Elsevier

The Ocular Surface

Volume 18, Issue 3, July 2020, Pages 494-498
The Ocular Surface

Innovative Techniques and Technology
A surgical skills assessment rubric for pterygium surgery

This work was presented as a poster at ARVO 2019 in Vancouver.
https://doi.org/10.1016/j.jtos.2020.02.004Get rights and content

Abstract

Purpose

To introduce an assessment tool (rubric) for evaluating ophthalmology residents’ competency in pterygium surgery.

Methods

A panel of experienced international surgeons collaborated and developed the rubric. After describing various stages of the procedure, the Dreyfus scale of skill acquisition was used for scoring each stage. After finalizing the rubric, two surgeons independently evaluated 20 masked pterygium surgery videos of 10 residents and scored the videos according to the rubric. The agreement between the scores of them was examined with the intra-class correlation coefficient test.

Results

This rubric divides pterygium surgery into 13 different stages and covers the two most common techniques of pterygium surgery; conjunctival autograft and amniotic membrane transplant. The rubric showed face and content validity. Overall, an intraclass correlation coefficient of 0.90 (95% confidence interval 0.76–0.96, P < 0.001) was achieved between the two surgeons. The residents scored significantly higher on surgeries performed later in their rotation compared to the earlier surgeries (4.32 ± 0.35 vs 3.96 ± 0.31, P = 0.006). Certain stages of pterygium surgery were more strongly correlated with the residents’ past pterygium surgical experience.

Conclusion

This study introduces an international rubric for assessing competency in pterygium surgery. In addition to face and content validity, this rubric shows high inter-rater reliability. This may be a useful tool for teaching and measuring competency in pterygium surgery.

Introduction

Pterygium is a common ophthalmologic disorder defined by the growth of fibrovascular tissue from the conjunctiva over the cornea [1]. Besides its adverse effects on cosmesis, pterygium can induce significant corneal astigmatism, decrease visual acuity and, in extreme cases, cause blindness [2,3]. The prevalence of this disease varies in different regions of the world, but it is particularly common in areas with higher UV radiation [4].

Surgical excision is the treatment of choice in symptomatic cases. It is considered one of the most essential procedures that get taught during ophthalmology residency training worldwide. The International Council of Ophthalmology (ICO) has determined pterygium surgery as one of its Must Know skills in the ICO Residency Curriculum [5]. The remarkable prevalence of pterygium on the one hand, and the lack of need for advanced surgical equipment, on the other hand, have made pterygium surgery one of the fundamental operations for ophthalmology residents [6].

A rubric or assessment tool is generally defined as a scoring tool for rating of a trainee's performance. Rubrics include criteria and standards to achieve those criteria. They help both the trainers and trainees realize what is important in learning a task [7]. Great efforts have been made by surgeons to introduce international assessment tools or rubrics for various ophthalmic surgeries. The International Council of Ophthalmology (ICO) has developed ophthalmology surgical competency assessment rubrics (OSCARs) for different ophthalmic surgeries such as extracapsular cataract extraction, phacoemulsification, strabismus surgery, lateral tarsal strip, ptosis surgery and pediatric cataract extraction [[8], [9], [10], [11], [12], [13]].

Due to the importance of pterygium surgery education in ophthalmology residency and the lack of an international and valid assessment tool for assessing ophthalmology residents' surgical competency in pterygium surgery, we aimed to introduce a rubric for this procedure. We further evaluated its inter-rater reliability and examined its utility in assessing residents’ experience.

Section snippets

Methods

Designed by a group of experienced surgeons, the initial draft of the rubric divided pterygium surgery into 13 different stages and provided descriptive tasks for each stage. The rubric was designed to include both conjunctival autograft and amniotic membrane transplant techniques. The scoring assignment at each descriptive stage was developed based on the previous rubrics introduced by the ICO [[8], [9], [10], [11], [12], [13]]; in particular, the Dreyfus scale of skill acquisition was used

Results

An international panel of experienced surgeons evaluated the rubric and made modifications until the final version of the rubric was agreed upon [Table 1]. This rubric is designed to include two most commonly used and recommended techniques in pterygium surgery; conjunctival autograft and amniotic membrane transplantation (AMT). The first eight stages and final two stages are common in both methods. These common steps are Disinfection and draping, Traction suture, Anesthesia technique, Removing

Discussion

In 2002, the American Board of Ophthalmology added surgery and surgical skills as the seventh independent category to the six categories previously defined by the Accreditation Council for Graduate Medical Education (ACGME) for evaluating competency as an educational outcome of residency programs [15,16]. Teaching surgical skills to ophthalmology residents, assessment of their progression and recognizing factors that may influence the results of their surgery, are principal aims of

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Contributed equally to the manuscript.

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