Impact of a formal manual small-incision cataract surgery curriculum in an American ophthalmology residency program
The Colorado Multiple Institutional Review Board (COMIRB) determined that this study protocol was exempt. This is due to the anonymity of the responses and the retrospective nature of the analysis. During the final year of residency, the University of Colorado’s ophthalmology residents underwent half a day of lectures spanning epidemiology of global blindness, the MSICS surgical technique, and how MSICS compared to phacoemulsification in terms of cost and sustainability in low-resource settings. Lectures were directly followed by a formal wet lab with one-on-one instruction that was put on by the University of Colorado’s department of ophthalmology in partnership with Surgical Eye Expeditions (SEE) International, a US-based non-profit organization that organizes over 50,000 outreach surgeries per year around the globe and specializes in MSICS wet lab curriculum. Pig eyes were used in the wet lab to practice steps including peritomy, cautery, scleral tunnel, corneal wound entry, capsulotomy, crystalline lens prolapse out of the capsular bag, and crystalline lens delivery out of the eye. Finally, residents were exposed to MSICS in the operating room throughout the year under the supervision of one of the authors (CI) at the teaching program’s safety net hospital, where a large volume of advanced cataracts are encountered due to the large volume of refugee, immigrant, indigent, and uninsured/underinsured patients who often face challenges with access to care. An anonymous web-based survey using Survey Monkey (San Mateo, California) was created. The survey was composed of three multiple-choice questions featuring a Likert scale and two fill-in-the-blank questions. All questions addressed specifics regarding the residency MSICS experience such as perceived value of experience and number of surgeries performed. The survey was sent using email and text messaging shortly after graduation to recently graduated senior ophthalmology residents at the University of Colorado. This was done each year for a total of three years from 2019 to 2021. Survey results were compiled using Microsoft Excel (version 2111, Redmond, WA). Means and standard deviations were used for numerical data and percentages for categorical data.   There was a 100% survey response rate from the residents (15/15). All residents agreed or strongly agreed with MSICS being a valuable skill to have and most (80%, 12/15) felt that exposure to MSCIS increased their likelihood of doing any type of outreach work in the future. Thirteen out of 15 (86.7%) residents agreed or strongly agreed that exposure to MSICS increased their understanding about sustainable outreach work. No resident disagreed or strongly disagreed with any of the three statements. displays the number of cases performed by residents. The mean number of MSICS cases was 8.2 per resident (SD 2.7, range 4–12). Five residents completed 11 cases during their residency training. The final, open-ended question eliciting any other comments about the MSICS education elicited response from four out of 15 residents. Three of the comments were positive, including the following comments: “exposure to a very useful skill that can translate to many other surgeries”, “MSICS education is great,” and “valuable experience.” Three comments included constructive criticism: “wet lab experience was difficult…not helpful with transitioning to creating a scleral tunnel in a real patient,” “other specific lectures on MSICS complications… would be great,” and “the challenge arises when there are complications during the surgery that I wouldn’t necessarily feel fully equipped to manage.” displays the Likert-scale responses.   In the current study, a formal MSICS curriculum was developed at the University of Colorado’s ophthalmology residency program that incorporated lectures on global ophthalmology and the MSICS technique, an MSICS wet lab, and a mentored surgical experience in the operating room alongside an experienced MSICS surgeon. This study is the first of its kind to evaluate the perception and impact of a formal MSICS curriculum on US-based ophthalmology residents. The overall response from the residents was positive, with room for improvement. This survey has helped validate the hypothesis that a lecture series designed to teach the steps of MSICS, the epidemiology of global visual impairment, and the role of MSICS in global work provides trainees with an improved understanding of global eye health and increases their perceived likelihood of doing any type of outreach work in the future. This is a powerful message since global visual impairment is slated to increase dramatically over the next few decades. Furthermore, prior studies have shown that the majority (63%) of US ophthalmology program directors who responded believe that global health was important to medical students when evaluating residency programs. Surgical outcomes were not explored since this study is geared towards better understanding the perceived value of MSICS curricula during residency in the US. Prior studies of US-based ophthalmology residency programs have reported on MSICS clinical outcomes. Zafar et al . reviewed 22 eyes of 17 patients who underwent planned resident-performed MSICS and found that intraoperative complications occurred in two (9.1%) eyes. The most common postoperative complication was transient increased intraocular pressure (9.1%). Furthermore, the group surveyed US-based residency programs regarding MSICS experience and received a response from 47 programs (40.1% response rate). The survey showed that US-based residents received some form of MSICS training in 66.7% of the responding programs. However, over half of the programs did not have MSICS-oriented educational resources available to residents. This study highlighted the value of a formal non-surgical introduction with access to educational materials. Lynds et al . published a similar paper reviewing 52 MSICS cases, with the most frequent intraoperative complications being iris prolapse (9.6%) and zonular dialysis (7.7%). Vitreous loss occurred in one case (1.9%). The most frequent postoperative complications were cystoid macular edema (5.8%), retained ophthalmic viscosurgical device (3.8%), intraocular lens displacement (3.8%), and microhyphema (3.8%). These complications are unsurprising since the cohorts from both studies were selected to receive MSICS when phacoemulsification was expected to be difficult and likely to have a higher complication rate (e.g., mature cataracts, traumatic cataracts, pseudoexfoliation syndrome, zonulopathies, etc.). MSICS can be the cataract surgical technique of choice for such cataracts instead of phacoemulsification. Historically, ophthalmology trainees attained much of their comfort with scleral wounds via ECCE and trabeculectomies. However, exposure to ECCE is becoming less common in training programs, and there may be a downward trend in trainee experience with trabeculectomies. Even if the resident chooses a clinical path that will not be performing MSICS routinely, the steps of MSICS can have crossover value with other ophthalmic surgical subspecialties. For instance, the peritomy used in MSICS can have clinical value for surgeons who will be performing glaucoma filtering procedures, scleral buckles, pterygium surgery, or other ocular surface procedures. The scleral tunnel can have clinical value for surgeons who will be placing anterior chamber intraocular lenses (ACIOLs) or performing glaucoma procedures involving crescent blades such as trabeculectomies. Intraocular lens (IOL) rotation and placement can have clinical value for surgeons who will be conducting 3-piece IOL insertion and secondary IOL surgeries. This list is not exhaustive and serves only to showcase the applicability of the MSICS technique to other subspecialties within ophthalmology. It should also be noted that few, if any, steps of MSICS are the same as phacoemulsification, highlighting the need to treat MSICS as a separate surgical procedure in ACGME case logs rather than grouping them with phacoemulsification as “cataract surgery”. This should be taken into consideration when a US-based surgical program decides on who will be instructing MSICS in the same way that emphasis is placed on who is capable of instructing phacoemulsification. This is especially important since MSICS-qualifying patients in the US tend to have more advanced pathology than routine cataract surgery patients. Limitations of this study include a limited cohort (15 surgeons), only including a single study site, and the inability to include surgical outcomes of cases. The strength of this study includes it being the first of its kind to evaluate the perception and impact of a formal MSICS curriculum on US-based ophthalmology residents. This information will hopefully guide residency programs toward incorporating MSICS training into their residency curriculum.   These data show that there is desire among ophthalmology trainees to learn MSICS and that a formal curriculum consisting of didactic lectures as well as hands-on wet lab training can help trainees feel more comfortable with MSICS and associated skills that may be beneficial in multiple types of ophthalmic surgery. Having a formal curriculum may also help avoid ethical concerns associated with residents learning these skills during an international mission trip. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.   Nil.   There are no conflicts of interest.   