Impact of COVID-19 on cataract surgical competency of ophthalmology residents
This is a retrospective cross-sectional study. Institutional review board approved the study. This study adhered to the tenets of the Declaration of Helsinki, and informed consent was obtained from the subjects after they were explained the nature and possible consequences of the study. Six ophthalmology residents between April 2018 and January 2019 (prepandemic group) and 11 residents between April 2021 and January 2022 (pandemic group) participated in the study. All residents were in postgraduate year 4 at a university-based hospital and they had performed at least 15 phacoemulsification surgeries before enrollment into the study. The resident performance was rated by a faculty member (LG, an anterior segment specialist) utilizing the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric for phacoemulsification (ICO-OSCAR: phaco). The rater directly visualized the surgery through the side glasses of the microscope. The residents were blinded about the study, rating process, and their scores. All eyes had uncomplicated phacoemulsification with 2.8-mm clear corneal incision under topical or general anesthesia. General anesthesia was preferred during the pandemic period and lockdown condition because the number of elective cataract surgeries was significantly reduced. By general anesthesia, uncooperative patients were also used for residential education with longer time of surgery. No sub-tenon or epibulbar augmentation was performed. The capsulorhexis was performed by cystotome using an insulin needle. The nucleus was removed by phacoemulsification using Infiniti (Infiniti Vision System; Alcon, Fort Worth, TX, USA) or Stellaris (Bausch and Lomb, Rochester, NY, USA) phaco machines. All cases were simple, moderate to severe cataracts without any other ocular disease. Preoperatively, one faculty member (LG, an anterior segment specialist) determined the severity of nuclear cataracts ranging from grade 2 to 4 based on lens opacities classification system (LOCS) III with/without posterior subcapsular or cortical cataract. The best corrected visual acuity worse than 20/40 to 20/50 was a prerequisite for cataract surgery, along with symptomatically decreased vision. The ICO-OSCAR: phaco assessment tool consists of a six-item global rating system (wound neutrality, eye positioned centrally, tissue handling, intraocular special awareness, iris protection, and overall speed) and a 14-item task-specific checklist (draping, incision, viscoelastic, capsulorhexis flap formation, capsulorhexis circular completion, hydrodissection, instrument insertion into the eye, the stability of the instrument, sculpting, nucleus rotation, nucleus cracking, irrigation, lens insertion, wound closure) consisting of breakdown of cataract surgery. Each global and task-specific component is rated as a novice (score 2), beginner (score 3), advanced beginner (score 4), and competent (score 5). Statistical analysis Data were entered using Statistical Package for the Social Sciences (SPSS) for Windows software version 22.0 (SPSS Inc., Chicago IL, USA). The Shapiro–Wilk test was used to test the normality. The comparisons between the pre- and post-pandemic groups were performed using Chi-Square and Mann–Whitney U test. P value of less than 0.05 was considered statistically significant.   Data were entered using Statistical Package for the Social Sciences (SPSS) for Windows software version 22.0 (SPSS Inc., Chicago IL, USA). The Shapiro–Wilk test was used to test the normality. The comparisons between the pre- and post-pandemic groups were performed using Chi-Square and Mann–Whitney U test. P value of less than 0.05 was considered statistically significant.   Totally, 142 cataract surgeries were rated, including 71 surgeries in the prepandemic and 71 surgeries in the pandemic group. More than 80% of surgeries were performed under general anesthesia in the pandemic group, while topical anesthesia was the most preferred type of anesthesia in the prepandemic group ( P < 0.001) . The two groups were similar in terms of phaco machine ( P = 0.60) and surgery time ( P = 0.29) . The pandemic and prepandemic groups had a mean total task-specific score of 49.69 ± 6.52 and 62.58 ± 4.01, respectively ( P < 0.001). Senior residents achieved the lowest score for nucleus cracking in both the pandemic and prepandemic groups . All task-specific scores of the pandemic group were lower than those of the prepandemic group (all P values < 0.001) . The two groups had the maximum difference in capsulorrhexis circular completion (1.21 score, P < 0.001), followed by probe and second instrument insertion (1.20 score, P < 0.001), effective use and stability of instrument (1.12 score, P < 0.001), and viscoelastic (1.11 score, P < 0.001). The least intergroup differences were in irrigation and aspiration (0.61 score, P < 0.001) and draping (0.73 score, P < 0.001). The mean total global score was 26.71 ± 2.40 in the prepandemic group and 20.46 ± 3.21 in the pandemic group ( P < 0.001). The lowest and highest global scores were in central eye position and iris protection, respectively, in both groups . All global scores of residents in the pandemic group were lower than those of the prepandemic group (all P values < 0.001) . The pandemic and prepandemic groups had the maximum difference in tissue handling (1.21 score, P < 0.001), followed by iris protection (1.15 score, P < 0.001), intraocular spatial awareness (1.04 score, P < 0.001), overall speed (0.95 score, P < 0.001), and wound neutrality (0.94 score, P < 0.001). The least intergroup difference was in central eye position (0.93 score, P < 0.001).   The impact of COVID-19 is more evident in the training of surgical subspecialties such as urology, general surgery, orthopedics, etc., While virtual educational platforms may be sufficient for the theoretical training of residents and fellows, the practical and surgical training had been halted during the pandemic due to the suspension of elective surgeries. Current study compared the residents' competency in performing phacoemulsification, before and during the pandemic. Residents had poorer performance in all task-specific and global scores during the pandemic. Ophthalmology residency provides extensive training to fulfill comprehensive core ophthalmology competency over a period varying from 4 to 7 years according to the country of training. A prolonged delay in practical and surgical training might not be recovered without an extension of training and can result in failure to acquire the necessary surgical and clinical skills for both residents. There has been limited research on the effects of the COVID-19 pandemic on ophthalmology residency training thus far. Almost all previous reports indicate a significant and usually negative impact of the pandemic on the process of training in ophthalmology. Our results were in agreement with previous studies and showed that the competency of residents dropped significantly during the pandemic compared to the prepandemic period. However, because some reports were published very early in the pandemic, they do not necessarily reflect its long-term impact on the education of ophthalmologists in training. Moreover, previous studies provided no objective data about the competency of residents. Reduction in residents' in-person hands-on practical surgical training is the most important reason for their poor surgical performance during the pandemic. During the pandemic, the highest drop in surgical procedures and outpatient consultations was recorded in ophthalmology (nearly 80%) among all fields of medicine. Nearly all elective ophthalmic surgeries, which constitute the vast majority of ophthalmic procedures, were almost totally suspended. It can be attributed to the higher risk of COVID-19 infection for ophthalmologists due to close contact with patients. As a result, ophthalmology residents have experienced remarkable limitations in their clinical training and surgical exposure. Alahmadi et al . evaluated the impact of the current pandemic on ophthalmology residency training by obtaining the residents' perspective. They reported a significant reduction in routine outpatient care and a dramatic decline in exposure to surgical training and minor procedures such as injections and lasers. In Ferrara et al .'s survey, clinical activity was reportedly reduced by at least 50% in more than three-quarters of trainees. However, no changes were noted in residents' emergency care exposure as emergency departments continued to run normally during the lockdown. Therefore, senior trainees seem to be affected to a greater extent compared to junior trainees during the COVID-19 pandemic. Amparore et al . also reported that the most impactful reduction in surgical training activities was shown by final-year residents. It is important as these are the residents who are on the verge of employment shortly and therefore need to gain independence in these procedures soon. One of the solutions is external rotation of the residents. Besides reduction in surgical exposure, pandemic-induced depressive disorders might affect the residents' performance. More than half of the ophthalmology residents had mild to severe depressive symptoms during the pandemic. The burnout rate was also higher than the traditional rates during the COVID-19 pandemic. Depression and burnout might not be just associated with long duty hours. Stress about contracting the virus and bringing it home to friends and family appears to be an important contributor to this during the pandemic. Phacoemulsification is one of the most common ophthalmic surgical procedures and is, therefore, an important component of residency training in ophthalmology. All residents should be reasonably proficient in this surgery at the end of their training. However, cataract surgery was the most restricted form of surgery in ophthalmology during the pandemic, even in university-based hospitals. In an international survey, more than half of the ophthalmology residents (53%) declared that they were unable to perform routine cataract surgery during the pandemic. Similarly, Silva et al . reported that up to 99% of Portuguese residents did not participate in any cataract surgery at that time. More than 60% of Indian residents also experienced deteriorated cataract surgery training during the pandemic. In the UK, 80% of ophthalmology residents did not reach the expected cut-off value of 350 procedures of phacoemulsification by the end of training. The learning curve for phacoemulsification cataract surgery is generally accepted to be quite steep. Previous studies showed that among various stages of phacoemulsification, nucleus dealing and capsulorhexis are always the most difficult parts in phaco learning curve. In line with previous studies, our residents also had the lowest scores in nucleus sculpting, nucleus rotation, and chopping before and during the pandemic. The residents of the pandemic group also attained the lowest scores in capsulorhexis among all task-specific measures, while the capsulorhexis scores of the prepandemic group were relatively higher compared to other task-specific measures. It might be explained by steeper learning curve for capsulorhexis than for phacoemulsification part. The senior trainees have less difficulty performing capsulorhexis, while they do not reach proficiency in phaco until their experience exceeds 100 cases. In other words, the senior residents of the pandemic group did not perform enough surgeries even to gain competency in capsulorhexis. Current study also showed that the residents of the pandemic group had worse performances in global measures concerning fine, well-controlled intraocular maneuvers such as iris protection or intraocular spatial awareness. Live surgeries, edited video-recordings of surgeries and surgical simulation, such as wet-labs and cataract or vitreoretinal surgical simulators, are powerful tools for supporting some educational needs during the pandemic. Specifically, surgical video-recordings are recognized as a safe and effective teaching tool that can be implemented with post hoc interactive discussion aiming to acquire crucial surgical and nontechnical skills, such as decision-making, surgical planning, situational awareness, and understanding of surgical steps. In this regard, Ferrara et al . asked ophthalmology trainees to evaluate if simulator training and web-based teaching sessions, including live discussion of edited surgical videos, could be helpful for surgical training during the pandemic. They observed an affirmative response of the trainees. Although the residents' satisfaction was remarkable with the virtual methods, they had negative perspectives on the quality of training during the pandemic. It is probably rooted in the lack of practical training and indicates that virtual methods cannot replace in-person training completely. Simulation-based tools do not provide enough abilities for surgery and cannot substitute real-life surgical scenarios. High “observational” surgical volume and time spent on direct patients are the major barriers to their widespread adoption. Current study has certain limitations. First, we did not consider the impact of environmental factors of the theater, such as probable guidance of the senior surgeons. Second, the number of previous surgeries for each resident was not considered in the analysis, although we set the cut-off point of 15 previous surgeries as the inclusion criterion. Moreover, other outcome measures such as surgery time were not assessed. The small sample size might be another limitation. Finally, the emotional impacts of COVID-19 may also affect the performance of residents and it is advisable to evaluate them using appropriate questionnaires.   The current study showed that the phacoemulsification competency of senior ophthalmology residents significantly decreased during the pandemic compared to the prepandemic period. It was more evident in nucleus handling, capsulorhexis, iris protection, and intraocular awareness. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.   Nil.   There are no conflicts of interest.   