PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS - SUBSPECIALTY CURRICULUM

PREAMBLE

COECSA Background

The College of Ophthalmology of Eastern Central and Southern Africa (COECSA) is a specialized virtual College founded in 2012 after a successful voluntary merger between the Eastern Africa College of Ophthalmologists (EACO) and Ophthalmological Society of Eastern Africa (OSEA).

The College seeks to work in tandem with regional and global initiatives and to support international commitments including Sustainable Development Goals (SDGs), WHO Vision2020: the Right to Sight; WHO AFRO Road Map for scaling up HRH; 4th EAC Development Strategy; national eye care plans in the region, and national development plans, towards Universal Health Coverage (UHC).

COECSA plays a critical role in the sector because of its mandate and available expertise in eye care at different levels. Its work augments what other partners are doing and provides a basis for further intervention in other areas that COECSA is not involved in. COECSA’s products such as research, curricula, standards, quality assessments, and policy reviews provide the basis to further programmatic intervention. COECSA, therefore, places premium on partnership and collaboration because it is the synergy that is brought by working with others that produces sustainable results. This is the reason why COECSA sees itself as a catalyst for action by many actors.

COECSA’s mandate is to: Support development of human resource for health through quality training in ophthalmology; set standards for professional ophthalmic practice; facilitate continuing professional development; contribute to health policy development; advocate for relevant policy changes in the region; promote research which advances ophthalmology in the region; and, create a forum for the ophthalmic practitioners to promote the profession and exchange skills and knowledge

Its Mission is: To improve the number and quality of eye care workers in Eastern, Central and Southern Africa through training, leadership and promoting standards of practice, research and advocacy.

The Vision is: Eye health for all in Eastern, Central and Southern Africa.

The Goal of COECSA is: Skilled and motivated eye health work force for quality eye care in Eastern Central &Southern Africa region.

Curriculum Model

The Fellowship in subspecialty curriculum is a hybrid model that promotes the following curriculum tenets: • Integration (horizontal & vertical) • Thematic/systematic Courses • Small group learning methods • Student-centred & Student-directed Learning • Optimum use of IT learning technologies • Primary care models (& health promotion approaches)

Curriculum Goal, Objectives and Outcomes

The Fellowship in subspecialty programmes provides essential intellectual and clinical information (i.e. cognitive and technical/surgical skills) that are necessary for ophthalmic personnel. The curriculum is a content outline for a fund of knowledge. It is not designed to be all-inclusive but rather a guideline for the subspecialty training.

Core Competences

Core competencies include: • Patient Care • Medical Knowledge • Practice-based Learning and Improvement • Communication Skills • Professionalism • Systems-based Practice

INTRODUCTION

i. Overview of Childhood Blindness Childhood blindness refers to a group of diseases and conditions occurring in childhood or early adolescence, which, if left untreated, result in blindness or severe visual impairment that are likely to be untreatable later in life. Blindness in children can be defined as a visual acuity of <3/60 in the eye with better vision of a child under 16 years of age [1]. This generally means that the child cannot see something three feet (about one meter) away, that another child could see if it was 60 feet (about 20 meters) away [2]. The major causes of blindness in children vary widely from region to region, being largely determined by socioeconomic development, and the availability of primary health care and eye care services.

It is estimated that there are about 1.4 million blind children in the world and that about one child goes blind every minute. Three-quarters of the world’s blind children live in the poorest regions of Africa and Asia. Although there are fewer blind children than adults, the number of years lived with blindness is much higher for children. More than half of blindness in children is avoidable (either preventable or treatable); majority of the children who become blind have a lifetime of visual disability ahead of them with all the associated emotional, developmental impact onto the child’s life.

ii. Definition of a Paediatric Ophthalmology and Rationale A Paediatric Ophthalmologist is a. an ophthalmologist who has been trained on paediatric fellowship in a COECSA accredited or recognized centre, OR b. Any ophthalmologist trained outside of the COECSA accredited or recognized centres and underwent supervision by a COECSA Paediatric Ophthalmologist for at least 3 months in an accredited or recognized centre.

Paediatric ophthalmologists and strabismologists manage the entire spectrum of eye diseases. This may require collaboration with other medical and ophthalmic specialty areas.

The fellowship training is therefore focused on additional in-depth understanding and management of paediatric eye diseases and strabismus beyond that obtained in residency training. This training occurs during a continuous minimum period of 1 year and includes intense and focused training in developing and maintaining knowledge, skills, scholarship, and professionalism.

It is important that most eye problems presenting in childhood be corrected as early as feasible. Failure to correct these problems at an appropriate time early in life may result in permanent visual deficits, eye muscle disorders, and possibly legal blindness. This early attention to a child’s ocular problems should permit him/her to have optimal vision in adulthood.

The Paediatric Ophthalmology and Strabismus Subspecialty Curriculum wish to ensure that all future fellows are properly trained in Paediatric ophthalmology and strabismus by satisfactorily completing an appropriate post-residency fellowship training program.

Note that the curriculum guidelines have been categorised as: • (M) Must have/required • (S) Should have

3. STRUCTURE OF THE PROGRAMME

The overall goal is that the fellows will acquire surgical skills in the common surgical procedures used in pediatric ophthalmology and strabismus

i. Goal of the Paediatric Ophthalmology program The goal of the pediatric ophthalmology program is to train the fellow to accurately diagnose and treat common and important pediatric eye diseases. Fellowship training in pediatric ophthalmology provides the fellow with the necessary knowledge and surgical skills to provide the patient with the highest quality medical and surgical care.

a) Subject Areas i. Vision development in infancy and childhood [M] ii. Ophthalmic examination in children [M] iii. Neonatal ophthalmology, including retinopathy of prematurity [S] iv. Refraction and amblyopia management [M] v. Pediatric eye diseases, including uveitis, glaucoma, cataract, retinal diseases [S] vi. Pediatric ocular tumors [S] vii. Ocular manifestations of systemic diseases in children [S] viii. Surgery, both primary and complex [S]

b) Pediatric Ophthalmology Knowledge and Diagnostic Skills Goals i. To perform and interpret eye examinations for children, including visual acuity tests appropriate for the child’s age and condition. [M] ii. To perform refraction in children, including retinoscopy.[M] iii. To identify and manage amblyopia. [M] iv. To participate in diagnosis and management of retinoblastoma. [S] v. To be able to recognize and treat uveitis in children. [S] vi. To be able to recognize and treat glaucoma in children by surgical and nonsurgical treatment. [S] vii. To be able to recognize and treat cataract and lens subluxation in children by surgical and nonsurgical treatment. [S] viii. To be able to recognize and treat retinal diseases in children by nonsurgical, laser, and surgical treatment. [S] ix. To be able to recognize and treat retinopathy of prematurity. [M] x. To be able to recognize and treat optic neuropathies.[S] xi. To able to recognize and treat nystagmus in children. [S] xii. To identify ocular and nonocular manifestations of systemic diseases with ocular involvement. [S]

c) Surgical Requirements for Pediatric Ophthalmologist-Based Fellowship i. For a fellowship focused on pediatric ophthalmology, the fellow should perform at least 100 surgical procedures as primary surgeon. ii. At least 80 surgical procedures should be non-strabismus procedures in pediatric ophthalmology, and at least 20 surgical procedures should be strabismus procedures as primary surgeon. iii. A fellow cannot serve as both a primary surgeon and a first assistant for the same surgical case. iv. Examinations under anesthesia do not qualify as major cases.

ii. Goal of the Strabismus Programme The goal of the strabismus program is to train the pediatric ophthalmology fellow to accurately diagnose and treat all forms of adult and pediatric strabismus and ocular motility problems. Fellowship training in strabismus provides the fellow with the necessary knowledge and surgical skills to provide the patient with the highest quality medical and surgical care.

a) Strabismus Knowledge and Diagnostic Skills Goals i. To describe and perform an accurate ocular motor and sensory examination––both basic and advanced––in pediatric and adult patients, including in patients who might be considered challenging (eg, uncooperative, cognitively impaired, nonverbal, preverbal). [M] ii. To apply the most advanced knowledge of eye movement anatomy, neuroanatomy, and physiology to patient evaluation and surgical-decision making. [S] iii. To describe clinical applications of basic and advanced sensory adaptations in strabismus patients. [S] iv. To be able to recognize and treat any cause of esotropia. [M] v. To be able to recognize and treat any cause of exotropia. [M] vi. To be able to recognize and treat more complex strabismus patterns, such as restriction, paresis, and dissociated strabismus. [S] vii. To be able to recognize and treat most complex etiologies of alphabet patterns and oblique muscle dysfunctions. [S] viii. To be able to appropriately order and interpret testing such as orbital images (eg, CT and MRI) and Hess/Lancaster in the diagnosis, and medical and surgical management of the strabismus patient. [S] ix. To be able to diagnose and correctly manage those strabismus patients in whom refraction management is indicated. [M] x. To competently be able to perform retinoscopy in children. [M] xi. To be able to perform successful Orthoptic assessments.

b) Surgical Requirements for Strabismus-Based Fellowships a. For a fellowship focused on strabismus, it is recommended that the fellow perform at least 60 surgical procedures, of which 50 surgical procedures are strabismus procedures performed as the primary surgeon. b. Being the primary surgeon means operating at least one complete muscle, under supervision. c. A fellow cannot serve as both a primary surgeon and a first assistant for the same surgical case. Examinations under anesthesia do not qualify as major cases.

c) Strabismus Specific Surgical Goals i. To understand and describe indications and contraindications for basic and more complex strabismus surgery. [S] ii. To perform the preoperative assessment for patients undergoing extraocular muscle surgery, including measurement of strabismus angle in primary positions as well as the 9 cardinal positions of gaze and head tilts. [M] iii. To know the indications for preoperative measurements in the various gaze positions. [S] iv. To know the surgical anatomy, including muscle measurements, specific characteristics of the conjunctiva, subconjunctival fascia, individual muscles, and vascular supply in relation to extraocular muscle surgery. [M] v. To know and be able to perform the basic surgical techniques involved in eye muscle surgery, including: setup, draping, prep and exposure, forced duction testing, incision options (and indications for the different incisions), and the principles of muscle dissection and suturing techniques. This would include proper instrument identification and choice and handling of instruments. [M] vi. To know and be able to perform basic rectus muscle recession and resection procedures. [M] vii. To know and be able to perform basic surgical procedures on the oblique muscles. This would include understanding of the indications for oblique muscle surgery and proper choice of available procedures. [S] viii. To perform more complex extraocular muscle surgery, including reoperation, tuck, and transposition procedures. [S] ix. To be able to manage postoperative complications for basic and more complicated strabismus surgery, such as a slipped muscle, globe perforation, endophthalmitis, anterior segment ischemia, and overcorrection. [S] x. To understand the risks and benefits of adjustable suture surgery and to understand the techniques involved in adjustable suture surgery. [S] xi. To have a working knowledge of the tables used for surgical numbers for eye muscle surgery. [S] xii. To assess the competency of the fellow using a measure such as the ICO-OSCARs. [S]

4. PROGRAM DELIVERY, CHARACTERISTICS AND TEACHING METHOD

The Paediatric Ophthalmology and Strabismus Fellowship must include lectures, conferences, or informal sessions at minimum in the following subject areas. Subject areas can be adapted to reflect local disease patterns and the particular needs of patients in the local area: [M]

Curriculum implementation shall be through apprenticeship, tutorials, log books, Workplace based assessments and any other method deemed appropriate

i. Program Qualifications a) The training program must be based at an institution that is accredited by COECSA for paediatric ophthalmology fellowship training. This institution shall be known as the parent institution. [M] Where training is conducted in two training institutions: • the admitting institutions assumes full responsibility for the candidates training. This will include, but not limited to verification and documentation of such training undertaken at the partner institution. • If during the course of the training, any of the two institutions involved in the training decides to be accredited as a standalone training centre, a consideration will be made at the end of the training cycle. b) The training institution should have a pediatric ophthalmologist with skills in strabismus surgery, as well as general pediatric surgeries e.g. congenital cataract. Where these are not available in the same center, the trainee will have to rotate to two or three accredited centers to complete the training requirements. [M] c) It is desirable that the parent institution is associated with a general paediatric residency training program [S] d) The number of fellowship positions approved must be determined based on the adequacy of clinical volume, number of faculty, and other resources, as determined by the fellowship director with the support and approval of the departmental chair. [S] e) The fellowship program must receive approval/support confirmation from the chairman and/or program director of the parent institution. [S]

ii. Program Compliance All fellowship programs must comply with the requirements listed below. [M a. Upon satisfactory completion of a fellowship training program, an individual will receive certification from COECSA and the training Institution. [M] b. All fellowship programs are subject to periodic review to assure their continued compliance to the requirements listed below. [M] c. Re-approval of a fellowship program is contingent upon having a fellow in training for at least one of the years covered by the triennial review. (A program that does not have a fellow for the three consecutive years of the triennial review period must reapply as a new program.) [M] d. The implemented curriculum should comply with local and national regulations. [M] e. Ethical Guidelines for Ophthalmologists: Ethical Principles and Professional Standards should also be practiced in the program. Each of the nine standards that follow includes a general principle from which the related standards evolve. The standards taken together are intended to represent comprehensive guidelines to reflect the ideals to which ophthalmologists should aspire as members of a specialist branch of the medical profession, and as socially responsible members of their respective professional societies. [S]. Below are the ethical Standards: o Patient Care Standards o Professional Practice Standards o Professional Community Standards o Standards for Working with Other Health Care Professionals o Research Standards o Social Standards o Commercial Standards o Teaching and Mentorship Standards o Standards Governing the Relationship to the Medical Industry

iii. Programme Characteristics a. Medical liability coverage must be provided to the fellow by the program or applicant during his/her training (unless provision of such coverage is in conflict with institutional policies or local statutes). [M] b. The medical and surgical care provided by the fellow during his/her training must be supervised. [M] c. A journal club specific to the paediatric ophthalmology/strabismus program must be held at least six times per annum. [S] d. The fellow should have ready access to a major medical library and facilities for electronic retrieval of information from medical journals and databases. [S] e. The fellow is required to prepare and present teaching conferences and participate in the teaching of residents and/or medical students. [M] f. The fellow should be involved in the ongoing research activities of the department. [S] g. The teaching program must include: o An ongoing program of study of the pertinent literature, guided by the faculty. [M] o Informal and formal didactic teaching, as well as access to pertinent reading materials. [M] o The provision of appropriate clinical material (i.e. patients for examination, evaluation, treatment, and discussion). [M]

5. ADMISSION REQUIREMENTS

In order for a consideration to be made for admission to this fellowship, the applicant must; i. Have satisfactorily completed a residency program in ophthalmology, and must be a COECSA fellow or possess its equivalence. NOTE: o The fellowship is primarily only open to COECSA fellows (1st Priority). Fellows will be admitted at a subsidized rate. o Second option is members of COECSA in good standing – These will be admitted at a Higher Fee agreed on in liaison with the Executive Committee. o Third option – Licensed, Qualified Ophthalmologists outside the region at a Much Higher Fee as agreed on in liaison with the executive committee ii. Possesses at least two years experience in active ophthalmology practice and must have performed at least 200 cataract surgeries independently. iii. The fellow must be able to fully comply with the clinical requirements of the program. iv. Prior to entry into the program, each fellow will be given an orientation period for familiarization with the institute, the clinic, and the basic examination skills. Each fellow is required to be notified of the required length of the program, policies for vacation, duties, stipends, and other forms of support.

6. SELECTION PROCESS

All applications shall be reviewed by a selection panel from COECSA and the training institutions. The panel will consist of:  The COECSA Education & Accreditation Committee,  2 Paediatric Ophthalmology and Strabismus Specialists, and  COECSA Education and Training Officer (ex-officio)

7. COURSE DURATION

o A minimum of 12 months (not necessarily consecutive) of clinical training is required, with vacation time and sick/personal leave at the discretion of the program director, and not exceeding two (2) weeks. Extension of the training period greater than 3 months, or an extended leave of absence, should have prior approval. A 24-month training program with 50% of the fellow’s time in fellowship training can also be considered. [M] o At least 50% (6 months) of the fellow’s time must be spent at the parent institution or at one of the hospitals or sites that are part of the parent institution. [S] o If part of the 12 months of training is spent away from the parent institution, verification and documentation of such training is the responsibility of the program director. [S] o Where training is conducted at two training institutions, the admitting institution assumes full responsibility for the candidates training. This will include, but not limited to verification and documentation of such training undertaken at the partner institution. o If during the course of the training, any of the two institutions involved in the training decides to be accredited as a standalone training centre, a consideration will be made at the end of the training cycle o During the time of accreditation and commencement of the COECSA Subspecialty Fellowship program, there may be candidates already in training, admitted by the institution. At the accreditation stage: - the training institution will submit names of candidates in training. - The candidates will then be assessed against COECSA’s admission and exit criteria to ascertain if they meet the minimum requirements for a COECSA fellowship/specialist qualification.

8. FACULTY/TRAINER QUALIFICATIONS AND RESPONSIBILITIES

Generally, the Faculty/Trainers need to be in the register of COECSA Faculty; Must be approved by paediatric community of practice, and have completed Train the Trainers and training in examination.

i. Fellowship Program Director There must be a single program director responsible for the fellowship program. [M]

1) Qualifications of the fellowship program director: a. Required to possess appropriate educational qualifications, including certification in ophthalmology and paediatric/strabismus-fellowship training. [M] b. Required to have at least 3 years of clinical experience in paediatric ophthalmology and strabismus following his/her fellowship training. [M] c. Required to have undergone COECSA training of trainers’ course. Note: In rare circumstances, in regions where there may not be a fellowship-trained program director, a senior ophthalmologist may have 10 or more years experience in substantial (greater than 50%) paediatric/strabismus practice, including contribution to the literature in the way of clinical or basic research. Such a clinician should be considered an appropriate primary supervisor. d. Should be engaged in ongoing basic and/or clinical science research in the area of pediatrics/strabismus, as demonstrated by regular publications in peer-reviewed journals and/or presentation of research material at national and international meetings. [S] e. Required to have a clinical practice with at least 50% of patients who have pediatric/strabismus-related disorders. [M] f. Required to have an academic appointment on the faculty of the affiliated ophthalmology-residency program or affiliated institution. [M] g. Required to be licensed to practice medicine in the state or country where the institution that sponsors the program is located. [M]

2) Responsibilities of the fellowship program director: a. Required to design and supervise the educational experience. [M] b. Required to prepare a written statement outlining the educational goals of the program with respect to knowledge, skills and other attributes, and educational goals for each major rotation or other program assignments. [M] c. Should promote awareness of the fellowship opportunity by providing a job description and requesting applications via a public website. [S] d. Required to develop and maintain documentation of institutional or inter-institutional agreements, the fellowship selection process, patient-care statistics, evaluations of faculty and the program, and assessment of the fellows’ performance. [M] e. Required to select fellows in accordance with institutional and departmental policies and procedures. [M] f. Required to designate and supervise the faculty through explicit descriptions of supervisory lines of responsibility for the care of patients. [M] g. Required to ensure the implementation of fair procedures and due process regarding academic discipline and fellow complaints or grievances, as established by the sponsoring institution. [M] h. Required to keep open lines of communication with their fellows and be sensitive to issues of professional and personal stress, which may interfere with the fellows’ interaction with patients and colleagues, both medical and non-medical. The fellowship program director should be aware of issues that would interfere with the professional development of their fellows and be willing to facilitate timely provision of confidential professional counselling and psychological support services to fellows. Training situations that consistently produce undesirable stress on fellows must be evaluated and modified. [M] i. Required to ensure that accurate statistical and narrative descriptions of the program are developed and maintained. [M] j. Any change in the fellowship director position is to be communicated within 90 days. [M]

3) Duties of the fellowship program director: a. Maintain an active clinical service in paediatric ophthalmology and/or strabismus at the parent institution. [M] b. Periodically (at least once every 6 months) assess the fellows by means of adequate documentation and make adjustments for areas of deficiency. [M] c. Personally, supervise the administration and implementation of fellowship requirements. [M] d. Certify the satisfactory completion of the course of training by the fellow at the end of the training program. [M] e. Engage in ongoing research in the field of paediatric ophthalmology and/or demonstrate regular publications in peer-reviewed journals and/or presentation of research material at national meetings, and/or appointments to national or international committees in this specialty. [S]

ii. Faculty in Paediatrics/Strabismus It is required that there be at least one faculty member who is the fellowship program director. [M] Additional supervising faculty for each approved fellowship position is desirable. [S]

1. Qualifications of the faculty: a. The primary faculty of the fellowship program must be a trained paediatric ophthalmologist and/or strabismologist. The fellowship program director must have had at least three years of clinical experience following his/her training, and hold a current appointment in the ophthalmology department of the parent institution. In addition, to serve as the program director, the faculty member must have been at the site of that program for at least two years, unless there is a current fellowship in place, in which case they can assume directorship immediately. [M] b. Must be a COECSA fellow in paediatric ophthalmology and strabismus, or from a recognized institution. c. In addition to working with the program director, the fellow(s) should have the opportunity to work at least 20% of the time (eg, one day/week) with the other faculty members in the program and this should be reflected in the weekly/monthly schedule. [S]

2. Responsibilities of the faculty: a. Be highly qualified and possess appropriate clinical and teaching skills. [M] b. Devote adequate time to the education of fellows. [M] c. Demonstrate a strong interest in the education of fellows, have sound clinical and teaching abilities, support the goals and objectives of the program, and be committed to their own continuing medical education and participation in scholarly activities. [M] d. Maintain regularly scheduled, documented meetings in order to review the program’s goals and objectives, as well as the program’s effectiveness in achieving goals and objectives. [M] e. Periodically evaluate the utilization of resources available to the program, the contribution of each institution participating in the program, the program’s financial and administrative support, the volume and variety of patients available for educational purposes, the performance of faculty members, and the quality of supervision of fellows. [M] f. Periodically evaluate outcomes of the research activities of the fellows. [M] g. Evaluate curriculum and career development of the fellows. [M] h. Each faculty member must have paediatric/strabismus subspecialty fellowship training or equivalent training and be a member of the faculty of the sponsoring institution. In addition, research faculty and scientists may be involved with the clinical fellowship program and are encouraged to interact with the fellows. [M]

iii. Other Program Personnel Programs must be provided with the additional professional, technical, and clerical personnel needed to support the administrative and educational activities of the program. [M]

9. TRAINING ASSESSMENT, EVALUATION& QUALIFICATION

Documentation and verification of the program’s activities is required annually and must include the following: i. A surgical log must be kept by the fellow and reviewed by the program director. The director must keep a summary of the fellow’s surgical experience over the one-year training period. The log must include diagnosis, surgery performed, outcome, and whether the fellow is first assistant or primary surgeon. [M] ii. A list of conferences/lectures given by the fellow. [M] iii. A list of journal club subjects evaluated by the fellow. [M] iv. A list of submitted/published papers and papers/research projects presented at national meetings by members of the department, including fellows. [M] v. Maintain regularly scheduled, documented meetings in order to review the program’s goals and objectives, as well as the program’s effectiveness in achieving its goals and objectives. [M] vi. The program director must provide a written, final evaluation for each fellow who completes the program. The evaluation must include a review of the fellow’s performance during the period of training and should verify that the fellow has demonstrated sufficient professional ability to practice competently and independently. This final evaluation must be part of the fellow’s permanent record maintained by the institution. [M] vii. Fellows compliance to the program and submission of an exit survey are program requirements. [M] viii. Should produce at least one publishable research during the training.

(See appendix C: Detailed Training Evaluation Forms)

10. EXIT CRITERIA

This shall take three stages: o Stage 1: Final Training Evaluation by the Training Institution, who will make recommendation to the COECSA subspecialty panel o Stage 2: Evaluation by the COECSA subspecialty selection panel, who will make recommendation to the College Senate o Stage 3: Validation and Approval by the College Senate

11. CERTIFICATION AND TITLE OF FELLOW

• Certification will be done by COECSA in conjunction with the training institution, after the exit process has been thoroughly completed. • Title to be awarded after completion of the training is: Paediatrics & Strabismus Specialist (COECSA)

12. UNSUCCESSFUL TRAINEE

In the event that a trainee does not meet the minimum requirements provided above; a) There will be an extension of the training by 3 months in order to meet the requirements. b) In the event that after the 3 months extension the candidate does not meet the above minimum requirements, training will discontinue.

13. INSTITUTION FACILITIES AND RESOURCES (GUIDELINES)

i. Institution Organisation a. If the Fellowship program in pediatric ophthalmology and strabismus is also in an institution that sponsor residency programs in ophthalmology, there should be coordination of the fellowship and residency programs, so that both benefit. While affiliation of the fellowship and residency programs may not be required, it is recommended. [S] b. The institution committed to offering a pediatric ophthalmology and strabismus fellowship program should have the capacity––and appropriate infrastructure––for high quality, diverse exposure to complex pediatric ophthalmology and strabismus cases and their management. Educational activities, including didactic lectures and grand rounds, are necessary. Research activities, including presentations at meetings, are part of the pediatric ophthalmology and strabismus fellowship program and fellows are encouraged to participate in such activities. [S] c. The number of fellowship positions approved will depend on the adequacy of clinical volume, number of faculty, and other resources, as determined by the fellowship director with the support and approval of the departmental chair. [S] d. The fellowship program should receive a letter of support from the chairman and/or program director of the parent department of ophthalmology. The fellowship program, as much as possible, should complement, support, and enhance the residency program. The department chair, fellowship program director, and residency program director should work together and periodically meet to assure that the presence of the subspecialty fellowship does not unduly draw cases, learning opportunities, or funding from the residency program. [S]

ii. Facilities and Resources A. Clinic The outpatient area of each participating institution must have a minimum number of fully equipped examination lanes for each fellow in the clinic. There must be access to current diagnostic equipment. [M]

The following are the recommended equipment requirements for the outpatient clinic: i) Direct and Indirect ophthalmoscopes ii) Lenses +20D, +90D and +75D. iii) Torch iv) Tonometers; i-care, Sciotz, Tonopen, Perkins or Air puff. v) Slit lamps- Portable or stand vi) Vision Charts:- Snellen, E, Pictoral vii) Refraction set +Retinoscope viii) Autorefractor ix) Prisms x) Patches/Occluders xi) Eyedrops/Diagnostics: - Amethocaine, Mydriatics, Atropine and Flourescein strips/drops

Fellows are encouraged to have the following as their personal equipment: i) Ophthalmoscopes; Direct and Indirect ii) Retinoscope iii) Prisms and Occluders iv) Lenses; +20D, +90D and/or+78D

B. Operating Facilities There must be adequate operating facilities, including an operating microscope to perform and teach surgeries. [M]

The following are the recommended basic requirements for theatre: i) Operating microscope ii) Vitrector- Vitron 2020 etc iii) IOLs iv) Viscoelastics v) Knives: - Keratomes, Crescent and MVR vi) Cryo vii) Laser viii) Implants ix) Sutures x) Lacrimal(probing and syringing) xi) Cataract sets xii) Portable hand held keratometer xiii) B-, and A-Scan for biometry

C. Inpatient Facilities There must be inpatient facilities with access to sufficient space and beds for good patient care. [M]

D. Library/Internet services Fellows must have ready access to a major medical library and facilities for electronic retrieval of information from medical databases. [M]

(See appendix D: Detailed institution accreditation guidelines)