Online ophthalmic learning in anterior segment surgery

May 6, 2020
Professor Jorge Alio

The educational goal of e-learning is to not to replace conventional hands-on experiences but to improve the quality of refractive surgery training worldwide, since learning is a non-stop process.

Living in an era of vast technological development has shifted the way we learn. Teachers and students no longer need to be physically present at the same time and place, but can instead engage from afar and this form of online learning, or “e-learning”, is increasingly becoming more the norm. Traditional learning still has an important role, however, and remains essential in maintaining the learning process.1,2

The concept of distance learning is not new; there is historical evidence as to its existence as far back as the 19th century, courtesy of Sir Isaac Pitman, who taught a system of shorthand in the 1840s for students living abroad, which was a method of exchanging mailing texts.3 There are many definitions for e-learning (also referred to as E learning, online training and online learning); however, broadly speaking, experts agree that it involves the electronic delivery of training or education and requires interaction with the Internet or other computer network via a computer or electronic device such as a mobile phone.4-6

Advantages of online learning

Many ophthalmologists seek continuous medical education in order to achieve personal growth and career development, especially when dealing with one of the most continuously advancing fields such as refractive surgery. However, for those with a full-time job or families, online learning becomes a particularly attractive proposition. For instance, it allows them to take care of their home and children during the day and study at night, making distance learning highly advantageous over the traditional educational system.

Overall, the benefits of e-learning are many, including “cost-effectiveness, enhanced responsiveness to change, consistency, timely content and flexible accessibility”.5,6 Moreover, e-learning technologies provide students with more control over the learning process in terms of content and pace of learning, which allows them to modify their experiences according to their individual learning objectives.

E-learning also enhances communication between those engaging with it by making open discussion panels possible. Since responses within e-learning can be made around the clock, students tend to be more highly motivated and more involved in the learning process2. In addition, there are no geographical barriers, making this style of learning accessible to doctors worldwide.

Disadvantages and challenges

Drawbacks of online courses include the limited emotional and personal interactions that take place, although this can be partially overcome by engaging in video conferences and live discussions. Another consideration is the ongoing expenses incurred by students, whilst those who create and need to maintain the courses also need to set aside a budget.

Moreover, participants need to have a good sense of self-discipline and time management in order to follow course timelines, which indeed may interfere or overlap with working hours or night times as they may take place in countries with different time zones.5,6 These factors can make compliance with attendance more challenging.

Another challenging feature of e-learning is that surgical skills have to be acquired by observation rather than through a hands-on approach available with traditional methods of teaching. A lack of reliable assessment after each lecture or course can be another issue with e-learning programmes.

E-learning in ophthalmology

Continuous medical education is considered compulsory for ophthalmologists to ensure that knowledge and skills are regularly updated. Due to growth in educational technologies, the e-learning resources that have become available to ophthalmologists worldwide has significantly increased.

Examples of major providers are: the International Council of Ophthalmology, the American Academy of Ophthalmology, the Asia-Pacific Academy of Ophthalmology, and Cyber Sight. Moreover, social media (such as Facebook, Twitter and LinkedIn) play some role in providing medical news feeds.

However, it is important to build the most effective online courses and provide a trusted source for continuous ophthalmic education, especially in subspecialty training with known syllabuses and flexible timelines.

E-learning in cataract and refractive surgery

We are still facing some limitations and scarcity in the field of refractive training, especially in relation to residents and young ophthalmologists. Most of their knowledge is provided through humble training or some courses they attend during international or regional conferences.

This is where online courses are important, since they provide in-depth theoretical training with flexible timelines without the need to leave their jobs and families. Such courses are given by the most prominent and well-respected figures in the field.

Moreover, these courses are not biased towards certain technologies. Such bias might be seen in other workshops or courses that are provided by companies wishing to highlight their products and any new technologies in the field of refractive surgery.7 Therefore, we can spread healthy practice policies and provide unbiased answers to ophthalmologists everywhere.

Refractive surgery online training programmes

There are four online courses in refractive surgery that were designed specifically to provide intensive specialty training, with a diploma or certificate awarded at the end of the course:

1) The Scientific Methodology in Cataract, Refractive Surgery and Corneal diseases, Miguel Hernández University, Alicante (Spain)8, is a 25-credits programme containing six modules, which are conducted over the period of one academic year. The course is two semesters long, and an official university certificate is issued on its completion.

The material for this course is prepared by a team of national and international professors and consultant ophthalmologists, providing a comprehensive learning channel that covers all aspects of modern refractive surgery science. The expected average of weekly educational activity required is 6 hours, depending of the learning base of the student; communication with the teaching faculty can take place at any time via email or direct communication to cover any difficulties the student may face.

One and a half years after the course began, the results were encouraging, with over 100 students enrolled worldwide. Interaction with students was maintained through weekly forums and the practical parts were covered through 1-week mini-fellowships offered only for Spanish ophthalmologists. However, it was found to be very time-consuming for academic staff.

2) The Cataract and Refractive Surgery (Theory) – Postgraduate diploma (PGDip), an online postgraduate course offered by Ulster University9 is over 2 years long. This programme has been designed in cooperation with the Royal College of Ophthalmologists’ standards and is the only endorsed RCOphth refractive surgery course that is completed entirely online in the UK. Through this platform, students are offered the chance to learn the latest highly advanced and revolutionary technologies in refractive corneal and lens-based surgeries.

3) Students undertaking a Master of Medicine (Cataract and Refractive Surgery) at the University of Sydney10 need to complete 48 credit points in order to obtain their degree. The course consists of 36 credit points of core units of study in addition to 12 credit points of research thesis.

Core units include studies in ophthalmic anatomy, ophthalmic optics, refractive surgery and practical refractive surgery. The online component of the course includes lectures from internationally recognised corneal and refractive surgeons and interactive online discussions with coordinators.

Students are also offered the opportunity to attend a week of hands-on training through workshops and wet labs at the Sydney Eye Hospital as well as undertaking placements in accredited refractive surgical centres.

4) The European Society of Cataract and Refractive Surgeons (ESCRS)11 provides over 30 hours of interactive, assessed and accredited e-learning content, including surgical videos, diagrams, animations and quizzes.
Cataract surgery, refractive surgery and corneal surgery courses are available as follows:

A) Cataract surgery. There are seven courses, including phacodynamics, the techniques and technology used in phacoemulsification, postoperative refractive outcomes and the management of endophthalmitis.

B) Refractive surgery. These six courses include refractive surgery, biomechanics and optics of the cornea, preparing for and performing LASIK, approaches to treat presbyopia and surface ablation techniques.

C) Cornea. These six courses including corneal diseases and dystrophies, diagnostic methods and a range of surgical procedures.

Other educational resources

There are other educational resources that do not end up providing professional certificates but contribute in major parts in scientific online resources. Examples include:
1) Cyber Sight12, developed and delivered by international ophthalmology experts, offers free online courses in ophthalmology, as well as a library containing a lot of hot topics discussed through live webinars, lectures and quizzes on subjects including cataract, glaucoma, paediatric ophthalmology and uveitis.

In addition, with ‘cyber sight consult’ you can contact 150 international experts who are standing by to help anyone who needs second opinions. Certificates earned contribute to Continuing Medical Education/ Continuing Professional Development (CME/CPD) credits, and all of the courses are optimised for mobile devices.

2) Wills Eye Hospital13. The department of Continuing Medical Education provides more than 100 courses in all eye subspecialties throughout the year. On Friday mornings weekly during the Chiefs round, the residents at the hospital present at least two unknown cases on different topics to attending staff, and other interested colleagues can attend through live webinars.

These excellent courses can be accessed free of charge on the website portal Wills Eye Knowledge, which also offers updates for glaucoma surgery, anterior segment surgery, orbital surgery, cataract surgery and retinal surgery.

3) 15-20 Institute14. The 15-20 Institute is a medical hospital ophthalmology training platform in France which has more than 3,000 registered users and 35,000 connections to platforms both in the country and abroad.
Meetings take place on Thursdays monthly, and are hosted by a different specialist each time who discusses various subjects in ophthalmology.

In 2018, ten courses were offered, including four sessions of live surgeries in the operating theatre. The institute also provides attendees with seminars and discussions as well as valid certificates that add more to their CME hours in cornea, cataract, glaucoma, surgical and medical retina, oculoplasty and neurophthalmology, and ophthalmic emergencies.

Further developments and outlook

Although e-learning has many advantages, there is still scope for improving the experience for students willing to engage with it. For example, learning could be made to be more adaptive, with courses tailored more to each specific student according to his or her specific learning needs and capabilities.

In addition, learners’ interactions with each other could be enhanced, with greater collaboration helping to increase levels of satisfaction and knowledge for students. And the role of the teacher needs to be truly transformative, so that they do not just distribute content but really facilitate the learning process and take an active part in assessing attendees’ performance8.

Again, it is important to bear in mind that e-learning is not intended to replace traditional methods. The educational goal is to improve the quality of refractive surgery training worldwide because learning is a non-stop process.

We believe that research should be directed towards studying both the effectiveness and limitations of online courses in refractive surgery so that any drawbacks can be overcome as it continues to develop as a learning modality. However, we have to keep in mind that surgical skills are still the core of ophthalmology practice and should be always secured through hands-on training.


PROFESSOR JORGE ALIO, MD
E: jlalio@vissum.com
Prof. Alio is based at Vissum Instituto Oftalmológico de Alicante, Universidad Miguel Hernández, Alicante, Spain.

DR ALMUTEZ GHARAIBEH, MD
Dr Gharaibeh is Visiting Professor of Ophthalmology at The University of Jordan, Faculty of Medicine, Amman, Jordan, and works for Vissum Instituto Oftalmológico de Alicante, Universidad Miguel Hernández, Alicante, Spain.

DR AHMED KHADER, MD
Dr Khader is an ophthalmologist at The University of Jordan Hospital, Amman, Jordan.

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7. Cataractle, Refractive E-Learning Course. https://crstodayeurope.com/articles/2008-mar/0308_25-php/.
8. https://www.umh.es/contenido/PAS/:tit_fpo_9466/datos_es.html.
9. Cataract and Refractive Surgery (Theory) - PgDip. https://www.ulster.ac.uk/courses/course-finder/201718/cataract-and-refractive-surgery-theory-13548.
10. Master of Medicine (Cataract and Refractive Surgery) https://sydney.edu.au/courses/courses/pc/master-of-medicine-cataract-and-refractive-surgery.html.
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