. This tool was able to differentiate between participants
according to their level of experience by automatically measuring their hand movements,
the path length of these movements, and time to perform the task. Moreover, as experience
increased over the course of training, the value variability between individuals within
the cohort decreased. In fact, one advantage of motion analysis is to provide direct
feedback on movement efficiency which helps trainees move toward the values obtained
by more experienced surgeons. Such autoevaluation does not require the intervention
of an attending and might motivate trainees to improve their scores on their own.
However, to be installed, the ICSAD system needs to be manipulated which increases
the risk of incorrect setup and, subsequently, distorted results, especially in the
absence of a supervisor. Its design might also impede a surgeon's movement during
microsurgical procedures as it is cumbersome.[15 ] Finally, the equipment needed is expensive.[15 ] Unfortunately, this study did not assess stitch quality and the 3–1-1 pattern proposed
is not universally used for corneal wound closure which might hamper its reproducibility.
Nevertheless, this is the only study proposing a comparison between surgeons with
different levels of experience in corneal suturing, and it defines some parameters
derived from movement efficiency that might differentiate between attendings' and
novices' performances. This creates an opening for future research to enlarge the
field of parameters for such differentiation and determine specific activities to
narrow the gap between novices and attendings.
Other automated feedback tools have been described in ophthalmic surgery, are not
yet validated: optic fiber on a patch to be pressed and pierced by wound stitches
for strain measurement and anterior segment optical coherence tomography real-time
feedback during procedures involving the anterior segment of the eye.[21 ]
[22 ]
Innovative Training Modalities
The importance of verbal communication during teaching has been highlighted in studies
including attending supervision. In study 2, a 1-day course with very precise schedule
was used, alternating lectures with practical sessions and feedback sessions. The
authors described a behavioral and cognitive learning approach in which the teachers
organize their teaching to mirror the internal learning process of their students.[15 ] This type of training was designed according to Gagné's instructional model and
aims to end passive learning sessions which should become more interactive and “linked
to external benchmarks” with a more efficient and cost-effective educational effort.[17 ]
[23 ] Also, in study 3,[18 ] verbal explanations were proposed to all residents to remind them of the process
of corneal suturing which the residents rated as very helpful.
Future Assessment Tools
Through the review of these three studies, we pointed out the rarity of available
tools for corneal suture assessment in residents. Moreover, none of the assessments
assessed here reflected both stitch quality and the overall ergonomics of the procedure,
while all were used for the evaluation of relatively short exercises. There is evidence
that more complete tools are required for such assessment. We believe that autofeedback
devices have a great potential for objective and reproducible assessments of residents'
skills while being a source of motivation and self-education for the residents. However,
it is mandatory to find a cost-effective and easy-to-manipulate device which should
be able to assess diverse metrics like body and head position, hand movements, and
stitch quality. Finally, surgical procedure time also defines its quality and should
be measured as well.[20 ] Although such a complex device does not exist yet, quite comprehensive corneal suturing
assessment scales already exist and might be considered for the design of a more complete
assessment method.[24 ]
[25 ]
While diverse cornea models were used in this review, there have been several other
models tested for training in corneal suturing.[26 ]
[27 ] Having one universally defined model might be of great help to ensure comparability
between published results and should be designed as a close-to-reality corneal model.
Conclusion
Finally, this review underlines the great need for new metrics to be defined for the
assessment of corneal suturing in ophthalmology. One reproducible tool might be tricky
to elaborate without knowing which parameters differentiate novice from attending
surgeons' performance. To define such metrics, prospective and comparative studies
between novices and attendings should be the chosen design for reliable evaluation
of those existing gaps. Specific points to work on, helping residents to approach
their superiors' experience, should consider timing, stitch quality, and ergonomics
for assessment parameters.
