Laird Harrison, CPT

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By the time they finish their training, the majority of British ophthalmologists feel confident in most aspects of their profession, and most do not think the training should be shortened in the future, a new survey shows.

At least 70% thought of those responding thought they could manage all aspects of medical ophthalmology listed in the survey. Penetrating keratoplasty was the only surgical procedure that fewer than 50% felt confident in handling.

A minority of trainees thought they got more training than they needed.

Results of the survey, by the Royal College of Ophthalmologists in conjunction with UK ophthalmic trainees and trainers, appear in the journal 

Adopted in 2005, the UK policy Modernising Medical Careers shortened training for ophthalmologists to 7 years, yet they still spend more time studying their profession and learn more procedures than any other ophthalmology trainees in the world, according to William H. Dean of the London School of Hygiene and Tropical Medicine and colleagues, who authored the report.

At the same time, UK medical trainees are currently limited by the European Working Time Directive (EWTD) to a mean of 48 hours worked per week, averaged over 6 months. This may limit the total surgical training time available, and the UK’s planned departure from the European Union opens up the possibility of changing this limit.

The UK Departments of Health have recently adopted the Shape of Training plan to shorten training and make it more flexible while increasing the number of generalists.

The first class to study under the Modernising Medical Careers regimen recently graduated. So Dean and colleagues wanted to know how confident UK ophthalmology trainees felt about the training they have been getting under the Modernising Medical Careers directives.

They sent a web-based questionnaire to all ophthalmology trainees in the UK. Their response rate of 188 out of 780 (24.1%) exceeded the minimum they calculated that they needed to achieve a 95% confidence level. The respondents were evenly divided among the 7 years of training.

Asked if ophthalmologist training should be shorter than 7 years, 34.4% of respondents agreed. And 44.8% thought that training could be shortened and still produce competent consultant ophthalmologist. About a quarter had opted out of the EWTD.

“This opposition to shortening a very long training period reflects the high level of competence in diverse areas of ophthalmology expected from a newly qualified UK consultant,” the authors of the report wrote.

Asked if their contracts reflected the actual number of hours they worked, 54.8% of the survey respondents agreed and 33.5% disagreed.

The number of procedures that British ophthalmology trainees must complete exceeds that of other countries. For example, British trainees must complete 350 full phacoemulsification procedures, while in the United States only 86 are required. Yet, 100% of survey respondents in both countries felt competent in the procedure by the time they had finished their training.

The British ophthalmology trainees expressed confidence in most of their non-clinical skills, including communication with patients and colleagues, small group teaching and presenting at conferences.

But 42% of respondents said they were not confident they could prepare a business case. This was similar to results among trainees in the United States and Canada, and among trainees in other medical specialities in the UK, Williams and colleagues wrote. They suggested that more training in business skills be offered.

Asked about career preferences, the largest percentage, 31.4%, chose oculoplastics, followed by vitreoretinal (25.1%), glaucoma (24.6%), and cornea (24.0%).

Most said they picked these subspecialties because of interest; only 11.7% gave “job opportunity” as a reason. In fact, these preferences do not appear to match the availability of “substantive” posts for consultant ophthalmologists in the UK, Williams and colleagues wrote. Over a 1-year period, they noted that only 7% of advertised positions were for oculoplastics, 5% for vitreoretinal, 21% for glaucoma, and 6% for cornea.

To make less popular subspecialties more appealing, Williams and colleagues suggested engaging trainees through sub-specialty associations and regional recruitment forums, and developing consultant job plans with dual subspecialisations or including subspeciality as a part of a generalist remit.

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Survey: British ophthalmology trainees mostly confident

Optical coherence tomography angiography (OCTA) may be changing the game when it comes to detecting glaucoma sooner, according to researchers.

“OCTA is non-invasive and of rapid execution; it could potentially elucidate vascular changes in glaucoma, and consequently detect glaucoma sooner,” according to Dr Ana I. M. Miguel, from the University of Portugal, and colleagues, who reported their finding in the British Journal of Ophthalmology.

Their analysis showed that vascular density is much lower in people with glaucoma than in people without glaucoma. OCTA is quicker, easier and more objective than visual fields in diagnosing glaucoma, according to the researchers.

While no one knows exactly what causes glaucoma, one theory is that axonal ischaemia causes decreased ocular blood flow and optic nerve perfusion.
	So imaging methods evaluating microvascular changes in glaucoma have attracted interest.

In particular, OCTA provides quantitative vessel density (VD) measurement. Approaches differ by manufacturer:
	• The RTVue of Avanti (Optovue) uses a split-spectrum amplitude-decorrelation algorithm to enhance the signal-to-noise ratio of the flow detection.
	• The CIRRUS 5000 and the PLEX Elite (Carl Zeiss Meditec) detect differences in scattered light from moving particles, such as red blood cells in the vessels, to visualise and quantify the microcirculation within tissue beds in the eye, an approach called microangiography (OMAG). In theory, OMAG enhances contrast and provides a more precise segmentation and isolation of individual retinal layers.

To see how well OCTA can diagnose glaucoma, Dr Miguel and colleagues conducted a meta-analysis of all the studies they could find on the subject.

They defined VD as the percentage of area occupied by flowing blood vessels. They defined the peripapillary region as an annulus extending outward form the optic disc boundary, typically 750 µm wide.

They looked for prospective trials comparing VD in patients with glaucoma to VD in healthy controls. They found 2660 records of which 177 had full text available. Of these, 24 met their criteria.

As their primary outcome, they used the standardised mean difference (SMD) in the peripapillary VD between the glaucoma patients and the controls.

The secondary diagnostic outcomes included the whole-image optic nerve VD, the whole image macular VD and the parafoveal VD.

Only 18 of the studies met the researchers’ criteria for inclusion in their meta-analysis. These studies examined a total of 888 glaucomatous eyes and 475 healthy controls.

All the studies evaluated the radial peripapillary capillary segment. But the researchers found significant heterogeneity among the them (I2=59%).

In the studies included in the meta-analysis, the mean peripapillary VD in patients with glaucoma was 57.53%, with a 95% confidence interval (CI) of 52.60% to 62.46%. In the healthy controls the mean peripapillary VD was 65.47% with a 95% CI of 59.82% to 71.11%, yielding a SMD of –1.41 (95% CI 1.162 to -1.20, P<0.05).

The mean whole-image VD centred in the optic nerve head – a scan of 4.5 mm x 4.5 mm – had an SMD of -9.63 (95% CI -10.22 to -9.03, P< 0.05) and heterogeneity of I2 of 86%.
	Two studies included the inside-disc VD. They had an SMD of -9.51 (95% CI -12.66 to -6.36, P< 0.05) with no heterogeneity. Two studies reported scans of 3 mm x 3 mm. They had an SMD of -4.81 (95% CI -5.97 to -3.66, P< 0.0001 and an I2 of 53%. In a subgroup analysis of OCTA devices, the 2 studies that used a Zeiss device had an SMD of -1.13. The other 17, using an Optovue device, had an SMD of -1.68.

And in a subgroup analysis of the risk of bias, those studies with the lowest risk had an I2 of 84%.

Overall, the area under the curve (AUC), when reported, was 0.983, suggesting that OCTA has a high diagnostic capacity. Studies that compared OCTA with OCT reached different conclusions: 4 found a superior AUC for OCTA, 5 found an inferior one and 2 an equivalent one.

Four studies found a better correlation between VD and visual fields than between OCT and visual fields. Those studies reporting the coefficient of variation of OCTA had values between 2.3% and 4.1%, which would give it better reproducibility than visual fields.

“This systematic review shows that peripapillary VD is decreased in patients with glaucoma compared with healthy controls,” the researchers concluded. “Future studies with a prospective longitudinal design are welcomed.”

Author | Laird Harrison, CPT

Articles

Survey: British ophthalmology trainees mostly confident

OCTA provides quantitative vessel density measurement