COECSA RESIDENCY CURRICULUM

PREAMBLE

INTRODUCTION

The College of Ophthalmology of Eastern, Central and Southern Africa (COECSA) is a specialized virtual college. The college was registered in 2012 after a successful merger between the Eastern Africa College of Ophthalmologists (EACO) and the Ophthalmological Society of Eastern Africa (OSEA). The aim of this college is to address the chronic shortage of ophthalmologists in Eastern, Central and Southern Africa (ECSA) as well as improve the quality of eye care services in the region. The institution is anchored within the Vision 2020 framework developed under the aegis of the World Health Organization (WHO) and the International Agency for Prevention of Blindness (IAPB). Its establishment was informed by similar initiatives including the Medical Colleges in South Africa and the United Kingdom. However, COECSA aims to address the unique needs ECSA region based on evidence and priorities identified in the region. COECSA’s geographic focus is the ECSA region comprising Kenya, Uganda, Tanzania, Rwanda, Burundi, Malawi, Ethiopia, Zambia, South Sudan, Zimbabwe, Somalia and Mozambique. COECSA works closely with other players in  eye health and allied sectors in making interventions in the region.

Vision

Eye health for all in Eastern, Central and Southern Africa.

Mission

To improve the quality of eye care through training, research and advocacy; provide leadership in eye care; and create a forum for exchange of ophthalmic skills, knowledge and resources in Eastern, Central and Southern Africa.

Scope of COECSA’s work

COECSA’s work is derived from its mission. The College acts as the voice of the profession in the region, tasked to set the curriculum and examinations for trainee ophthalmologists, provide training in ophthalmology, set and maintain standards in the practice of ophthalmology and promote research and advance science in the specialty. COECSA is not a regulatory body and does not have a role in disciplinary actions relating to ophthalmologists. COECSA does not offer advice to patients on their individual condition or treatment options.

COECSA’s Mandate

COECSA operates within the wider environment of health in the region. However, eye health remains an obscure footnote in the health agenda. More often than not, focus on eye health is not given sufficient attention and support. COECSA and its partners wish to make better known the issues of eye health in the region. The mandate of COECSA is to:

• Contribute to the  human resources  for  health through  quality  training in ophthalmology
• Set standards for  professional  ophthalmic  practice
• Facilitate continuing professional development
• Contribute to health policy development 
• Promote research which advances ophthalmology in the region
• Create a forum for exchange of skills and knowledge

COECSA CURRICULUM

The COECSA curriculum offers regional consensus on what competences are required and what should be taught to residents. This curriculum is meant to be a guide for ophthalmology departments in designing training programs in their respective institutions. The curriculum will also act as a guide to trainees by providing a reference against which they can assess their progress. All institutions accredited to offer residency training programs shall be required to comply fully with the provisions of the College Council accreditation norms and standards.

ACKNOWLEDGEMENT

The COECSA Residency Curriculum – 2020 Version has been developed following a review of the 2017 version of the curriculum based on recommendations from an independent consultancy which was commissioned by the College. The consultancy was a review of curriculum documents, an assessment on how they can be utilised and development of additional resources that will enhance and be supplementary to the existing curriculum. The curriculum review will now be conducted every after 5 years.

The key highlights of the 2020 Version aside from the general correction of formatting errors include:

• A break of the different learning domains into detailed sub domains/competences
• Defined learning milestones for each of the sub-domain
• Assessment forms for each competence
• Description of the Exams to be administered under the curriculum and an additional learning outcome on Gonioscopy

COECSA leadership wishes to acknowledge the immediate past President Dr. Ibrahim Matende under whose leadership the COECSA curriculum work was initiated. We further acknowledge the Education and Accreditation Committee for providing leadership in the development and review of the residency curriculum.  The College acknowledges in particular the able leadership of Dr. Anna Sanyiwa (Muhimbili University of Health &Allied Sciences), Chair of the Curriculum Subcommittee (2016-2019) under which this work was made a success.

We further acknowledge the following for the immense contributions towards development of the first version of this curricula.

• Dr. Anne Ampaire Musika (from Makerere University, Uganda)
• Dr. Seneadza Asiwome
• Dr. Millicent Kariuki, Prof. Dunera Ilako and Dr. Kahaki Kimani (all of University of Nairobi, Kenya)
• Dr. John Nkurikiye and Prof. Wanjiku Mathenge (both of Rwanda International Institute of Ophthalmology)
• Dr. Levi Kandeke (Burundi)
• Dr. Gerald Msukwa and Dr. Petros Kayange (University of Malawi),
• Dr. Yeshigeta Gelaw (Jimma University, Ethiopia),
• Dr. Grace Chipalo - Mutati (University Teaching Hospital, Zambia),
• Dr. Geoffrey Wabulembo and Dr. Grace Ssali (Makerere University, Uganda),
• Dr. William Makupa (Kilimanjaro Christian Medical Centre),  
• Prof. Amos Twinamasiko and Dr John Onyango (both of Mbarara University of Science and Technology, Uganda)
• Dr.  Elias Hailu (Addis Ababa University, Ethiopia)
  

We also extend our gratitude to the team that reviewed and compiled the 2020 Version of the curriculum, for their commitment and hard work. These are:

1.      Prof. Ciku Mathenge, (Rwanda International Institute of Ophthalmology, Rwanda)

2.      Dr. John Cropsey (Kibuye Hope Hospital, Burundi)

3.      Mr. Robert Ntitima (COECSA – Education and Training)

4.      Dr. Zipporah Phiri (University Teaching Hospital, Zambia)

Special thanks also go to the Royal College of Ophthalmologists (RCOphth, UK) curriculum team comprising Dr. David Cottrell, Dr. Mike Nelson, Dr. Fiona Spencer, Prof. Carrie MacEwen, Ms. Kathy Evans, Mrs. Emily Beet, Ms. Beth Barnes, Ms. Denise Mabey and Ms. Susannah Grant for the technical input and support throughout the development process.

We further appreciate Softcall Communications for developing the online curriculum management system and for offering technical and training support.

The College extends special gratitude to Tropical Health Education Trust (THET) for providing funding through the London School of Hygiene and Tropical Medicine (LSHTM) and the International Centre for Eye Health (ICEH) that made this process possible. We are particularly grateful to Mr. Nick Astbury and Ms. Marcia Zondervan of the LSHTM for their unrelenting support.

Last but not least, we would like to acknowledge the secretarial and logistical support of the COECSA Secretariat throughout this process.

Dr. John Nkurikiye

COECSA President

Rationale

As a virtual college, COECSA works closely with accredited residency training institutions in the region to deliver ophthalmology training. This curriculum is meant to be a guide for ophthalmology departments in designing training programs in their respective institutions. Departments will be expected to structure their programs according to the system in their universities.  At present, some universities still operate on term system while others have adapted the semester system.  Also program duration varies from one institution to the other. In most residency training institutions in the region, the ophthalmology residency program (Master of Medicine in Ophthalmology) runs for three years, while in some institutions it runs for four years.  Departments will therefore be required to organize the recommended content to fit within their own time structure. The curriculum will also act as a guide to trainees by providing a reference against which they can assess their progress.

All institutions accredited to offer residency training programs shall be required to comply fully with the provisions of the College accreditation norms and standards.

PROGRAM DELIVERY

Recommended length of COECSA Residency Program

To deliver all the learning outcomes in the COECSA curriculum, it is recommended that a residency training program should be structured to be completed in a minimum period of 4 years.

ASSESSMENT TOOLS

The resident will be assessed using the assessment and feedback tools recommended in the curriculum and by the COECSA examination. The assessment and feedback tools allow each workplace based assessment to be recorded and the minimum recommended numbers are included for the relevant learning outcomes.

COECSA residency curriculum adoption by existing training programs

The institutions that are just about to commence training are recommended to use the COECSA Competency Based Curriculum as the foundation of their training course. It is suggested that:

• A presentation be made to have the COECSA Competency Based Curriculum accepted at the National Accrediting Authorities.
• Existing institutions integrate the curriculum at the earliest opportunity during the curriculum review process.
• A staff meeting / workshop be conducted to introduce the COECSA Competency Based Curriculum.
• An introductory lecture at ophthalmology meetings locally or nationally could be used to introduce the COECSA Competency Based Curriculum to a wider audience.
• All the parties involved should be encouraged to familiarize themselves with the learning outcomes and assessment / feedback tools. A workshop for making the assessment and feedback tools effective is important (see Training the Trainers).
• Issuance of a Digital Version of the COECSA Competency Based Curriculum be made to each resident so they have access to it where web access is limited.

Achievement of learning outcomes

This curriculum has 139 learning outcomes (see 2.0: learning outcomes summary table). For the different learning outcomes to be achieved, reference should be made to the 10 domains of the COECSA curriculum to establish the specified target years of achievement.

The domains describe the outcomes which the ophthalmology trainee should strive to achieve and ophthalmologists should refer to these domains throughout the process of maintaining competence. The 10 domains include Basic & Clinical Sciences, Clinical Assessment, Patient Investigation, Patient Management and Practical Skills. Others are Surgical Skills, Community Eye Health, Communication, Best Practice and Management and Leadership.

It should be noted that the various domains have some crosscutting learning outcomes; thus, there is need to pay attention to the related learning outcomes while addressing a particular learning outcome.

Learning Methods/Delivery

A combination of several methods of delivery will be used to achieve face to face apprenticeship. The methods include Lectures, Clinical Work, Clinical Teachings, Tutorials, Seminars, Conferences and Demonstrations.

It will further be implemented through teaching in Surgical Skills Laboratory and Wet Lab, Log Books, Dissertations, Self-Directed Learning, Clinical Clerkship including normal working hours and calls as well as conducting Ward Rounds. Other methods include Supervising and Teaching the Junior Medical Staff who include undergraduate Medical Students and Paramedical Trainees, carrying out Call Duties as per the Hospital Schedule as well as external Clinical Rotations with the goal to have 2 external Clinical Rotations of 8 weeks each during the 2nd and 3rd Year of the Course.

THE SUMMARY TABLE

DOMAINS	1) Basic & Clinical Sciences	2) Clinical Assessment	3) Patient Investigation	4) Patient Management	5) Practical Skills	6) Surgical   Skills	7) Community Eye Health	8) Communication	9) Best Practice	10) Management and Leadership
LEARNING  OUTCOMES	Anatomy And Embryology	Clinical History	Orthoptic Assessment	Management Plan	Refraction	Simulation And Wet Lab	Screening	Establishing Rapport	Learning	Health Service Organization
	Physiology	Assess Vision	Corneal Assessment	Triage/Prioritization	Periocular And Intraocular Drug Administration	Operating Microscope	Injury Prevention	Active Listening	Records	Clinical Governance
	Biochemistry & Cell Biology	External Eye Examination	Ultrasonography	Therapeutics/Local And Systemic Therapies	Diathermy/Cautery	Aseptic Technique	Disease Risk Reduction	Delivering Information	Guidelines	Cooperation With Other Services
	Pathology	Pupil Examination	Angiography	Patient Selection For Surgery	Cryotherapy	Cataract Surgery	Immunization And Supplementation	Directing Patients To Information	Portfolio	Role As A Leader
	Optics	Ocular Motility	Retinal And Optic Nerve Imaging	Recognize And Manage Complications	Assess Tear Film	Surgery For Raised IOP	Determining the magnitude and burden of blindness	Obtaining Consent	IT	Role As A Community/Clinical Researcher
	Clinical Ophthalmology	IOP Measurement	Radiology/ Other Imaging	Emergencies/ First Aid/Resuscitation	Assess Lacrimal Drainage	Repair Trauma	Develop Health Promotion Action Plan	Breaking Bad News	Manage Referrals	Role As A Teacher
	Clinical Pharmacology	Slit Lamp	Electrophysiology	Rehabilitation And Low Vision	Corneal Scrape	Common Lid Surgery		Barriers To Communication	Waiting List Management	Role As A Manager
	General Medicine For Ophthalmology	Fundus Examination	Laboratory Investigations	Refer Appropriately	Ocular Surface Foreign Body	Surgery For Surface Protection		Body Language	Use Of Databases	Apply Clinical Reasoning Using An Evidence Based Approach
	1) Basic & Clinical Sciences	2) Clinical Assessment	3) Patient Investigation	4) Patient Management	5) Practical Skills	6) Surgical   Skills	7) Community Eye Health	8) Communication	9) Best Practice	10) Management and Leadership
	Research Methodology, Epidemiology And Evidence Based Medicine	General Medical Examination	Biometry	Systemic Implications	Removal Of Sutures	Lateral Canthotomy/Lysis		Respond To Complaints	Critical Incident Management	Departmental Audit
	Instruments	Paediatric/ Developmental Examination	Visual Fields	Spectacle Lenses	Bandage Contact Lens	Biopsy Eyelid And Ocular Tissue		Communicate With Other Professionals	Compassionate	Personal Audit
	Statistics	Neuro Examination	Contact lens and diagnostic equipment care	Contact Lenses	Corneal Glue	Strabismus Surgery		Keeping Clinical Records	Patient Autonomy	Health Economics/Managing Resources
	Clinical Genetics	Differential Diagnosis			Forced Duction Test	Removal Of Eye		Write And Dictate Clearly	Consideration	Prepare Monitoring And Evaluation Tools Of Projects
		Gonioscopy
					Biometry	Laser - Lens Capsule		Preparing An Operating List	Patient Empathy
					Hand Hygiene	Laser - Raised IOP		Organizing Leave	Patient Confidentiality
						Laser - Retina			Insight Into Limitations
						AC/Vitreous Tap			Seeking Help
						Anterior Vitrectomy			Appraisal And 360 Degree Feedback
									Equality And Ethics
									Probity
									Practice According To National Legal Requirements
									Data Protection
									Human Tissue
									Child Protection/ Safeguarding
									Time Management
									Reflective Practice
									Self-Learning
									Uncertainty
									CPD
									Career Development
									Personal Health

COECSA DOMAINS FOR CLINICAL PRACTICE SUMMARY

COECSA has defined 10 domains for clinical ophthalmology practice. These domains describe a framework of competencies applicable to all ophthalmologists across the continuum of professional development from formal medical education and training through to maintenance of professional competence. They describe the outcomes which the ophthalmology trainee should strive to achieve and ophthalmologists should refer to these domains throughout the process of maintaining competence.

The 10 domains include:

1. Basic & Clinical Sciences          
2. Clinical Assessment    
3. Patient Investigation  
4. Patient Management  
5. Practical Skills              
6. Surgical Skills
7. Community Eye Health
8. Communication            
9. Best Practice
10. Management and Leadership

The table below summarizes the competences for the learning outcomes in their respective domains.

PLEASE NOTE that in the various domains there are some crosscutting learning outcomes, hence the need to pay attention to the related learning outcomes while addressing a particular learning outcome.  

BASIC CLINICAL SCIENCES (BCS)[edit | edit source]

Anatomy and Embryology[edit | edit source]

                                               

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Anatomy and Embryology
Code	BCS1
Description	Trainees must understand and apply knowledge of the anatomy and embryology of the eye, adnexae, visual pathways and associated aspects of head, neck and neuro anatomy. It extends to applied anatomy relevant to clinical methods of assessment and investigation relevant to ophthalmic practice. They must be able to use this knowledge when interpreting clinical investigations and in the practice of ophthalmic surgery.
Assessment	Portfolio/Log Book: And End Of Part 1 – Exams/ COECSA Exams
Target Year of Achievement	Target Year 1- 2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide  3.1.13, BSC1

Physiology[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Physiology
Code	BCS2
Description	Trainees must understand and apply knowledge of the physiology of the eye, adnexae and nervous system, including related general physiology. This includes the applied physiology relevant to clinical methods of assessment in ophthalmic practice. They must be able to use this knowledge when interpreting clinical symptoms, signs and investigations and in the practice of ophthalmic medicine and surgery.
Assessment	Portfolio/Log Book: And End Of Part 1 – Exams/ COECSA Exams
Target Year of Achievement	Target Year 1- 2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide  3.1.13, BSC2

Biochemistry Molecular and Cell Biology[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Biochemistry Molecular and Cell Biology
Code	BCS3
Description	Trainees must understand and apply knowledge of the basic biochemistry and cell biology. This includes in particular those aspects relevant to common eye diseases. They must be able to use this knowledge when interpreting clinical symptoms, signs and laboratory investigations and in the practice of ophthalmic medicine and surgery.
Assessment	Portfolio/log book: and end of Year /COECSA exams
Target Year of Achievement	Target Year 1- 2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC3

Pathology[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Pathology
Code	BCS4
Description	Trainees must understand and apply knowledge of pathology of the eye, adnexae and visual system. This includes histopathology, microbiology and immunology and other branches of pathology. They must be able to use this knowledge when interpreting clinical symptoms, signs and investigations and in the practice of ophthalmic medicine and surgery.
Assessment	Portfolio/log book: and end of Year /COECSA exams
Target Year of Achievement	Target Year 1-2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC4

Optics[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Optics
Code	BCS5
Description	Trainees must understand and apply knowledge of optics, ultrasound and electromagnetic wavelengths relevant to ophthalmic practice. They must be able to use this knowledge when interpreting clinical symptoms, signs and investigations and in the practice of ophthalmic medicine and surgery.
Assessment	Portfolio/log book: and end of Year /COECSA exams
Target Year of Achievement	Target Year 1-2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC5

Clinical ophthalmology[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Clinical ophthalmology
Code	BCS6
Description	Trainees must be able to evaluate a patient’s ocular, medical and surgical problems in order to formulate a differential diagnosis to serve as a basis for making laboratory and clinical investigations.
Assessment	portfolio/log book and end Year 2-3/4 – Exams /COECSA exams
Target Year of Achievement	Year 1,2,3 and 4
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC6

Clinical Pharmacology[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Clinical Pharmacology
Code	BCS7
Description	Trainees must understand and apply knowledge of clinical pharmacology relevant to ophthalmic practice. They must be able to use this knowledge when prescribing for a patient. They must understand the medications used in general medicine and surgery to a basic standard. They must be aware of the possible ocular effects of systemic and topical medications and systemic effects of ocular and systemic medications.
Assessment	portfolio/log book and end Year 2-3/4 – Exams /COECSA exams
Target Year of Achievement	Year 1.2, ¾
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC7

General Medicine for Ophthalmology[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	General Medicine for Ophthalmology
Code	BCS8
Description	Trainees must understand and apply knowledge of general medicine and surgery relevant to ophthalmic practice. They must be able to recognise when a patient is seriously ill and make appropriate arrangements for the patient's care
Assessment	portfolio/log book: and end Year /COECSA exams
Target Year of Achievement	Year 1 ,2,3,4
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide  3.1.13, BSC8

Clinical Epidemiology and Evidence Based Medicine[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Clinical Epidemiology, Statistics and Evidence Based Medicine
Code	BCS9
Description	Trainees must understand and apply knowledge of clinical epidemiology, statistics and evidence based medicine relevant to ophthalmic practice. They must be able to use this knowledge during clinical assessment, interpreting investigations and planning clinical management for a patient. Their knowledge must include the influence of economic and political considerations (on a local and global scale) on individual and community health and how these may be influenced.
Assessment	Cbd, journal club and Research Project and end of year/COECSA exams
Target Year of Achievement	Year 1, 2,3,4
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC9

Instruments TECHNOLOGY[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Instruments
Code	BCS10
Description	All trainees must understand and apply knowledge of instrument technology relevant to ophthalmic practice. They must be aware of the limitations of technology and the risks involved in their use.They must be able to maintain an understanding of new developments in relevant technologies.
Assessment	Portfolio, logbooks and end of year/ COECSA exams
Target Year of Achievement	Year 2 and Year ¾
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC10

BIOStatistics[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Biostatistics
Code	BCS11
Description	All trainees must understand and apply knowledge of statistics relevant to ophthalmic practice. They must be able to use this knowledge in the interpretation and publication of research.
Assessment	Presentations and Research Project, end of year/COECSA exams
Target Year of Achievement	Year 1, 2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC11

Clinical Genetics[edit | edit source]

BASIC CLINICAL SCIENCES (BCS)
Learning Outcome	Clinical Genetics
Code	BCS12
Description	Trainees must understand and apply knowledge of clinical genetics relevant to ophthalmic practice. They must be able to use this knowledge when advising patients about patterns of inheritance. They must recognise when it is appropriate to refer a patient for genetic counselling. They must recognise when it is important to offer a consultation with family members.
Assessment	Cbd, portfolio/log book and end of Year /COECSA Exams
Target Year of Achievement	Year 1-2
Related Learning Outcomes	BCS1-BC12
Other Links	Study Guide 3.1.13, BSC12

                           

Basic Clinical Sciences Study Guides[edit | edit source]

ABBREV	OUTCOME	HOW CAN I ACHIEVE THIS OUTCOME		HOW WILL THIS OUTCOME BE ASSESSED		HOW CAN I HELP A TRAINEE ACHIEVE THIS OUTCOME
		Resources	Methods/ experience	Indirect	Direct
BCS1	Anatomy	Text books, Web sites part 1	Reading Tutorials E learning Discussion forum	Clinical and surgical anatomy knowledge in work based assessments	COECSA Year  1 Written/clinical exam	Explain clinical and surgical anatomy in clinical teaching sessions Encourage/facilitate tutorials Facilitate use of local medical school anatomy museum
BCS2	Physiology	Text books, Web sites part 1	Reading Tutorials E learning Discussion forum	Applied physiology knowledge in work based assessments	Part 1 Written/clinical exam	Explain applied physiology in clinical teaching sessions Encourage/facilitate tutorials
BCS3	Biochemisty and Cell Biology	Text books, Web sites part 1	Reading Tutorials E learning Discussion forum	Applied science in work based assessments	Part 1 Written/clinical exam	Explain applied biochemistry & cell biology in clinical teaching sessions Encourage/facilitate tutorials
BCS4	Pathology	Text books, Web sites part1	Reading Tutorials E learning Discussion forum Clinical-pathologic al conferences	Clinical discussions in work based assessments	Part 1 Written/clinical exam -	Arrange clinical-pathology meetings Explain pathology, microbiology, immunology in clinical teaching sessions Encourage/facilitate tutorials Encourage learning with pathologists and microbiologists Facilitate use of local medical school pathology museum
BCS5	Optics	Text books, Web sites Part1 syllabus	Reading Tutorials E learning Discussion forum professionals Attend LVA sessions Attend optometric practice Demonstrate use of Optic equipment	Clinical discussions in work based assessments	Part 1 Written/clinical exam	Explain applied optics and medical physics in clinical teaching sessions Encourage/facilitate tutorials Encourage learning with optometrists
BCS6	Clinical Ophthalmology	Text books, Web sites Part 1/2 syllabus Skills/Wet Lab par 1,2,3	Reading Tutorials E learning Discussion forum Clinical discussions Part 2 preparation courses	Clinical discussions in work based assessments	Part 2 Case based discussions Case presentations	Arrange case discussions Encourage trainees to do case presentations Provide feedback Mock OSCEs Encourage learning with neurologists, rheumatologists etc.
BCS7	Clinical pharmacology	Text books, Web sites Part 1 syllabus	Reading Tutorials E learning Discussion forum Clinical-pharmacological conferences	Applied science in work based assessments	Part 1 Written/clinical exam	Explain clinical pharmacology in clinical teaching sessions Encourage/facilitate tutorials
BCS8	General medicine for ophthalmology	Text books, Web sites Part 1 syllabus Part 2 syllabus	Reading Tutorials E learning Discussion forum Clinical discussions Hospital grand rounds	Clinical discussions in work based assessments Multi source feedback	Part 1/Part 2 Case based discussions Case presentations	Arrange clinical updates from non-ophthalmic colleagues Encourage trainees to do case presentations Provide feedback Mock OSCEs Encourage learning with physicians/surgeons
BCS9	Clinical epidemiology and EBM	Text books, Web sites Part 1/2 syllabus	Reading Tutorials E learning Discussion forum Clinical discussions Journal club research	Case presentations Publishing research	Part 2 Written exam/Dissertation	Run journal clubs .Teach critical appraisal skills
BCS10	Instrument technology	Text books, Web sites Part 1 syllabus Part 2 syllabus	Reading Tutorials E learning Discussion forum Clinical discussions	Case presentations Clinical discussions in work based assessments Rating scales	Part 1/Part 2 Case based discussions Case presentations Trust based competence assessments	Arrange teaching on instruments. Provide feedback
BCS11	Biostatistics	Text books, Web sites Part 1 syllabus Part 2 syllabus/Journals/Research	Reading Tutorials E learning Discussion forum Journal club Research Statistics exercises/ Workshops	Case presentations Publishing research	Part 1/Part 2 Dissertation/Publications and research output	Encourage and provide research opportunities Provide feedback
BCS12	Clinical Genetics	Text books, Web sites Part 1	Reading Tutorials E learning Discussion forum Clinical discussions Part 2 preparation courses Genetics clinics	Clinical discussions in work based assessments Multi source feedback	Part 1/Part 2 Case based discussions Case presentations	Arrange case discussions Encourage trainees to do case presentations Provide feedback Encourage learning with clinical geneticists

CLINICAL ASSESSMENT­ (CA)

Patient’s history[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Patient’s history
Code	CA1
Description	Trainees must be able to gather focussed information from patients or patient caretaker in an organised way and document the clinical situation based on the individual patient’s needs.
Assessment	CRS1,portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1  and 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide - 3.2.1.2 below

Patient’s history Study Guide[edit | edit source]

Think:

·        Many of your communication skills will have been acquired in your foundation training. How do these skills apply to an ophthalmic patient?

·        How should I proceed when there is conflict between the history from the patient and that from relatives and careers?

·        In what situations may it be helpful to revisit the history with the patient?

·        What aids to history-taking can be used? (e.g. Questionnaires etc.?)

·        How can I be sure that I have accurately identified the patient's concerns?

Activity:

·        Observe senior colleagues and ask them to observe you

·        With the patient's consent, video-record your consultation and discuss your performance with your trainer

Resources:

·        Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco.  American Academy of Ophthalmology. 2005

Self Assessment:

·        Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback

Vision assessment[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Vision assessment
Code	CA2
Description	Trainees must be able: To assess visual acuity for both distance and near; to assess and interpret colour vision; to know the principles of contrast sensitivity assessment; to assess visual acuity in children and adults with barriers to communication; to assess vision outside the OPD environment and to perform and interpret confrontation visual fields.
Assessment	CRS2, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide  3.2.2.2 below

Vision assessment STUDY GUIDE[edit | edit source]

Think:

·        What is meant by 'visual acuity'?

·        What are the various related tests done in assessment of vision?

·        How do you assess vision in children or people with learning or communication difficulties?

·        How do you assess vision away from the eye clinic?

·        How can colour vision be assessed?

·        When is it appropriate to test colour vision?

·        Which test is best used for the different causes of impaired colour vision?

Knowledge:

·        Understanding the underlying principles, benefits and pitfalls of visual acuity assessment methods including Snellen, logMAR Sheridan-Gardner etc.

Activity:

•        Ask your orthoptist if you can participate in an orthoptist clinic assessing children’s vision

Resources:

•        Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco.  American Academy of Ophthalmology. 2005

External eye examination[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	External eye examination
Code	CA3
Description	Trainees must be able to perform an examination of the external eye – (sclera & cornea), ocular adnexae, eyelids, and orbits and face using appropriate equipment/instruments. They must be able to carry out further examination utilizing other techniques as indicated.
Assessment	CRS3, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12

External eye examination STUDY GUIDE[edit | edit source]

Resources:

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005

Self Assessment:

·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.

PUPIL EXAMINATION[edit | edit source]

­ LEARNING outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Examine the pupil and perform appropriate diagnostic pharmacological tests
Code	CA4
Description	Trainees must be able to assess the pupil for abnormalities of shape, size and reactions and interpret their findings. They must know how to perform and interpret appropriate pharmacological tests for specific pupil abnormalities.
Assessment	CRS4, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.4.2 below

Examination of the pupils and perform diagnostic pharmacological tests STUDY GUIDE[edit | edit source]

Think:

• ·What are the pupillary pathways?
• ·What does a normal pupil look like?
• ·What are the causes of an abnormal pupil?

Resources:

• ·Kline LB, Bajandas FJ. The Pupil. Neuro-ophthalmology Review Manual. 5th ed. 2004
• ·American Academy of Ophthalmology. Pupil. Neuro-ophthalmology. 1997.
• ·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005.

Self Assessment:

·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback

Ocular Motility[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Ocular Motility
Code	CA5
Description	Trainees must be able: to perform and interpret cover tests; to assess and interpret ocular movements; to perform prism cover tests and to describe nystagmus if present.
Assessment	CRS5, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.5.2 below

Perform a cover test and assess ocular motility STUDY GUIDE[edit | edit source]

Think:

·What are the actions of the extraocular muscles?

·This is an examination technique that requires a lot of practice

·What are the implications of the different types of nystagmus?

Activity:

·Spend time with your orthoptist and ask to participate in their clinics or the strabismus clinics.

Resources:

·Rowe F. Clinical Orthoptics. Blackwell; 2004.

·MacEwen CJ, Gregson RMC. Manual of Strabismus Surgery. 1st ed. Butterworth Heinemann; 2001.

·http://www.mrcophth.com/videosonclinicalexamination

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005

Self Assessment:

·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.

IOP measurement using various tonometers[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	IOP measurement using various Tonometers
Code	CA6
Description	Trainees must be able to measure IOP accurately using a variety of tonometers and understand the limitations of each. They must be able to check the calibration of the tonometer.
Assessment	CRS6, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12

Measure intraocular pressure using applanation tonometry STUDY GUIDE[edit | edit source]

Think:

·How would I feel if I were the patient having applanation done for the first time, and how can I help them to relax appropriately?

·What can make the measurement of IOP less accurate? - How can I ensure the most accurate result possible?

·What factors should influence my interpretation of the result?

·In what situations should I be wary of performing applanation?

·What damage could applanation cause to the patient?

Activity:

·Watch senior colleagues and discuss the nuances of their technique

Resources:

·http://www.opt.indiana.edu/riley/HomePage/new_Goldmann_tonometry/2Goldmann_Tonometry.html

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005

Slit lamp examination[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Slit Lamp Examination
Code	CA7
Description	Trainees must be able to examine the eye and adnexae using the slit lamp and interpret their findings. They must know the indications for and uses of different kinds of illumination and filters. They must know the proper care and economical use of the instrument.
Assessment	CRS7, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.7.2 below

Slit lamp biomicroscopy EXAMINATION STUDY GUIDE[edit | edit source]

Think:

·It is important to know exactly how the slit lamp and its accessories work

Activity:

·Make sure that you can use the  hand held and the table-mounted slit lamp microscope

·Ask a senior to observe and confirm your gonioscopic technique and findings

·Get a senior colleague to show you and the instruction manuals are a useful resource!

Resources:

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005

Fundoscopy[edit | edit source]

Learning outcome[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Fundoscopy
Code	CA8
Description	Trainees must be able to examine the fundus using a direct and indirect ophthalmoscope, and slit lamp biomicroscopy (with contact and non-contact lenses).  They must understand the optics of the techniques and the resulting images.  They must be able to examine the peripheral retina with indentation
Assessment	CRS8a CRS8b CRS8c CRS8d   end of year exams, COECSA Exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.8.2 below

FUNDOSCOPY STUDY GUIDE[edit | edit source]

Think:

·Is pupil dilation necessary to achieve adequate examination?

·Scleral indentation is a skill that takes a lot of practice

·When is it appropriate to use the different types of lenses that are available for fundus examination? How do all the techniques differ in magnification, orientation of the retinal image and field of view?

Activity:

·Take as many opportunities as you can to practice

·Watch senior colleagues and discuss the nuances of their technique, then practice again

Resources:

·Rosenthal ML. The Technique of Binocular Indirect Ophthalmoscopy. In: Hilton GF, McLean EB, Chuang EL, editors. Retinal Detachment. 5th ed. San Francisco: American Academy of Ophthalmology; 1989: 160-203.

·Fred Wilson. Practical Ophthalmology; A Manual for Beginning Residents. 5^th Edition. San Francisco. American Academy of Ophthalmology. 2005

Self Assessment:

·Clinical Rating Form. Ask a colleague to observe your technique, complete a clinical rating form and give you feedback.

General Medical examination[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	General Medical examination
Code	CA9
Description	Trainees must be able to perform a basic medical examination relevant to ophthalmic disease and understand the importance of their findings so as to be able to know when a patient requires appropriate referral.
Assessment	Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.9.2 below

General medical examination STUDY GUIDE[edit | edit source]

Think:

·Many of your general medical examination skills will have been developed during your foundation years. Which ophthalmological problems would prompt you to use these skills as an ophthalmologist?

·When should I request a chaperone?

Activity:

·Offer to help a medical trainee with eye examination skills for postgraduate examinations if they will help you with your general medical examination skills (record this in your portfolio)

Resources:

·MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005. Editors: Douglas,G. Nicol,F. Robertson,C.

Paediatric developmental examination[edit | edit source]

Learning outcome Overview[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Paediatric developmental exam
Code	CA10
Description	The trainee should be able to perform an appropriate assessment of a child’s developmental milestones, understand the associations between systemic and ophthalmic diseases and recognise when it is appropriate to seek a paediatric opinion.
Assessment	Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 / Year 3-4
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.10.2 below

Paediatric and developmental examination STUDY GUIDE[edit | edit source]

Think:

• ·What developmental milestones would you expect a two year old have?
• ·What key areas should be examined in a child concerning their development?
• ·when should a paediatric specialist’s opinion be sought

Activity:

·Offer to help a paediatric trainee with eye examination skills for postgraduate examinations if they will help you with your paediatric examination skills (record this in your portfolio)

Resources:

·MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005. Editors: Douglas,G. Nicol,F. Robertson,C.

Neurological examination[edit | edit source]

Learning outcome Overview[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Perform a focused neurological examination taking into account the associations between systemic and ophthalmic diseases
Code	CA11
Description	Trainees must be able to perform a basic neurological assessment with particular emphasis on the cranial nerves and conditions relevant to ophthalmic disease. They must be able to recognise when serious neurological problems are present that require the opinion of a neurologist. They must be able to recognise neurological emergencies.
Assessment	Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.11.2 below

Perform a focused neurological examination STUDY GUIDE  [edit | edit source]

Think:

·Many neurological problems present to the ophthalmologist and a competent neurological assessment of patients is required

Activity:

• ·Arrange sessions with your local neurology/neurosurgical department in their clinics or ward rounds to develop your examination skills
• ·Offer to help a medical trainee with eye examination skills for postgraduate examinations if they will help you with your neurological examination skills (record this in your portfolio)

Resources:

·MacLeod's Clinical Examination 11th Edition. ISBN 0443074046. April 2005. Editors: Douglas,G. Nicol,F. Robertson,C.

Differential diagnosis[edit | edit source]

Learning outcome Overview[edit | edit source]

CLINICAL ASSESSMENT­
Learning Outcome	Formulate a differential diagnosis
Code	CA12
Description	Trainees must be able to formulate and justify an appropriate differential diagnosis for a patient as part of the management plan.  They must be able to identify the most likely diagnosis and initiate management.  They must consider the common conditions as well as the rare but important ones in the differential diagnosis.
Assessment	CbD, Portfolio/logbook and end of year review/exams
Target Year of Achievement	Year 1 – 2 yr program/ Year 3/4 yr program
Related Learning Outcomes	CA1-CA12
Other Links	Study Guide -3.2.12.2 below

DIFFERENTIAL DIAGNOSIS STUDY GUIDE[edit | edit source]

Activity:

• ·Make it routine at the end of a consultation to document a differential diagnosis.
• ·Make sure that you discuss your differential diagnosis during CbD

Resources:

• The Wills Eye Manual: Office and Emergency Room Diagnosis and treatment of Eye Disease. Kunimoto et al. Lippincott Williams and Wilkins (2004)
• Oxford Textbook of Ophthalmology. Easty and Sparrow. Oxford Medical Publications (1999)

Assessments:

• ·Case based discussions
• ·Part 1 COECSA
• ·Part 2 COECSA. OSCE

Gonioscopy[edit | edit source]

Learning outcome OVERVIEW[edit | edit source]

CLINICAL ASSESSMENT
Learning Outcome	Gonioscopy
Code	CA13
Description	Trainees must be able to perform gonioscopy with an indirect gonioscopy lens, identify anterior chamber angle anatomy and interpret the clinical significance of their findings.  They should be able to use the major angle grading systems clinically.
Assessment	CRS13, portfolio/logbook and end of year review/ COECSA exams
Target Year of Achievement	Year 1 – 2
Related Learning Outcomes	CA1 - CA12
Other Links	Study Guide -3.2.13.2 below

Gonioscopy Study Guide  [edit | edit source]

Think:

• ·Why is gonioscopy physically required to see the angle and why is it needed clinically?
• ·How would I feel if I were the patient having gonioscopy done for the first time, and how can I help them to relax appropriately?
• ·What are the major classes of gonioscopy lenses and how do their uses differ?
• ·What are the anatomic landmarks of the angle?
• ·What landmark can be identified using the corneal light wedge technique?
• ·How can one distinguish an open angle from a closed angle?
• ·What is dynamic gonioscopy and when does it help you assess the angle?
• ·What are the major grading systems used in evaluating/reporting the angle?
• ·In what situations should I be wary of performing gonioscopy?
• ·What damage could gonioscopy cause to the patient?

Activity:

• ·Watch senior colleagues and discuss the nuances of their technique.
• ·Perform gonioscopy on all glaucoma patients.
• ·Perform the corneal light wedge technique to identify Schwalbe’s line.
• ·Perform dynamic gonioscopy with an indirect Posner, Sussman or Zeiss style lens.

Resources:

• ·Alward, W. L. M. (2007) Atlas of Gonioscopy. gonioscopy.org
• ·eyewiki.aao.org/Gonioscopy
• ·American Academy of Ophthalmology, Glaucoma, Section 10. Basic and Clinical Science Course. San Francisco: American Academy of Ophthalmology; 2014:38-42.

ASSESSMENTS

Assessments Overview

Broadly speaking the learning outcomes for each domain of clinical practice are assessed as follows:

	Domain of Practice	Assessment
BCS	Basic and clinical sciences	Part 1 COECSA, Part 2 COECSA exams
CA	Clinical assessment	WpBA*rating scales, Part 2 COECSA exams
PI	Patient investigation	WpBA*rating scales, Part 2 COECSA exams
PM	Patient management	WpBA*rating scales ,Part 2 COECSA exams
PS	Practical skills	WpBA*rating scales ,Part 2 COECSA exams
SS	Surgical skills	WpBA*rating scales, Part 2 COECSA exams
CEH	Community eye health	WpBA*rating scales ,Part 2 COECSA exams
Com	Communication	WpBA*rating scales ,Part 2 COECSA exams
BP	Best practice	WpBA*rating scales
ML	Management and leadership	WpBA*rating scales

EXAMINATIONS

A.     Summative assessment in Ophthalmology residency

To qualify as an ophthalmologist under COECSA, a candidate must pass:

• ¨  Basic sciences exam ( Part1)
• ¨  Refraction and Optics (intermediate)
• ¨  Ophthalmic medicine and Ophthalmic surgery exam( Part 2)
• ¨  Clinical final exam
• ¨  (Dissertation/Publication)

B.      Exams: Part 1 (Visual/Basic Sciences & Refraction and Optics)

• ¨  COECSA Part 1: ideally done during the first year of training. In the interim period, COECSA has opted to use ICO part one for convenience. The standards of ICO exams are universally accepted and a good number of residents are already sitting it in the region.
• ¨  ICO Part 1 will be adopted as COECSA part 1 till April 2021.
• ¨  The University MMed part 1 will be accepted as equivalent till end of 2019
• ¨  In 2020, COECSA senate shall assess the value of ICO exams for COECSA, and decide whether to continue or set own?
• ¨   From March 2022, COECSA will have its own part 1 exam if a decision to go that route is taken.
• ¨  Further, COECSA Optics and refraction exam will also be the ICO exam from April 2019 until April 2022.
• ¨   COECSA will have its own exam intermediate exam (Optics) from March 2023
• ¨  MMed Optics and Refraction (if any), will be accepted as equivalent till End of December 2020

C.       Exams: Part 2 (Opth medicine and surgery)

• ¨  COECSA Ophthalmic Medicine and surgery part 2 exam will be the ICO exam from April 2021 till March 2024.
• ¨  MMed part 2 exam will be accepted as equivalent till end of 2021.
• ¨  From April 2025, COECSA will have its own part 2 exam subject to College Senate decision

D.      Clinical Final Exam

• ¨  The current COECSA Fellowship Exam will remain as the final exit Clinical Exam

Target Year of Achievement (TYA)

These are summarized as follows:

TYA	Explanation	Example
Year 1	This LO must normally be achieved during the first year of training and by the end of year 1 at the latest.	CA1 (Clinical history)
Year 2	This LO must normally be achieved during the first or second year of training and by the end of year 2 at the latest. Failure to achieve a significant number of these LO before the end of year 2 without mitigating circumstances may lead to a trainee being removed from the training programme.	BCS (Basic & Clinical Sciences)
Year 3	This LO must normally be achieved during the first three years of training and by the end of year 3 at the latest. Failure to achieve a significant number of these LO before year 3 may require year 3 to be repeated.	SS4 (Cataract) PS1 (Refraction)
Year 1,2,3/4 annual review	This LO must be achieved before the end of year 2 and will be assessed annually thereafter.	BP10-30 COM1-14
Year 3/4	This LO must be achieved in order to complete the core curriculum. It is unlikely to be achieved in the first two years of training but may be achieved anytime during years 3/4	SS5 (surgery to lower IOP)

WorkPLACE BaseD Assessments

The following WpBA assessment tools are available for Training:

Tool	Code	Number of tools	Main Learning Outcome Domains Assessed
Clinical Rating Scale (modified CEX)	CRS	8	Clinical Assessment; Practical Refraction
Case based Discussion	CbD	1	Patient Investigation; Communication; Patient Management; Best Practice; Community Eye Health; Management and Leadership; Basic and Clinical Sciences
Direct Observation of Procedural Skills	DOPS	1	Practical Skills; Communication; Patient Investigation
Objective Assessment of Surgical and Technical Skills Ophthalmology Surgical Competency Assessment Rubric	OSATS OSCAR	4	Surgical Skills; Communication
Multi-source feedback (modified PAT)	MSF	1	Communication; Best Practice

The WpBA tools are available through the website to download for completion, validation by the trainer and can be stored in a paper-based portfolio/e-portfolio (when available). Guidance is available at your institution about who should be the assessor as not all assessments need to be performed by a consultant ophthalmologist. The target year of achievement (TYA) guidance indicates when each WpBA should be achieved.

If a trainee does not complete an assessment successfully, the assessment tool will act as a useful source of feedback and allow preparation for a subsequent assessment. It therefore allows for both formative (developmental) and summative (competence) assessment. Trainees should be encouraged to undergo formative assessment regularly as part of their training and not see 'failure' at an assessment as a problem. Trainees should keep all assessment forms in their portfolio to show that they are obtaining appropriate feedback and making progress. A portfolio that only contains 'passed' assessments should be discouraged - there should be a "culture of deferred success". A variety of assessors should be used, and especially where two satisfactory assessments are required in any year these should be completed by different assessors where possible.

MILESTONES

Milestones are knowledge, skills, attitudes, and other attributes organized in a developmental framework from less to more advanced.  They are descriptors and targets for resident performance as the resident moves from entry into residency through graduation.  These milestones were adapted from the ACGME Milestones used for residency training in the USA facilitated by the International Council of Ophthalmology and Orbis International. Each of the COECSA sub-domains of performance have been mapped to the milestones. The original ACGME milestone language has been modified when necessary to reflect practice in the COECSA region and correspond to the COECSA Curriculum. 

Every six months, the level of milestones that best describes each resident’s current performance level should be selected based on appropriate assessment methods. The suggested methods are listed after each milestone.  Thus, a variety of assessment tools must be completed every 6 months. These include oral and/or written tests, multisource feedback (360 degree assessment), observed clinical evaluations (CRS, OCEX) and assessments of procedural and surgical skill (DOPS, OSATS, OSCAR). This reporting form should be reviewed with each resident individually to give feedback regarding their progress. Completion of the milestone document will show if there are specific weaknesses in individual residents and allow early detection and hopefully successful remediation.

Milestones are arranged into expectations based on progression through training and not necessary according to the year of residency.  Level 3 corresponds to the halfway point of training which will depend on the number of years of training the program has. Selection of a level implies that the resident substantially demonstrates the milestones in that level as well as those in earlier level.  (See Reporting Form diagram below.)   

Level 1: The resident demonstrates milestones expected of someone at the beginning ophthalmology residency.  

Level 2: The resident is advancing and demonstrating year 1 milestones.  

Level 3: The resident continues to advance and is demonstrating additional milestones; the resident consistently demonstrates the majority of milestones targeted for mid residency. 

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency.  This level is designed as the graduation target. Successfully graduating residents should be achieving this level in all areas.

Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years.  It is expected that only a few exceptional residents will reach this level.  

PORTFOLIO

The trainee's portfolio serves 2 important purposes for WBA:

• It contains all of the documents produced through the WBA tools described above
• It contains evidence that the trainee collects to show that they have met the remaining LO in the curriculum

The trainee should regularly maintain the portfolio and use it for the following:

• To store and organize WBA documents as they occur
• To record clinical experience (log book)
• To reflect upon clinical experience and plan learning (reflective diary)
• To record meetings with educational supervisor (appraisal documents)
• To prepare for the annual assessment (revalidation)
• To record formal and informal learning episodes (CPD document)
• To store audit/research/teaching activities
• To record any critical incidents, complaints, guidelines (clinical governance)
• Any other information that supports the trainee's Good Medical Practice e.g. letters from patients, feedback

Specific Learning Outcomes that are assessed at the annual assessment by reviewing the portfolio are:

Learning Outcome (LO)		Target Year (TYA)*	Example of possible evidence
PS1	Refraction	2	DOPS
PS13	Biometry	2	DOPS
PS14	Hand Hygiene	1	MSF
BP17	Appraisal and 360 degree feedback	2	Record of discussion, MSF,
BP19	Probity	1	Statement
BP20	Practice according to National Legal requirements	2	Record of discussion,  MSF
BP21	Data Protection	1	Record of discussion
BP22	Human Tissue	2	Record of discussion
BP23	Child Protection and safeguarding	2	Record of discussion
BP30	Personal Health	1	Statement
PS8	Ocular surface foreign body	1	DOPS forms
PS7	corneal scrape	1	DOPS forms
SS2	Operating Microscope	1	OSATS forms

QUALITY ASSURANCE

In order to ensure that trainees have undergone the same training, quality assurance (QA) tools will be demanded at the end of the training programme as part of the assessment.

APPENDIX

ThE COECSA MILESTONES

Milestone Reporting

This section presents milestones designed for programs to use in semi-annual review of resident performance. Milestones are knowledge, skills, attitudes, and other attributes organized in a developmental framework from less to more advanced.  They are descriptors and targets for resident performance as the resident moves from entry into residency through graduation.  These milestones were adapted from the ACGME Milestones used for residency training in the USA facilitated by the International Council of Ophthalmology and Orbis International. Each of the COECSA sub-domains of performance have been mapped to the milestones. The original ACGME milestone language has been modified when necessary to reflect practice in the COECSA region and correspond to the COECSA Curriculum.  

Every six months, the level of milestones that best describes each resident’s current performance level should be selected based on appropriate assessment methods. The suggested methods are listed after each milestone.  Thus, a variety of assessment tools must be completed every 6 months. These include oral and/or written tests, multisource feedback (360 degree assessment), observed clinical evaluations (CRS, OCEX) and assessments of procedural and surgical skill (DOPS, OSATS, OSCAR). This reporting form should be reviewed with each resident individually to give feedback regarding their progress. Completion of the milestone document will show if there are specific weaknesses in individual residents and allow early detection and hopefully successful remediation.

Milestones are arranged into expectations based on progression through training and not necessary according to the year of residency.  Level 3 corresponds to the halfway point of training which will depend on the number of years of training the program has. Selection of a level implies that the resident substantially demonstrates the milestones in that level as well as those in earlier level.  (See Reporting Form diagram below.)

   

Level 1: The resident demonstrates milestones expected of someone at the beginning ophthalmology residency.  

Level 2: The resident is advancing and demonstrating year 1 milestones.  

Level 3: The resident continues to advance and is demonstrating additional milestones; the resident consistently demonstrates the majority of milestones targeted for mid residency. 

Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency.  This level is designed as the graduation target. Successfully graduating residents should be achieving this level in all areas.

Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years.  It is expected that only a few exceptional residents will reach this level.  

COECSA Milestones Template Description

The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet.  For each reporting period, a resident’s performance on the milestones for each sub-competency will be indicated by:

·        selecting the level of milestones that best describes the resident’s performance in relation to the milestones

Or

·        selecting the “Has not Achieved pre-residency level” option

Each COECSA curriculum Sub-domain is mapped to the appropriate milestone here

PC-1 Patient Interview COECSA CA1, CA10

Has not achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

NA for PC-1 Filling this box at the first assessment means the trainee has made no progress since enrolment COECSA Milestones Template Description

1.  Obtains and documents basic history for ophthalmic complaint

1. Acquires accurate and relevant problem-focused history for common ocular complaints 2. Obtains and integrates outside medical records

1. Obtains relevant historical subtleties including paediatric milestones in children that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient

1.  Demonstrates role model interview techniques to obtain subtle and reliable information from the patient for junior members of the healthcare team, particularly for sensitive aspects of ocular conditions

1. Incorporates new information from literature to tailor interview questions

Selecting a response box on the line in between levels indicates that milestones in lower levels have been substantially demonstrated as well as some milestones in the higher levels. Comments:

Selecting a response box in the middle of a level implies that milestones in that year and in lower levels have been substantially demonstrated.

Assessment method indicated here

COMPLETE LIST OF COECSA MILESTONES

PATIENT CARE AND PROCEDURAL SKILLS

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must demonstrate competency in:

PC-1 Patient Interview COECSA CA1, CA10

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Obtains and documents basic history for ophthalmic complaint

1. Acquires accurate and relevant problem-focused history for common ocular complaints 2. Obtains and integrates outside medical records

1. Obtains relevant historical subtleties including paediatric milestones in children that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient

1.  Demonstrates role model interview techniques to obtain subtle and reliable information from the patient for junior members of the healthcare team, particularly for sensitive aspects of ocular conditions

1. Incorporates new information from literature to tailor interview questions

Comments:

         Assessment Tools: Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2 Patient Examination COECSA CA2-11

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes components of complete ophthalmic examination 2. Performs the basic parts of a screening or bedside eye examination without special equipment

1. Performs and documents a complete ophthalmic examination targeted to a patient’s ocular complaints and medical condition 2. Distinguishes between normal and abnormal findings

1.  Performs problem-focused exam and document pertinent positive and negative findings 2. Consistently identifies common abnormalities; may identify subtle findings

1.  Identifies subtle or uncommon findings of common entities and typical or common findings of rarer entities

1. Incorporates into clinical practice new literature about exam techniques

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2A Vision Testing & Low Vision COECSA CA2, PM7, PM10, PM11, PS1
Level 1	Level 2	Level 3	Level 4	Level 5
1. Check visual acuity (VA) in each eye with a near card and perform confrontation visual field testing	1. Accurately measure and document VA, routine refractive errors, and color and field deficits, including Amsler grid 2. Recognize when low vision services are needed	1. Perform more difficult refractions; use retinoscopy to refine technique and diagnose 2. Ability to prescribe glasses and contact lenses appropriately 2. Describe types of low vision devices.	1. Perform complicated refractions, including post-operative; apply specialized visual tests (e.g., vertical prism test for non-organic visual loss)	1. Develop advanced techniques for measuring vision in unusual circumstances
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2B External COECSA CA3
Level 1	Level 2	Level 3	Level 4	Level 4		Level 5
1. Describe components of external exam	1. Detect obvious abnormalities (e.g., ptosis, exophthalmos); assess 5th and 7th cranial nerve function	1. Identify less obvious abnormalities (e.g., mild ptosis, lid retraction, globe dystopia)	1. Detect or verify most subtle abnormalities; confirm presence or absence of pertinent disease-specific findings (e.g., floppy lid, subtle retropulsion resistance)		1. Develop advanced techniques for assessing external exam findings in unusual circumstances
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2C Ocular Motility/Orthoptic Evaluation COECSA CA5, PI1, PS12
Level 1	Level 2	Level 3	Level 4	Level 5
1. Describe components of ocular motility exam; test versions and ductions	1. Accurately test and record ductions, versions, saccadic and pursuit movements; detect obvious ocular misalignment; identify nystagmus	1. Accurately measure alignment with prisms; detect less obvious misalignment; distinguish phoria and tropia, perform forced ductions	1. Detect or verify subtle motility abnormalities; classify common nystagmus patterns	1. Recognize and classify complex eye movement abnormalities at subspecialty level
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2D Pupils COECSA CA4
Level 1	Level 2	Level 3	Level 4	Level 5
1. Describe components of pupil testing, including test for relative afferent pupillary defect (RAPD)	1. Accurately grade pupil size and reactivity; detect obvious asymmetry and RAPD	1. Detect less obvious abnormalities (e.g., mild RAPD, efferent defect, sympathetic denervation); perform and interpret pharmacologic testing	1. Detect or verify subtle abnormalities (e.g., light-near dissociation); search for associated neurologic findings; (e.g., lid or motility abnormalities)	1. Recognize and classify pupillary abnormalities at subspecialty level
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2E Slit Lamp Biomicroscopy COECSA CA7
Level 1	Level 2	Level 3	Level 4	Level 5
1. Describe components of slit lamp exam; identify corneal abrasion	1. Identify anterior segment structures; recognize common corneal and conjunctival abnormalities, iritis	1. Recognize less obvious abnormalities (e.g., corneal edema, endothelial loss, dysplasia)	1. Detect or verify subtle abnormalities (e.g., corneal thinning); search for associated findings (e.g., orbital signs)	1. Recognize and classify anterior segment abnormalities at subspecialty level
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2F Gonioscopy
Level 1	Level 2	Level 3	Level 4	Level 5
1. Describe purpose of gonioscopy	1.  Describe principles and indications, and properly perform basic techniques of gonioscopy 2.  Recognize normal angle structure; identify angle closure	1. Grade more questionable angles using compression and lens tilting; identify more subtle features (e.g., neovascularization, recession, synechiae)	1. Perform in technically difficult examinations; detect or verify subtle abnormalities (e.g., pigmentation, plateau iris)	1. Recognize and classify gonioscopic abnormalities at subspecialty level
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2G Tonometry COECSA CA6
Level 1	Level 2	Level 3	Level 4	Level 5
1. Describe applanation technique of measuring intraocular pressure	1. Accurately measure intraocular pressure in routine patients using applanation		1. Combine or modify techniques in patients with abnormal corneas or limited cooperation (e.g., Tono-Pen, average Goldmann readings 90 degrees apart)	1. Develop advanced techniques for measuring intraocular pressure in unusual circumstances
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-2H Ophthalmoscopy (Direct and Indirect) COECSA CA8
Level 1	Level 2	Level 3	Level 4	Level 5
1.  Identify optic nerve using direct ophthalmoscopy 2.  Estimate optic nerve cup-disc ratio	1.  Perform slit lamp indirect ophthalmoscopy 2.  Recognize normal optic nerve and retinal appearance; detect obvious abnormalities (e.g., optic atrophy, papilledema, retinal detachment)	1.  Perform slit lamp ophthalmoscopy with the Hruby, +78, +90 lenses, 3- mirror contact lens, and trans-equator (pan- funduscopic) contact lens 2.  Detect less obvious abnormalities (e.g., early glaucomatous excavation, macular degeneration, large retinal tear) 3.  Perform indirect ophthalmoscopy and peripheral retinal examination	1. Detect or verify subtle abnormalities and unusual presentations (e.g., mild maculopathy, shallow detachment, subtle tear); perform scleral depression	1. Recognize and classify complex optic disc and retino-vitreous abnormalities at subspecialty level
Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3 Diagnostic Procedures & Instruments COECSA BCS10, PI7

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describes role of office   diagnostic procedures in diagnosis of ophthalmic disease

1. Selects and/or performs appropriate routine diagnostic tests and imaging procedures based on patient’s ocular complaints and medical condition

1. Interprets routine findings.  Recognize indications for advanced diagnostic tests and imaging procedures

1.  Interprets unusual findings, identify artifacts. Employ routine and advanced diagnostic tests and imaging procedures according to evidence based medicine

1.  Selects diagnostic procedures in a cost-effective manner

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3A Perimetry COECSA PI10

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe role of perimetric tests to quantify and categorize visual loss in damage of the visual pathway

1. Describe fundamentals of perimetry, including kinetic and static techniques; interpret perimetry in routine optic nerve and central nervous system (CNS) disorders

1. Interpret perimetry in more complex optic nerve disorders, including glaucoma, and CNS disorders, including homonymous and bitemporal defects

1. Interpret complex perimetric results, including change over time, using statistical algorithms; identify artifacts

1. Recognize and classify complex perimetric abnormalities at subspecialty level

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3B Corneal Pachymetry and Topography COECSA PI2

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe purpose of corneal pachymetry and topography

1. Describe indications for pachymetry and tomography; interpret basic abnormalities (e.g., irregular astigmatism, corneal thinning)

1. Perform and interpret corneal topographic and pachymetric measurements, and apply these to refraction, contact lens fitting, glaucoma management

1. Perform and interpret advanced corneal topographic and pachymetric measurements, and apply these to refractive surgery

1. Recognize and classify complex pachymetry and topography abnormalities at subspecialty level

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3C Ultrasonography & Biometry COECSA PI3, PI9, PS13

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe role of ultrasonography for diagnosis when ocular media not clear

1. Describe principles of, indications for, and techniques of ocular A- and B-scan ultrasonography

1. Perform A- and B-scan and interpret basic findings (e.g., retinal and choroidal detachment, axial length)

1. Utilize A-scan data to calculate intraocular lens (IOL) power; interpret complex A- and B-scan ultrasonography (e.g., choroidal melanoma)

1. Recognize and classify complex ultrasonographic abnormalities at subspecialty level

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3D Optic Coherence Tomography (OCT)/Confocal Laser Tomography (CLT) COECSA PI5

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe purpose of OCT and CLT

1. Describe principles of, indications for, and techniques of OCT and CLT in analyzing retina and optic disc

1. Interpret basic OCT and CLT findings (e.g., nerve fiber layer thinning, macular edema, optic disc excavation)

1. Interpret complex findings (e.g., epiretinal membranes); identify artifacts

1. Recognize and classify complex OCT and CLT abnormalities at subspecialty level

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3E Fluorescein Angiography COECSA PI4

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe role of fluorescein angiography in diagnosis of retinal and optic nerve disease

1. Describe principles of, indications for, and techniques of fluorescein angiography in analyzing the retina and optic disc (e.g., phases of the angiogram) 2. Interpret basic fluorescein angiography in common retinal disorders (e.g., diabetic retinopathy, cystoid macular edema)

1. Interpret fluorescein angiography in less common retinal diseases

1. Interpret fluorescein angiography in complex retinal vascular and other diseases (e.g., occult and recurrent choroidal neovascular membranes)

1. Recognize and classify complex fluorescein angiographic abnormalities at subspecialty level

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD)

PC-3F Neuroimaging (CT and MRI) COECSA PI6

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe basic principles of CT and magnetic resonance (MR) imaging

1. Describe indications for neuroimaging in ophthalmology; identify major MR sequences (e.g., T1, T2, FLAIR, fat suppression)

1. Recognize normal anatomy of orbits and parasellar regions

1. Identify major abnormalities (e.g., orbital and parasellar tumor, stroke, multiple sclerosis [MS] lesions)

1. Recognize and classify complex CT & MRI abnormalities at subspecialty level

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD), oral/written exams, DOPS

PC-3G Ocular Lubrication Testing COECSA PS5

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe role of office testing to identify dry eyes

1. Describe indications for and perform tests to identify dry eye syndrome and exposure keratopathy (e.g., assessment of tear film breakup time, corneal stain with fluorescein and rose bengal dyes, Schirmer test)

1. Perform diagnostic temporary punctal occlusion

1. Develop advanced techniques for quantifying ocular lubrication in unusual circumstances

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD), oral/written exams, DOPS

PC-4 Disease Diagnosis COECSA BCS6, CA12, PM9, PM10

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describes basic clinical features of common ophthalmologic disorders, e.g. red eye, glaucoma, cataract, diabetic retinopathy

1.  Recalls and presents clinical facts of the history and basic eye exam without higher level of synthesis and generates at least one item of the differential diagnosis for common ophthalmologic disorders

1.  Abstracts and reorganizes elicited clinical findings 2. Prioritizes potential causes of patient complaint; compares and contrasts diagnoses under consideration, considers manifestations of systemic diseases 3. Generates more focused differential diagnosis and organized final assessment

1. Organizes clinical facts in a hierarchical level of importance.   Identify discriminating features between similar patients Incorporates most current literature findings in formulation of differential diagnosis 2. Generates focused differential and evaluation strategy to finalize diagnosis 3. Verifies diagnostic assessments of junior members of healthcare team

1 Continues to incorporate most current literature findings in formulation of differential diagnosis

Comments:

Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD), oral/written examination

PC-5 Nonsurgical Therapy COECSA BCS7, PM1, PM2, PM3, PM6, PS10

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes basic concepts of ophthalmic pharmacotherapy, e.g. most common topical diagnostic and therapeutic agents 2. Ability to manage medical emergencies (e.g. allergic reaction, cardio-respiratory failure, LOC),

1.  Describes categories of medications (e.g. lubricant, antibiotic, anti-inflammatory, anesthetic); describes basic pharmacology of drug therapy and broad indications/contraindications for medical therapy of common ophthalmic conditions; describes routes of drug administration (e.g. topical, oral, periocular, and intravenous) and dosing regimens

1.  Initiates therapy with medication for common ophthalmic diseases; monitor for adverse drug reactions and interactions 2.  Describes indications for oral and intravenous therapy; recognize possible racial, gender, and genomic differences in outcomes of medical therapy 3.  Demonstrates ability to use electronic prescribing (where available); demonstrate competence in periocular injections 4. Ability to use bandage contact lenses appropriately.

1.  Manages and individualizes medical therapy for more complex ophthalmic conditions 2.  Recognizes indications for alternative therapies, including surgical intervention; integrate environmental/behavioral factors 3.  Manages complications 4.  Considers non-medical factors such as cost, convenience, ability to receive medication 5.  Demonstrates competence in intravitreal injections

1. Adopts new therapies based on CME and literature review. Identifies gaps in care and process for improvement

Comments:

           Assessment Tools:  Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD), oral/written examination/DOPS

PC-6 Minor Surgery COECSA PM1, PM2, PM4, PM5

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes essential components of care related to non-OR surgery, e.g., informed consent, indications and contraindications for surgery, pertinent anatomy, anaesthetic and operative technique, potential intra- and postoperative complications

For each procedure: 1.  Lists indications and describe relevant anatomy and pathophysiology of disorder 2.  Identifies findings that are indicators for the procedure and potential postop complications 3.  Describes anaesthetic & surgical technique, mechanism of effect, and specific instruments required 4.  Performs directed pre-op assessment; administers anesthesia and performs procedure with direct supervision; provides appropriate post-op care

1. Administers anaesthesia and perform procedure with indirect supervision   2.  Recognizes intra- and postoperative complications

1.  Administers anaesthesia and performs procedure with oversight supervision 2. Manages intra- and postoperative complications 3. Ability to interpret and act on results

1.  Attains individual outcome & process measures within 2 standard deviations of benchmark means

Comments:

Assessment Tools: DOPS, OSAT

PC-6A Laser Procedures COECSA SS13, SS14, SS15

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe uses of laser in ophthalmology

1.  Identify mode of tissue interaction, therapeutic effect, side effects, complications, safety issues 2.  Describe appropriate laser settings 3.  Use equipment effectively with correct contact lens, including peripheral retina, lens capsule

1. Perform glaucoma (e.g., iridotomy, trabeculoplasty) and retina (e.g., panretinal photocoagulation, laser retinopexy for isolated retinal breaks) procedures, Yag capsulotomy

1. Perform more complicated retinal procedures (e.g., diabetic focal/grid macula, repeat panretinal photocoagulation laser retinopexy of large or multiple breaks)

1. Perform laser procedures at subspecialty level

Comments:

Assessment Tools: DOPS, OSAT

PC-6B Nasolacrimal Probing and Irrigation COECSA PS6

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe purpose of nasolacrimal probing and irrigation

1. Perform basic lacrimal assessment (e.g., dye testing, punctal dilation, canalicular probing)

1. Perform basic lacrimal procedures (e.g., lacrimal drainage testing, irrigation, dye disappearance test) and lacrimal intubation

1. Perform advanced lacrimal assessment (e.g., intra- and post-operative testing, canalicular probing in trauma)

1. Perform nasolacrimal probing and irrigation in unusual circumstances at subspecialty level

Comments:

Assessment Tools: DOPS, OSAT

PC-6C Chalazion Excision, Excision/Biopsy Lid/Conjunctiva Lesion Tarsal plate rotation Corneal scrape COECSA SS10

Level 1

Level 2

Level 3

Level 4

Level 5

1. Demonstrates PC-6 Level 1 milestones for the procedures above with direct supervision

1. Demonstrates PC-6 Level 2 milestones for the procedures above with direct supervision

1. Demonstrates PC-6 Level 3 milestones for the procedures above with indirect supervision

1. Demonstrates PC-6 Level 4 milestones for the procedures above with oversight supervision

1. Demonstrates PC-6 Level 5 milestones for the procedures above with oversight supervision

Comments:

Assessment Tools: DOPS, OSAT

PC-7 OT Surgery COECSA PM4, PM5, PS3, PS4, SS1, SS2, SS3, COM5, COM6, COM13

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describes essential components of care related to OR surgery, e.g., informed consent, indications and contraindications for surgery, pertinent anatomy, anesthetic and operative technique, potential intra- and postoperative complications

For each procedure: 1. Lists indications for, procedure selection, describe relevant anatomy, instrumentation for procedures, including calibration and operation of the microscope, and necessary postoperative care 2. Identifies common intra-operative and post-operative complications and perform postoperative care managing common complications 3. Prepares and drapes for extraocular & intraocular procedures (good aseptic technique) 4. Describes methods for regional and general anesthesia 5. Performs portions of selected procedures 6. Wet lab participation

1.  Obtains informed consent and perform selected procedures 2. Identifies and manages less common intraoperative and postoperative complications 3. completion of surgical wet lab curriculum, simulation if available, and assisting rotation 4. Prepares theater list considering patient needs (oversees all pre-operative planning)

1. Obtains informed consent and perform selected procedures 2. Identifies and manages uncommon intraoperative and postoperative complications

1. Attains individual outcome & process measures within 2 standard deviations of benchmark means 2. Uses results of MOC to develop individual PI plan

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric,

PC-7A Cataract Surgery COECSA SS4

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe indications and technique of cataract surgery

1. Perform selected portions of cataract surgery, including wound construction and microsurgical suturing

1. Perform informed consent for cataract surgery 2. Describe MSICS/ phacoemulsification instruments and  settings and how they facilitate the procedure 3. Describe categories of IOLs, advantages, and disadvantages 4. Perform cataract surgery 5. Perform post-operative care of cataract surgery patients, identify post-operative complications

1. Perform cataract surgery proficiently, including complex technical aspects 2. Describe indications and insertion techniques for premium IOLs to correct astigmatism and provide near correction Manage post-operative complications

1. Perform cataract surgery at subspecialty level

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric,

PC-7B Strabismus Surgery COECSA SS11

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe indications for and technique of strabismus surgery

1. Perform selected portions of strabismus surgery, including extraocular muscle suturing 2. Perform post-operative care of strabismus surgery patients

1. Obtains informed consent for strabismus surgery 2. Perform horizontal strabismus surgery recession and resection 3. Manage intra- and post- operative complications of strabismus surgery

1. Perform vertical and oblique muscle strabismus surgery 2. Describe surgical considerations for re- operations in strabismus surgery

1. Perform strabismus surgery at subspecialty level

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric,

PC-7C Cornea COECSA PS7, PS8, PS9, PS11

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe indications for and technique of cornea surgery

1. Describe concepts of corneal astigmatism/ refractive error, stromal scarring, and endothelial function, and their surgical management 2. Perform corneal foreign body removal at slit lamp

1. Obtains informed consent for common corneal surgeries 2. Perform suture removal and corneal scrape at slit lamp 3. Describe techniques of corneal patch grafting, gluing, chelation of band keratopathy, conjunctival flaps, and amniotic membrane grafting 4. Perform suturing of corneal wounds (traumatic or surgical) 5. Perform pterygium surgery

1. Perform limbal relaxing incisions or arcuate keratotomy as part of cataract surgery 2. Perform post-operative care for common keratorefractive surgeries 3. Recognize and initiate management of common post-operative complications (e.g., graft rejection)

1. Perform cornea surgery at subspecialty level

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric

PC-7D Glaucoma COECSA SS5
Level 1	Level 2	Level 3	Level 4	Level 5
1. Describe indications for and technique of glaucoma surgery	1.  Describe indications for glaucoma surgery 2.  Describe basic steps and goals of glaucoma surgery 3.  Identify common post- operative findings	1.  Obtains informed consent for common glaucoma surgeries (e.g., trabeculectomy, tube shunt, ciliary body ablation) 2.  Assist on and perform selected portions of selected procedures 3.  Perform post-operative evaluation, and identify post-operative complications	1.  Perform common glaucoma surgeries (e.g., trabeculectomy, tube shunt, ciliary body ablation) 2.  Perform post-operative care for uncomplicated glaucoma surgery patients 3.  Manage post-operative complications for common glaucoma surgeries	1. Perform glaucoma surgery at subspecialty level

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric

PC-7E Oculoplastic/Orbit COECSA SS6, SS7, SS8, SS9, SS12

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe indications for and technique of oculoplastic/orbit surgery

1.  Demonstrate basic lid and skin suturing techniques 2.  Close simple wounds not involving the eyelid margin 3.  Provide appropriate post- operative care for selected procedures

1.  Use functional symptoms and exam findings to generate a treatment plan for oculoplastic care 2.  Assess facial and eyelid trauma (including imaging studies) to develop a treatment plan 3.  Obtains informed consent for oculoplastic procedures 4.  Close complex wounds, including those involving the eyelid margin and evisceration

1.  Demonstrate and incorporate knowledge of facial anatomy into treatment plan 2.  Weigh alternative treatment options and describe risks and benefits of each 3.  Perform basic oculoplastics procedures (e.g., tarsal strip, blepharoplasty, ptosis repair, closure of complex wounds, canthotomy, cantholysis, enucleation) 4.  Perform simple flaps and grafts

1. Perform oculoplastic/orbit surgery at subspecialty level including exenteration

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric,

PC-7F Retino-vitreous COECSA SS16

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe indications for and technique of retinovitreous surgery

1. Describe indications for and associated risks of intra- vitreal injections

1.  Perform intra-vitreal injections & taps 2.  Describe indications for, and techniques and complications of pars plana vitrectomy and sclera buckling surgery; assist on retinal surgery 3.  Describe indications for, and techniques and complications of radiation therapy for ocular tumors (e.g., radioactive plaque localization, external beam radiation, radiation retinopathy)

1.  Obtains informed consent for vitreoretinal surgery 2.  Perform parts of a scleral buckling surgery and/or pars plana vitrectomy for retinal detachments

1. Perform retinovitreous surgery at subspecialty level

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric,

PC-7G Globe Trauma COECSA SS6

Level 1

Level 2

Level 3

Level 4

Level 5

1. Describe indications for and technique of globe trauma surgery

1.  Describe common setting for globe trauma and injury prevention 2.  Describe use of protective eye shield in potential globe rupture 3.  Perform examination under anesthesia for suspected globe rupture 4.  Prepare patient with suspected rupture for surgery 4.  Describe surgical steps to identify globe rupture 5.  Describe techniques and sutures for repair of ruptured globe

1.  Obtains informed consent for ruptured globe repair 2.  Perform closure of corneal or scleral wounds 3.  Manage ruptured globes post-operatively, including complications

1. Perform repair of complicated corneal and scleral wounds

1. Perform globe trauma surgery at subspecialty level

Comments:

Assessment Tools: DOPS, OSATS, OSCARs, video review with rubric,

PC-8 Consultation COECSA BP6, BP7, BP16, BP27, ML3

Level 1

Level 2

Level 3

Level 4

Level 5

Level 1

1.  Describes the role of ophthalmology consultation in systemic disease

1.  Provides specific, responsive ophthalmologic consultation to other medical specialties 2.  Recognizes urgent versus non-urgent ophthalmic consultation and seeks help when needed. 3. Examines inpatient at bedside, including visual acuity and field, portable slit lamp exam (+  fluorescein stain), IOP measurement, ophthalmoscopy 4.  Communicates findings (written and oral) to consulting service

1.  Recognizes ophthalmic emergencies and immediate, necessary interventions 2.  Provides appropriate differential diagnosis and initiate nonsurgical treatment plan 3.  Orders ancillary testing; request ophthalmic subspecialty involvement when indicated 4.  Maintains continuing communication with other  involved medical specialists

1.  Identifies consultations requiring surgical intervention, including procedural options and timing 2.  Interprets ancillary tests, formulate and initiate treatment plan independently 3. Coordinates treatment plan with multiple specialties

1.  Provides ophthalmic subspecialty consultation when indicated

Comments:

Assessment Tools: Clinical Rating Scale – consultation skills, OCEX, Case Based Discussion (CbD), oral/written exams

PC-9 Community Eye Health: Screening, Eye Injuries, Immunizations, Health Promotion COECSA CEH1, CEH2, CEH5, CEH6

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1 understand general principles of screening and immunization

1. understand basic principles of the public health aspect of eye care.  2. describe local eye-care screening and management programs 3. understand global initiatives that effect eye care (e.g. Vision 2020).

1. participate in community screening and refer when appropriate 2 educate community about relevant diseases including eye injuries, immunizations and vitamin deficiencies

1. Apply basic principles of the public health aspect of eye care.  2. Understand how to assess burden of eye disease and define context specific strategies for control

1. organize/conduct new screening programs and surveys 2. advocate for occupational eye safety plans 3 develop eye-care health promotion action plan

Comments:

Assessment tools: written or oral tests, faculty evaluation

MEDICAL KNOWLEDGE

Residents must demonstrate knowledge of established and evolving basic science, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents must demonstrate level-appropriate knowledge in the following core domains: anatomy, physiology, biochemistry, molecular and cell biology, genetics, General Medicine; Fundamentals & Principles of Ophthalmology; Optics & Refraction; Ophthalmic Pathology & Intraocular Tumors; Neuro-Ophthalmology; Paediatric Ophthalmology & Strabismus; Orbit, Eyelids, & Lacrimal System; Cornea, External Disease, & Anterior Segment Trauma; Lens & Cataract; Refractive Management & Intervention; Intraocular Inflammation & Uveitis; Glaucoma; Retina/Vitreous

MK-1 Demonstrate level-appropriate knowledge COECSA BCS 1-5

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Has successfully completed internship after basic medical degree graduation

1. successfully passes exams of medical knowledge as required to progress through program

1. successfully passes exams of medical knowledge as required to progress through program

1. successfully passes exams of medical knowledge as required to progress through program

1. Achieves COECSA Fellowship certification.

Comments:

Assessment Tools:  Viva, written exams (semester/annual), ICO Exams, COECSA Fellowship exam

MK-2 Demonstrate level-appropriate knowledge applied to patient management COECSA BCS8, BCS12

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1. Demonstrates level-appropriate knowledge for patient management on ophthalmology rotation

1.   Demonstrates level-appropriate knowledge for patient management for level

1.   Demonstrates level-appropriate knowledge for patient management for level

1.  Demonstrates level-appropriate knowledge for patient management on for level

1. Participates in CPD according to country requirements

Comments:

Assessment Tools:  Observed patient encounter (OCEX CCRS), Viva preferred over written, Case-Based Discussion evaluation 

MK-3 Equipment Maintenance COECSA CEH4

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

Appreciate cost and delicate nature of ophthalmic equipment

1 Able to describe parts and function of diagnostic equipment/lenses and their basic maintenance 2.Use appropriately for their level

Level appropriate use and maintenance of diagnostic equipment/lenses

1 Able to describe and teach proper diagnostic equipment use and maintenance

Works within the system to obtain most cost-efficient equipment

Comments:

Assessment tools: faculty evaluation, written/oral test

PROFESSIONALISM

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.  Residents are expected to demonstrate:

PROF-1: Compassion, integrity, and respect for others; sensitivity and responsiveness to diverse patient populations COECSA BP18

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Recognizes and never participates in: verbal or physical abuse to patients, peers, staff, or supervisors; sexual harassment 2.  Recognizes and never participates in: discrimination based on gender, age, culture, race, religion, disability, sexual orientation, socioeconomic status

1.  Consistently demonstrates behaviour that conveys caring, honesty, and genuine interest in patients and families 2. Demonstrates compassion, integrity, respect, sensitivity, and responsiveness 3.  Exhibits these attitudes consistently in common and uncomplicated situations 4.  Usually recognizes cultural and socioeconomic issues in patient care

1. Exhibits these attitudes in complex and complicated situations 2.  Almost always recognizes cultural and socioeconomic issues in patient care 3. Adheres to ethical principles

1. Exhibits these attitudes consistently in all relationships and situations 2.  Consistently recognizes cultural and socioeconomic issues in patient care

1. Role models behavior demonstrating compassion and respect for others, cultural and socioeconomic issues in patient care 2. Mentors junior members of health care teams 3. Develops organizational policies and education to support the application of these principles

Comments:

             Assessment Tools: 360 degree/multisource feedback, OSCE

PROF 2: Responsiveness to patient needs that supersedes self-interest COECSA BP18, BP24, BP30

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1. Recognizes and never participates in: refusal to perform assigned tasks, answer pages or calls; avoidance of scheduled call duty

1. Almost always completes patient care tasks promptly and completely; punctual; appropriately groomed 2.  Manages fatigue, sleep deprivation and personal health issues. 3.  Identifies impact of personal beliefs and values on practice of medicine

1.  Consistently completes patient care tasks promptly and completely; punctual; appropriately groomed 2.  Manages personal beliefs and values to avoid negative impact on patient care

1. Monitors fatigue, sleep deprivation and personal health in junior members of health care team 2. Mentors junior members of the healthcare team to manage barriers to effective patient care

1.  Role models behavior demonstrating compassion and respect for others 2.  Develops organizational policies and education to support the application of these principles

Comments:

Assessment Tools 360 degree/multisource feedback

PROF-3: Respect for patient privacy and autonomy COECSA BP14, BP18, BP21

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1. Conforms to national patient rights regulations 2. Recognizes and never participates in: unauthorized examination of patient records disclosure of protected health information to unauthorized personnel

1. Almost always: recognizes and implements required procedures for patient involvement in human research; inform patients of rights; involve patients in medical decision-making

1. Consistently recognizes and implements required procedures for patient involvement in human research; informs patients of rights; involves patients in medical decision-making 2. Mentors junior members of the healthcare team regarding protection of patient privacy

1.  Role models behavior regarding protection of patient privacy 2.  Mentors residents involved in administration of research projects involving humans 3.  Develops organizational policies and education to support the application of these principles

Comments:

            Assessment Tools: 360 degree/multisource

 

PROF-4: Accountability to patients, society and the profession COECSA BP4, BP8, BP9, BP17, BP18, BP19, BP20, BP22, BP23

Has not Achieved pre-residency

Level 1

Level 2

Level 3

Level 4

Level 5

1. Recognizes and never participates in: deception regarding level of training and experience, medical errors; demeaning other practitioners 2. Recognizes and never participates in: plagiarism, falsification of records, misrepresentation of training, unexplained absences 3. Adheres to national legal requirements for medical practice 4. Aware of local guidelines and legislature impacting eye care (e.g. use of human tissue, child care protection)

1. Usually recognizes simple conflict of interest scenarios 2. Almost always completes medical record-keeping, reporting and critical incident tasks promptly and completely 3. Maintains up-to-date portfolio/training log-book 4. Always identifies self to patients as resident

1.  Almost always recognizes and takes appropriate steps to manage simple conflict of interest scenarios 2. Consistently completes medical record-keeping, reporting and critical incident tasks promptly and completely 3. Maintains up-to-date portfolio/training log-book 4.  Almost always recognizes limitations and request help or refer patients when appropriate 5. Knows specific ophthalmic conditions requiring use of human tissue

1. Consistently recognizes and takes appropriate steps to manage more complex conflict of interest scenarios 2. Consistently acts within limitations and seek help when appropriate 3. Maintains up-to-date portfolio/training log-book

1.  Assumes leadership and mentoring role in management of more complex conflict of interest scenarios 2.  Develops organizational policies and education to support the application of these principles

Comments:

Assessment Tools: 360 degree/multisource, oral/written exam, portfolio

INTERPERSONAL AND COMMUNICATION SKILLS

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:  

ICS-1: Communicate effectively with patients and families with diverse socioeconomic and cultural backgrounds.  1. Rapport development      3.  Counsel and educate 2. Interview skills                   4.  Conflict management COECSA COM1, COM3, COM4, COM7, COM10, COM11, COM12, BP 10, BP11, BP12, BP13

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Develops positive relationship with patients in uncomplicated situations based on mutual trust; demonstrate empathy 2.  Describes factors that affect communication (e.g. modality, language, use of interpreters, other family in the room, hearing, vision, and cognitive impairments, body language) 3.  Engages in active listening, teach-back and other strategies to ensure patient understanding. 4.  Recognizes ethical and relational communication conflicts

1. Develops positive relationships with families and team members 2.  Identifies special communication needs of vulnerable populations 3.  Counsels patients compassionately at appropriate level for comprehension regarding disease: causes & mechanisms; risk factors; prognosis; management options; risks & benefits 4.  Engages patient in shared decision-making, based on the patient’s understanding and ability to carry out the proposed plan 5.  Negotiates and manages simple patient/family-related conflicts

1.  Develops working relationships in complex situations across specialties and systems of care 2.  Effectively communicates with vulnerable populations, both patients at risk and their families, orally and in writing 3.  Actively seeks information from multiple sources, including consultations. 4.  Organizes family/patient/team member conferences and facilitate/lead them. 5.  Counsels patients regarding emotionally difficult information such as blindness; use appropriate technique for "breaking bad news" 6.  Negotiates and manages conflict in complex

1.  Sustains working relationships during complex and challenging situations including transitions of care and breaking bad news. 2.  Coordinates care for vulnerable populations across health care and social/governmental systems using both oral and written communication 3.  Demonstrates effective integration of all available sources of information when gathering patient-related data 4.   Counsels patients regarding potential short and long term impact of complex, higher risk disease and intervention; address special needs; direct to resources 5.  Documents results of communications, patient preferences, conflict resolution, advance directives

1.  Sustains relationships across systems of care and with patients during long-term follow-up 2. Advocates for vulnerable populations to improve care provided through healthcare, social/community and governmental systems 3. Counsels patients regarding unusual or experimental therapies, including clinical trial participation when indicated 4. Mentors junior members of the health care team  to improve communication skills

Comments:

Assessment Tools: 360 degree/msf, OCEX, OSCE, chart review

ICS-2: Communicate effectively with physicians, other health professionals, and health related agencies 1. Comprehensive, timely, and legible medical records 2. Consultation requests 3. Care transition (Patient hand-over) 4. Conflict management (workplace) COECSA PM8, CEH3

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1. Produces comprehensive, timely, and legible non-ophthalmic medical records 2. Describes effects of computer use on accuracy of information gathering and recording, and potential disruption of the physician patient relationship 3. Describes effect of poor communication on the risk of medical error. 4. Describes importance and procedure for request of consultation. 5.  Lists steps for appropriate care transition 6.  Manages one-on-one conflicts

1. Produces comprehensive, timely, and legible ophthalmic medical records 2.  Ensures that the written record (e.g. EMR, PHR/patient portal, hand-offs, discharge summaries) are accurate and complete, with attention to preventing confusion and error. 3. Recognizes need for consultation; requests appropriate consultant with assistance 4. Performs appropriate basic ophthalmology care transition 5. Manages conflicts within peer group

1.  Maintains face-to-face patient communication while using EMR 2.  Recognizes need, identifies and requests appropriate consultant 3. Performs more complex subspecialty care transitions; ensures accurate documentation and face-to-face communication where needed 4.  Manages conflicts within department

1.  Effectively and ethically uses all forms of communication including face-to-face, telephone, electronic, and social media. 2. Coordinates multiple consultants 3. Manages complex multisystem care transitions 4. Manages conflicts with superiors and payers

1.  Develops models/approaches to managing difficult communications

Comments:

Assessment Tools: 360 degree/msf, OCEX, OSCE, chart review

ICS-3: Work effectively as a member or leader of a healthcare team or other professional group 1.  Clinical team (outpatient clinic, inpatient consult service) 2.  Operating room team 3.  Professional workgroup, e.g. QI committee COECSA ML7

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1. Defines team purpose

1.  Describes role and responsibility of each team member 2. Prepares for team role and fulfil assignments 3. Follows institutional policies

1. Implements team activities as directed by team leader 2. Identifies individual vs. group collaborative roles

1. Selects, evaluates, provides feedback, and remediates team members    2. Identifies team goals 3. Provides team assignments to achieve team goals     4. Designs and implements plan for team improvement

1.  Develops institutional and organizational strategies to improve team functions, trains physicians and educators

Comments:

Assessment Tools: 360 degree/msf, portfolio

ICS-4: Effectively present didactic and case-based educational material to physicians and other healthcare professionals COECSA ML6

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Organizes clear and accurate non-ophthalmic case presentation with level-appropriate diagnostic and management recommendations

1. Organizes case presentation for basic ophthalmic conditions, with diagnostic and management recommendations 2. Presents focused literature review

1. Organizes case presentation for more complex ophthalmic conditions, with diagnostic and management recommendations 2.  Presents comprehensive literature review

1.  Schedules, organizes, and implements case-based and didactic conference program 2.  Mentors presentations

1.  Provides leadership for conference implementation

Comments:

Assessment Tools: 360 degree/msf, portfolio, faculty evaluation

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals:

PBLI-1: Self-Directed Learning 1.  Identify strengths, deficiencies, and limits in one’s knowledge and expertise. 2.  Set learning and improvement goals. 3.  Identify and perform appropriate learning activities. 4.  Use information technology to optimize learning. COECSA BP1, BP2, BP3, BP5, BP15, BP15, BP25, BP26, BP28

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Identifies gaps in personal knowledge and expertise 2.  Demonstrates computer literacy and basic computer skills in clinical practice

1.  Assesses performance by self-reflection and review of   feedback and evaluations 2. Develops a learning plan, based on feedback, with supervision 3.  Utilizes review articles or practice guidelines to answer specific questions in clinical practice

1. Develops learning plan independently with supervision, with accurate assessment of competence and areas for continued improvement 2. Utilizes appropriate evidence-based information tool to answer specific questions while providing care

1.  Utilizes self-directed learning with little external guidance 2.  Consistently uses evidence-based information tools to answer specific questions 3.  Utilizes system or process for keeping up with relevant changes in medicine

1.  Maintains knowledge and regular review of best evidence supporting common practices and acknowledges strengths and deficiencies 2.  Participates in CPD requirements 48 months

Comments:

Assessment Tools: portfolio, faculty evaluation

PBLI-2: Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems. COECSA BCS9, BCS11, PM1, PM2, BP1, BP2, BP3, ML5, ML8, ML9,  ML10, ML12

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes basic concepts in clinical epidemiology, biostatistics, and clinical reasoning 2.  Categorizes study design of a research study

1.  Ranks study designs by validity, generalizability to larger populations, and identifies critical threats to study validity 2.  Distinguishes relevant research outcomes from other types of evidence 3.  Formulates a searchable question from a clinical question and use IT to investigate it 4. Participate in clinical audit

1.  Applies a set of critical appraisal criteria to different types of research, including synopses of original research findings, systematic reviews and meta-analyses, and clinical practice guidelines 2.  Critically evaluates information from others: colleagues, experts, pharmaceutical representatives, and patient-delivered information 3. Conduct & interpret clinical audit

1.  Demonstrates a clinical practice that incorporates principles and basic practices of evidence-based practice and information mastery 2. Conduct, interpret and manage junior residents in clinical audit

1.  Independently teaches and assesses evidence-based medicine and information mastery techniques 2.  Cites evidence supporting several commonly used techniques in own practice

Comments:

Assessment Tools: faculty evaluation, portfolio

PBLI-3 Research Projects/ Dissertation* ·         The COECSA Curriculum does not require a dissertation or research project. This milestone only applies to programs that require a dissertation or publication of research

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1 Be aware that a dissertation or research project is required

1.  Learn about research methods 2. Identify dissertation/ research topic

1. Dissertation/Research  proposal completed & approved by deadline set by program 2. Data collection has started

1. Completed Data collection 2. Completed & submitted dissertation/ research paper 3. Published at least 1 article 4. Presented research in a conference

1.  Continue publishing 4. Presented research in an international  conference

Comments:

Assessment: Supervisor Review, Dissertation Grade

SYSTEMS-BASED PRACTICE

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

SBP-1: Work effectively and coordinate patient care in various health care delivery systems COECSA BP6, ML1

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes basic levels of systems of care (self-management to societal)

1. Describes systems of care within residency training program 2. Lists potential impediments to safe and efficient handovers of care within and between systems

1.  Identifies impediments to safe and efficient referrals within and between systems 2.  Manages routine handovers safely

1.  Proposes solutions to impediments to safe and efficient transitions of care within and between systems 2.  Manages complex handovers of care within and between systems

1.  Leads systems change at micro and macro level

Comments:

Assessment Tools: faculty evaluation, 360 degree/msf 

SBP-2: Incorporate cost-effectiveness, risk/benefit analysis, and IT to promote safe and effective patient care COECSA ML11

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes scenarios in which physician may affect cost-effectiveness in patient care 2.  Explains the role of the Electronic Health Record (EHR) in prevention of medical errors

1.  Describes cost-effectiveness in patient care 2.  Aware of cost options for most frequently ordered tests and medications 3.  Utilizes where available the Electronic Health Record (EHR) to order tests and medications, document notes; 3.  Demonstrate medication reconciliation for patients 4. Uses information systems for patient care

1.  Almost always practices cost-effective care

1.  Consistently practices cost-effective care 2.  Applies risk-benefit analyses in ophthalmic care 3.  Contributes to reduction of risks of automation and computerized systems by reporting system problems

1.  Advocates for cost-effective care and use of risk-benefit analyses within health care system 2.  Recommends systems re-design for faulty computerized processes

Comments:

Assessment Tools: faculty evaluation

SBP-3: Work in inter-professional teams to enhance patient safety, identify system errors and implement solutions COECSA ML2, ML4,

Has not Achieved Level 1

Level 1

Level 2

Level 3

Level 4

Level 5

1.  Describes epidemiology of medical errors and differences between medical errors, near misses, and sentinel events 2.  Describes role of teamwork and communication failure in healthcare as a leading cause of preventable patient harm

1.  Reports problematic processes including errors and near misses to supervisor 2.  Describes use of checklists and briefings to prevent adverse events in healthcare

1.  Analyses causes of adverse events through root cause analysis (RCA) 2.  Applies checklist-guided briefings in healthcare activities 3. Can function as the leader of the team when called upon.

1.  Develops content for and facilitate patient safety M&M presentation or conference focusing on systems-based errors in patient care 2.  Analyses shared team experience (e.g. procedure) with debriefing to solve problems 3. Can function as the leader of the team when called upon.

1.  Designs checklists for use in healthcare 2.  Creates curriculum to teach teamwork and communication skills to healthcare professionals

Comments:

Assessment Tools: faculty evaluation

WORKPLACE BASED ASSESSMENTS

Clinical Rating Scale

CRS	Learning Outcome		Target Year (TYA)#	Assessor*
CRS1	CA1	Consultation	1 annual review	Cons
CRS2	CA2	Vision	1	Cons/AHP
CRS3	CA3	Fields	1	Cons
CRS4	CA4	External eye	1	Cons
CRS5	CA5	Pupil	1	Cons
CRS6	CA6	Ocular motility	2	Cons
CRS7	CA7	IOP	1	Cons/AHP
CRS8	CA8	Slit lamp	1	Cons
CRS9a, CRS9b CRS9c,  CRS9d	CA9	Fundus	2	Cons
CRSret	PS2	Retinoscopy (Paed)	3	Cons/Optometrist

* Assessors:

• Cons: consultant ophthalmologist
• AHP: appropriately trained allied health professional (nurse, orthoptist, optometrist)

Clinical Rating Scale CRS1 (Outcome CA1: CLINICAL HISTORY)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS1      (Outcome CA1-Clinical History)

All trainees must be able to take a clinical history from a patient, which is appropriate for the clinical problem and the individual patient’s needs.

Trainee’s Name                                                                                                                                                                       Date (dd/mm/yyyy)          

YEAR 1                                       YEAR 2                           YEAR 3                    YEAR 4          Other (specify)

Assessor's name                                                                                          Type of assessment:  Formative        Summative                                                              

Assessor's status           Consultant                       Senior Trainee              Other (Specify)

Brief description of case                                       

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout the interview shows that they are actively listening to the patient by gestures, words of encouragement and appropriate eye contact. They establish a good rapport with the patient which is respectful of any ethnic, religious or social preferences that they express. They are empathic and sensitive to the patient’s concerns. Poor trainees neither introduce themselves nor identify the patient.  They hurry the patient and ignore what the patient is saying.  They look away or appear impatient during the history taking. There are unable to establish rapport with the patient and show  little respect.
	Poor	Fair	Good	V Good	n/a
Introduction and start of interview
Rapport with patient and development of trust
Listening skills, appropriate eye contact and non-verbal communication
Empathy and sensitivity
Respect for patient

Information gathering
V good trainees capture all of the appropriate information required for the ophthalmic examination and diagnosis, the planning of investigations and subsequent management. Their questions are structured and guided by the differential diagnosis suggested by the presenting complaint. Poor trainees ask questions by rote. They omit important areas.  They do not pursue an appropriate line of questioning informed by a differential diagnosis.
	Poor	Fair	Good	V Good	n/a
History of presenting complaint
Past ophthalmic history
Family history
Past medical history/general health
Systems enquiry
Drug history and allergies
Social history
Other relevant enquiries pertinent to case
Assessment of mental state

Awareness
V good trainees are attentive the patient’s anxiety and main concerns.  They are sensitive to the social impact of the patient’s problems. They adapt the interview appropriately as determined by the patient’s age, mental state and any communication problems such as poor hearing or language barriers. Poor trainees disregard the patient’s main concerns or anxieties and any impact their problem may have on their social circumstances. They are insensitive to the potential barriers to good communication raised by extremes of age, mental state, hearing impairment or language.
	Poor	Fair	Good	V Good	n/a
Sensitive and responsive to patient anxieties and concerns
Aware of the social impact of problems for patient
Interview sensitive and responsive to age of patient, mental state and any communication problems

Management of interview
V good trainees are skilled in questioning with an appropriate mixture of open and closed questions.  They clarify what they have understood and check this with the patient by appropriate summaries. They use the time efficiently and guide the patient with sensitivity. They explain terms appropriately and finish the interview effectively, making future plans clear. Poor trainees ask closed questions which do not encourage the patient to tell her/his story. They do not clarify points or attempt to summarise.  They waste time through repetition or inappropriate questioning. They do not guide the patient appropriately.  Information if provided at all unclear or too technical.  They do not make it clear when the interview has come to an end or what the next step is.
	Poor	Fair	Good	V Good	n/a
Mode of enquiry: appropriate use of closed, open, directed and probing questions.  Clarification and summarising.
Appropriate control and direction
Efficient use of time
Delivery of information
Termination of interview

Overall performance in this assessment	Poor	Fair	Good	V Good

Summative Outcome (Delete as appropriate if tool used for summative assessments)                             Pass/Fail

Pass/Fail = Meets expectation /Does not meet expectation for stage of training

(Note: "Pass" requires an overall assessment grade of "Good" and NO individual "Poor" grades

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

              

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee:

Clinical Rating Scale CRS2 (Outcome CA2: ASSESS Vision)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS2 (Outcome CA2: Assess Vision)

All trainees must be able to assess visual acuity for near and distance using an appropriate method and interpret the results. They must be aware of and be able to interpret and apply newer methods of assessing visual acuity when they are introduced into clinical practice. They must be able to test colour vision using an appropriate method and interpret the results. They should also know the principles of the assessment of contrast sensitivity. They must be able to assess vision in children and in adults who have language and other barriers to communication. They must be able to assess vision in circumstances outside the OPD environment.

Trainee’s Name                                                                                                                                                                Date (dd/mm/yyyy)                     

YEAR 1                                YEAR 2                   YEAR 3            YEAR 4             Other (specify)

Assessor's name                                                                                             Type of assessment:  Formative           Summative                                                                

Assessor's status           Consultant                       Senior Trainee                    Other (Specify)

Brief description of case                                       

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They explain the purpose of the test and how it will be carried out. Poor trainees neither introduce themselves nor identify the patient.  They hurry the patient and ignore what the patient is saying. They do not explain the test in an appropriate manner.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of test
Rapport with patient, empathy and sensitivity to age and context
Respect for patient

Visual acuity Method*: Snellen/LogMar/Sheridan-Gardner/other, specify (* Please circle method as appropriate or specify “other”…………………………………………….)
Very good trainees occlude each eye in turn to perform the test.  They use an appropriate form of visual acuity assessment determined by the patient’s age and level of understanding.  They can compare results from different tests.  They use appropriate refractive correction and instruct the patient on the best use of a pinhole. They record the visual acuity correctly. Poor trainees do not occlude appropriately.  They do not use an appropriate test method.  They do not understand the equivalence of results from different tests. They do not use an appropriate method of correcting refractive error. The visual acuity is recorded inaccurately or incorrectly.
	Poor	Fair	Good	V Good	n/a
Appropriate occlusion
Technique of assessment appropriate for age and context
Appropriate use of refractive correction
Appropriate use of pinhole
Accurate recording of distance acuity
Accurate recording of near acuity

COECSA Workplace Based Assessments

Clinical Rating Scale CRS2 (Outcome CA2: Assess Vision)

All trainees must be able to assess visual acuity for near and distance using an appropriate method and interpret the results. They must be aware of and be able to interpret and apply newer methods of assessing visual acuity when they are introduced into clinical practice. They must be able to test colour vision using an appropriate method and interpret the results. They should also know the principles of the assessment of contrast sensitivity. They must be able to assess vision in children and in adults who have language and other barriers to communication. They must be able to assess vision in circumstances outside the OPD environment.

Colour vision (Method: Ishihara/other pseudoisochromatic/other)
V good trainees occlude each eye in turn to perform the test.  They use an appropriate form of colour vision assessment determined by the patient’s age and level of understanding.  They can compare results from different tests. They record the results of the colour vision test correctly and know how to interpret them. Poor trainees do not occlude appropriately.  They do not choose an appropriate test method.  They do not understand the equivalence of results from different tests.  The colour vision is recorded inaccurately or incorrectly.  They do not understand the implications of the result.
	Poor	Fair	Good	V Good	n/a
Appropriate occlusion
Technique of assessment appropriate for age and context
Appropriate use of colour vision test
Accurate recording of colour vision

Overall performance in this assessment	Poor	Fair	Good	V Good

Summative Outcome (Delete as appropriate if tool used for summative assessments)                             Pass/Fail 

(Note: "Pass" requires an overall assessment grade of "Good" and NO individual "Poor" grades.) 

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee:

Clinical Rating Scale CRS3 (Outcome CA3: EXTERNAL EYE EXAMINATION)

COECSA Workplace Based Assessments

Clinical Rating Scale CR3 (Outcome CA3: External Eye Examination)

All trainees must be able to perform an examination of the external eye, ocular adnexae, eyelids and orbits using appropriate equipment and illumination. They must be able to modify the examination and utilise other techniques as indicated by the clinical findings.

Trainee’s Name                                                                                                                                                 Date (dd/mm/yyyy)       

YEAR 1                                YEAR 2                   YEAR 3            YEAR 4             Other (specify)

Assessor's name                                                                                         Type of assessment: Formative         Summative                                                              

Assessor's status           Consultant                       Senior Trainee                   Other (Specify)

Brief description of case                                       

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out. Poor trainees fail to introduce themselves and do not identify the patient.  They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient

External eye examination
V good trainees carry out a thorough inspection of the patient and this efficiently guides the examination. They examine the patient’s face, lymph nodes and neck and observe, palpate and auscultate the orbit as indicated.  They examine the lacrimal gland, sac, canaliculi and puncta. They examine static and dynamic lid position and make accurate and surgically relevant measurements (e.g. Bells, corneal sensation).  They identify any abnormalities of the lashes and meibomian glands. They examine the bulbar, tarsal and forniceal conjunctiva and the cornea, in particular identifying abnormalities thereof secondary to lid abnormalities. Poor trainees examine the external eye in an ill-structured and inefficient way and without adequate illumination. They restrict their examination to the eyelids, even when the clinical condition suggests an examination of wider facial or ocular structures. They are unable to assess lid position accurately. They fail to examine all of the conjunctiva and the lacrimal system, or the cornea. They do not assess the orbital margin.  They fail to recognise important abnormalities of the external eye.
	Poor	Fair	Good	V Good	n/a
Assessment of face/head
Palpation of orbital margins
Examination of lacrimal system
Assessment of lid position with appropriate measurements
Examination of lashes
Examination of meibomian glands
Examination of conjunctiva
Examination of cornea

COECSA Workplace Based Assessments

Clinical Rating Scale CR3 (Outcome CA3: External Eye Examination)

All trainees must be able to perform an examination of the external eye, ocular adnexae, eyelids and orbits using appropriate equipment and illumination. They must be able to modify the examination and utilise other techniques as indicated by the clinical findings.

Use of ancillary tests
V good trainees use these techniques skilfully and without prompting.  They recognise the limits of normality and correctly interpret their findings. Poor trainees require prompting to use these techniques.  They have a poor method and fail to recognise normal and abnormal findings.
	Poor	Fair	Good	V Good	n/a
Lid eversion
Exophthalmometer
Other (please specify)

Overall performance in this assessment	Poor	Fair	Good	V Good

Summative Outcome (Delete as appropriate if tool used for summative assessments)                             Pass/Fail

(Note: "Pass" requires an overall assessment grade of "Good" and NO individual "Poor" grades.)

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

              

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee:

Clinical Rating Scale CR4 (Outcome CA4: EXAMINATION OF PUPILS)

COECSA Workplace Based Assessments

Clinical Rating Scale CR4 (Outcome CA4: Examination of Pupils)

All trainees must be able to assess the pupil for abnormalities of shape, size and reactions and interpret their findings.  They must also be able to perform and interpret appropriate pharmacological tests for specific pupil abnormalities.

                                              

Trainee’s Name                                                                                                                                                          Date (dd/mm/yyyy)                 

YEAR 1                                YEAR 2                   YEAR 3            YEAR 4             Other (specify)

Assessor's name                                                                                         Type of assessment: Formative          Summative                                                              

Assessor's status           Consultant                       Senior Trainee                    Other (Specify)

Brief description of case:

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out. Poor trainees fail to introduce themselves and do not identify the patient.  They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient

Examination of the pupils V good trainees examine the patient in low ambient light and record the pupil size, position, shape and symmetry. They ensure that the subject fixates on a distance target.  They use a bright focussed light to examine the direct and the consensual reaction in each eye, noting the extent, speed and recovery of the reaction.  They then progress to the swinging flashlight test (SFT), dwelling on each eye for a second or two and moving the light swiftly across to the other pupil.  They correctly interpret the results of a SFT even when one pupil is dilated or obscured.  They test the accommodative reaction using an appropriate target and instruction.  They ask to view the pupils on the slit lamp.  They are familiar with pharmacological tests for abnormal pupil reactions. They suggest an appropriate cause for any abnormalities observed.  Poor trainees examine the pupils in an ill-structured and inefficient way with inappropriate illumination.  They fail to ensure that the subject fixates on a distance target and get in the way of the subject’s direction of gaze. They allow the test light to spill into the non-tested eye.  They forget to record the size, shape and position of the pupils.  They perform the SFT with a slow arc under the nose from one eye to the other.  They are unable to comment on pupil reactions if one pupil is dilated or obscured.  They elicit the accommodative reaction by rapidly approaching the eyes with one finger and are unaware of the threat response.  They exhibit confusion about the theory and practice of pharmacological tests. They forget to view the pupils on the slit lamp. They are unable to interpret the results of the test.
	Poor	Fair	Good	V Good	n/a
General inspection in ambient light with measurements
Appropriate use of distance target
Direct pupillary reaction and recovery
Consensual reaction and recovery
Swinging flashlight test
Accommodative reaction and recovery
Slit lamp examination
Correct reactions identified
Suggestion of suitable aetiology
Suggestions for suitable further tests

COECSA Workplace Based Assessments

Clinical Rating Scale CR4 (Outcome CA4: Examination of Pupils)

All trainees must be able to assess the pupil for abnormalities of shape, size and reactions and interpret their findings.  They must also be able to perform and interpret appropriate pharmacological tests for specific pupil abnormalities

Overall performance in this assessment	Poor	Fair	Good	V Good

Summative Outcome (Delete as appropriate if tool used for summative assessments)                             Pass/Fail

(Note: "Pass" requires an overall assessment grade of "Good" and NO individual "Poor" grades.)

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

              

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee:

Clinical Rating Scale CRS5 (Outcome CA5: OculaR MOTILITY)

                                              

COECSA Workplace Based Assessments

Clinical Rating Scale CRS5 (Outcome CA5: Cover Test and Ocular Motility)

All trainees must be able to perform a cover test, assess ocular movements and interpret the findings. They must be able perform a prism cover test.  They must also be able to recognise and describe nystagmus if present.

Trainee’s Name                                                                                                                               Date (dd/mm/yyyy)                 

YEAR 1                                YEAR 2                   YEAR 3            YEAR 4             Other (specify)

Assessor's name                                                                                         Type of assessment:  Formative        Summative                                                              

Assessor's status           Consultant                       Senior Trainee                     Other (Specify)

Brief description of case                                       

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out. Poor trainees fail to introduce themselves and do not identify the patient.  They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient

Cover test and eye movements
V good trainees comment on corneal reflexes and any abnormal head posture, ptosis, pupils etc. They use suitable near and distance fixation targets. They perform cover-uncover and alternate cover tests purposefully without excessive repetition and identify abnormalities accurately. Their instructions to the patient are clear and unambiguous throughout. The examination flows easily and appropriate versions, ductions, vergences and saccade checks are performed in response to findings. Poor trainees fail to perform a general inspection of the patient. Their instructions to the patient are ambiguous and confusing so that the patient is unclear what is expected of them. They perform the tests clumsily, without an obvious plan and important steps are missed. They miss and/or fail to interpret important clinical signs.
	Poor	Fair	Good	V Good	n/a
Observation of associated ocular signs and head position
Use of fixation targets
Performance of cover, cover-uncover test and alternate cover test.
Assessment of versions, ductions, vergences, saccades
Interpretation of findings

COECSA Workplace Based Assessments

Clinical Rating Scale CRS5 (Outcome CA5: Cover Test and Ocular Motility)

All trainees must be able to perform a cover test, assess ocular movements and interpret the findings. They must be able perform a prism cover test.  They must also be able to recognise and describe nystagmus if present.

Prism cover test
V good trainees give clear instructions to the patient. They perform the test at near and distance and with/without glasses or head posture if appropriate. They hold the prism bar at a comfortable and effective distance with prisms aligned in the correct position for the deviation. They perform an alternate cover test with increasing prism strength until the deviation is reversed. They interpret the test accurately. Poor trainees leave the patient unclear what is expected of them. They are unfamiliar with the prism bar. They miss important steps and they fail to assess the angle with acceptable accuracy.
	Poor	Fair	Good	V Good	n/a
Explanation of test
Appropriate positioning of  prism bar
Assessment of angle
Interpretation of results

Overall performance in this assessment	Poor	Fair	Good	V Good

Summative Outcome (Delete as appropriate if tool used for summative assessments)                             Pass/Fail 

(Note: "Pass" requires an overall assessment grade of "Good" and NO individual "Poor" grades.) 

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee:

Clinical Rating Scale CRS6 (Outcome CA6: IOP MeASUREMENT)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS6 (CA6: IOP Measurement)

All trainees must be able to measure the intraocular pressure accurately using a variety of applanation techniques and understand the limits of each.  They must be able to check the calibration of the tonometer.

Trainee’s Name                                                                                                                                                                                         Date (dd/mm/yyyy)          

YEAR1                                        YEAR 2                            YEAR 3                                    YEAR 4                                   Other (specify)

Assessor's name:

Assessor's status:         Consultant                                               AHP                           Other (Specify)

Brief description of case(s)                                  

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the identity of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out.  They ensure that the patient is comfortable and that adequate privacy is maintained. Poor trainees fail to introduce themselves and do not identify the patient. They appear to hurry or ignore what the patient is saying.  They do not explain the test in an appropriate manner.  They pay little or no attention to confirmation of patient comfort or privacy.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient and their comfort

IOP measurement (Technique: Goldmann/Tonopen/Perkins/other)
V good trainees ensure adequate disinfection of the tonometer before and after use. They insert appropriate amounts of appropriate drops, avoid contact of the tonometer with lids or lashes and complete the measurement swiftly without prolonged contact between tonometer and cornea. They achieve a reading accurate to within 2 mm Hg of the assessor’s reading. They are conversant with all types of IOP measurement methods and the advantages and disadvantages of each. Poor trainees have to be prompted to ensure disinfection of the tonometer tip before and after use.  They insert inappropriate quantities of anaesthetic drops or use inappropriate drops.  They push roughly on the patient’s eye and lids and touch the tonometer on the lids.  They have difficulty achieving a reading, requiring several attempts, and fail to achieve accuracy to within 2 mm Hg.  They frequently cause trauma to the corneal epithelium. They are not fully aware of all types of measurement methods or their advantages and disadvantages.
	Poor	Fair	Good	V Good	n/a
Consent for test
Application of anaesthesia and fluorescein
Stabilisation of lids and eye
Use of tonometer.  Accurate placement on eye
Accurate IOP recording.  Accurate to within 2mm Hg
Interpretation of result
Corneal appearance after examination
Care of tonometer head
Infection control

Checking calibration of tonometer
V good trainees know how to use the calibration arm and what to do if the reading is inaccurate. Poor trainees do not know what to do with the calibration arm and do not know what an inaccurate reading is, or what to do about it.
	Poor	Fair	Good	V Good	n/a
Knowledge of reasons for calibration
Appropriate use of calibration arm
Interpretation of results
Appropriate action taken

Overall performance in this assessment	Poor	Fair	Good	V Good

Outcome (Delete as appropriate)                              Pass/Fail

NB The following boxes MUST be completed:

              

Please note any aspects which were especially good:

Please note any suggestions for improvement and action points:

              

Signature of assessor:                                                         Signature of trainee:

Clinical Rating scale CRS7 (CA7: Use of Slit Lamp)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS7 (CA7: Use of Slit Lamp)

All trainees must be able to examine the eye and adjacent structures using the slit lamp and interpret their findings. They must be able to employ all of the functions of the slit lamp and use accessory equipment when indicated. They must know how to care for the equipment properly and prevent cross infection.

                                                                                              

Trainee’s Nam                                                                                                                                                        Date (dd/mm/yyyy)              

YEAR 1                                YEAR 2                   YEAR 3            YEAR 4             Other (specify)

Assessor's name                                                                                          Type of assessment:  Formative          Summative                                                                

Assessor's status           Consultant                       Senior Trainee                    Other (Specify)

Brief description of case                                       

                                              

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out. Poor trainees fail to introduce themselves and do not identify the patient.  They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient

Knowledge of slit lamp
V good trainees set up the slit lamp properly in advance of conducting the examination. They appropriately set the IPD and focus of each eyepiece, and have a good knowledge of all the slit lamp functions and techniques of illumination to achieve the optimum view of the part of the eye being examined. They know what adjustments to make to view different areas of the anterior and posterior segment. They are aware of appropriate care and maintenance of the slit lamp. Poor trainees fail to set up the slit lamp properly. Their examination technique is slip shod and halting and they make constant aimless readjustments. They appear unaware of the best slit lamp settings to optimise the examination of different parts of the anterior and posterior segments.
	Poor	Fair	Good	V Good	n/a
Appropriate IPD
Appropriate eyepiece focus
Appropriate selection of slit beam size and angle
Use of full range of available magnification powers
Use of appropriate filters

Signature of assessor:                                                         Signature of trainee:

Clinical Rating scale CRS8 (CA8: Fundus Examination – Direct opthalmoscope)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS8 (CA8: Fundus Examination)

All trainees must be able to examine the fundus of the eye using appropriate techniques and interpret their findings. They must be able to use the direct and indirect ophthalmoscopes. They must be able to use a variety of lenses for binocular fundus examination with the slit lamp. They must be able to use appropriate indentation techniques.

                              

Trainee’s Name                                                                                                                                Date (dd/mm/yyyy)                

YEAR 1                                YEAR 2                   YEAR 3            YEAR 4             Other (specify)

Assessor's name                                                                                           Type of assessment:  Formative         Summative                                                              

Assessor's status           Consultant                       Senior Trainee                  Other (Specify)

Brief description of case                                       

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the name of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out. Poor trainees fail to introduce themselves and do not identify the patient.  They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient
Aware of patient’s comfort

Direct ophthalmoscope
V good trainees check the ophthalmoscope before using it. They select the most appropriate colour, shape, size and brightness of light beam at every stage. They always choose the most appropriate correcting lens. They explain the procedure and show that they understand the discomfort caused by the brightness of the light. They readily achieve a good view of the central fundus and achieve a view as far peripherally as is feasible. Their technique is efficient and fluent. They will describe their findings accurately. Poor trainees launch into the examination without checking the instrument settings. They show no understanding of the uses of the different settings. Their use of the lenses is haphazard. They are unable to co-ordinate an examination of the peripheral fundus. They fail to understand and empathise with the patient when the patient finds the light uncomfortable. They miss abnormalities altogether and/or fail to describe them.
	Poor	Fair	Good	V Good	n/a
Instructions to patient
Familiarity with use of ophthalmoscope
Correct use of illumination
Appropriate use of lenses
Description of findings

Clinical Rating scale CRS8 (CA8: Fundus Examination – indirect ophthalmoscope)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS8 (CA8: Fundus Examination)

All trainees must be able to examine the fundus of the eye using appropriate techniques and interpret their findings. They must be able to use the direct and indirect ophthalmoscopes. They must be able to use a variety of lenses for binocular fundus examination with the slit lamp. They must be able to use appropriate indentation techniques.

Indirect ophthalmoscope
V good trainees adjust the equipment appropriately before use, in particular adjusting the light for optimum viewing. They examine the patient in a reclined position whenever appropriate and ensure their comfort. They choose the most appropriate condensing lens and demonstrate an efficient and fluent technique, holding the lens at the best distance from the eye. When appropriate they use indentation efficiently and gently. They use the minimum light necessary for a proper view and empathise with the patient when the light or the indentation causes discomfort. They describe their findings accurately. Poor trainees struggle to place the ophthalmoscope in position on their head squarely and securely. They are unable to adjust the light appropriately. They fail to ensure that the patient is comfortable or appropriately positioned. They use too much or too little illumination. Their use and positioning of the lens is haphazard. They are unable to co-ordinate an examination of the peripheral fundus and are rough with and/or unsuccessful at indentation. They fail to understand and empathise with the patient when the patient finds the test uncomfortable. If they manage to achieve a view at all they miss abnormalities altogether and/or fail to describe them.
	Poor	Fair	Good	V Good	n/a
Instructions to patient
Familiarity with use of ophthalmoscope
Correct use of illumination
Appropriate use of lenses
Indentation technique
Description of findings

Clinical Rating scale CRS8 (CA8: Fundus Examination – 78d/90d lens)

COECSA Workplace Based Assessments

Clinical Rating Scale CRS8 (CA8: Fundus Examination)

78D/90D lens
Very good trainees set up the slit lamp illumination and eyepieces before commencing the examination. They help the patient to get into position if necessary. They warn of the brightness of the light. They select the most appropriate lens and show expertise in holding it in the correct position and orientation. They choose the most appropriate colour, size and brightness of light at every stage and empathise with the patient who has difficulty looking in the correct direction. Thel have a fluent technique and achieve as good a view of both central and peripheral retina as is possible. They describe their findings accurately. Poor trainees rush into the examination without setting the slit lamp properly. They start with an inappropriately bright light but have to fiddle around to get it pointing correctly. They show frustration when the patient cannot place his/her head appropriately or cannot move the eye into the desired position. They choose an inappropriate lens and/or show difficulty in getting it positioned correctly. If they manage to achieve a view at all they miss abnormalities altogether and/or fail to describe them.
	Poor	Fair	Good		V Good	n/a
Instructions to patient
Familiarity with use of lenses
Correct use of slit lamp illumination
Appropriate use of lenses
Description of findings

Clinical Rating Scale CRSret (Outcome PS1a: Refraction)

COECSA  Workplace Based Assessments

Clinical Rating Scale CRSret (Outcome PS1a: Refraction)

All trainees must be able to perform an accurate refraction objective and subjective refraction, performing appropriate tests (for adults) and provide an appropriate prescription.

Trainee’s Name                                                                                                                                                                                         Date (dd/mm/yyyy)                  

     YEAR1                                YEAR 2                            YEAR 3                                    YEAR 4                                   Other (specify)

Assessor's name:

Assessor's status:         Consultant                                               AHP                           Other (Specify)

Brief description of case                                      

Attitude and manner
V good trainees introduce themselves and establish the identity of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout the interview shows that they are actively listening to the patient by gestures, words of encouragement and appropriate eye contact. They establish a good rapport with the patient which is respectful of any ethnic, religious or social preferences that they express. They are empathic and sensitive to the patient’s concerns. They ensure that the patient is comfortable and that adequate privacy is maintained. They guide the patient considerately through the clinical examination. Poor trainees neither introduce themselves nor identify the patient. They hurry the patient and ignore what the patient is saying.  They look away or appear impatient during the history taking.  They are unable to establish rapport with the patient and show little respect. They pay little or no attention to confirmation of patient comfort or privacy. They proceed with the examination without adequate explanation and with little consideration for patient comfort.
	Poor	Fair	Good	V Good	n/a
Introduction and start of interview
Rapport with patient and development of trust
Listening skills, appropriate eye contact and non-verbal communication
Empathy and sensitivity
Respect for patient

Retinoscopy
V good trainees carry out an examination in an appropriate environment, and allow adequate time for full cycloplegia if needed.  They carry out an accurate retinoscopy at a suitable working distance. Use of lenses and frames is tidy and efficient. Their examination is fluent where possible and appropriate opportunities are maximised when cooperation is suboptimal. Accurate notation of retinoscopy, using power crosses and indication of working distances, is used. An appropriate prescription is then calculated with an understanding of adjustments made in relation to the clinical case. They carry out proper subjective refraction. Poor trainees position the patient or themselves poorly. They do not allow adequate time for cycloplegia. They do not attend to the room environment (patient comfort, lighting etc). Retinoscopy is chaotic with untidy use of lenses and other equipment. Notation of findings is unclear or ambiguous. They do not understand the importance of adjusting the final prescription.
	Poor	Fair	Good	V Good	n/a
Patient positioning/room setup
Appropriate cycloplegia
Use of trial frame/lenses
Appropriate refining (Cross cylinder, Duochrome test)
Time taken/flow of examination
Accuracy of retinoscopy
Notation of retinoscopy/working distance
Appropriate prescription issued

Overall performance in this assessment	Poor	Fair	Good	V Good

Outcome (Delete as appropriate)            Pass/Fail

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee

CRSret (Outcome PS1b: Cycloplegic Refraction)

COECSA Workplace Based Assessments

Clinical Rating Scale CRSret (Outcome PS1b: Cycloplegic Refraction)

All trainees must be able to perform an accurate cycloplegic refraction (especially on a child) and provide an appropriate prescription.

Trainee’s Name                                                                                                                                                                                         Date (dd/mm/yyyy)                  

     YEAR1                                YEAR 2                            YEAR 3                                    YEAR 4            Other (specify)

Assessor's name:

Assessor's status:         Consultant                                               AHP                           Other (Specify)

Brief description of case                                      

Attitude and manner
V good trainees introduce themselves and establish the name of the child and any other attendant (e.g. parent, carer). They explain the purpose of the test and how it will be carried out. They interact with the child using language and gestures appropriate for the child’s age. They are sympathetic to any distress felt by the child or carer and offer on-going encouragement and praise throughout the examination. They display good judgement regarding the limitations of the assessment and pursuit of clinical signs. Poor trainees neither introduce themselves nor identify the patient.  They are insensitive to distress felt by the child and their carer. Their demeanour is often inappropriate for the child’s age and they make little attempt to interact with the child. They offer little or no encouragement. They needlessly prolong the examination to no benefit.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with child/carer, empathy and sensitivity to age and context
Respect for child/carer

Retinoscopy
V good trainees carry out an examination in an appropriate environment, and allow adequate time for full cycloplegia.  They carry out an accurate retinoscopy at a suitable working distance. Use of lenses and frames is tidy and efficient. Their examination is fluent where possible and appropriate opportunities are maximised when cooperation is suboptimal. Accurate notation of retinoscopy, using power crosses and indication of working distances, is used. An appropriate prescription is then calculated with an understanding of adjustments made in relation to the clinical case. Poor trainees position the patient or themselves poorly. They do not allow adequate time for cycloplegia. They do not attend to the room environment (patient comfort, lighting etc). Retinoscopy is chaotic with untidy use of lenses and other equipment. Notation of findings is unclear or ambiguous. They do not understand the importance of adjusting the final prescription.
	Poor	Fair	Good	V Good	n/a
Patient positioning/room setup
Appropriate cycloplegia
Use of trial frame/lenses
Time taken/flow of examination
Accuracy of retinoscopy
Notation of retinoscopy/working distance
Appropriate prescription issued

Overall performance in this assessment	Poor	Fair	Good	V Good

Outcome (Delete as appropriate)            Pass/Fail

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

Anything especially good?	Suggestions for development:
Agreed action:

              

Signature of assessor:                                                         Signature of trainee

Clinical Rating scale CRS13 (CA13:  Gonioscopy)

COECSA Workplace Based Assessments

Clinical rating Scale CRS13 (CA13: Gonioscopy)

All trainees must be able to perform gonioscopy using an indirect gonioscopy lens, identify the major angle landmarks, record their findings using a major grading system and clinically apply their findings.

 

Trainee’s Name                                                                                                                                                                                                                                                                                                                 Date (dd/mm/yyyy)         

YEAR1                                                                 YEAR 2                            YEAR 3                                    YEAR 4                                   Other (specify)

Assessor's name:

Assessor's status:          Consultant                                                 AHP                                                     Other (Specify)

Brief description of case(s)                                                                                     

Please grade the following areas using the scale below (use tick or cross)

Attitude and manner
V good trainees introduce themselves and establish the identity of the patient and any other attendant (e.g. spouse, parent, carer). Their demeanour throughout shows that they are attentive to the patient by gestures, words of encouragement and appropriate eye contact. They clearly explain the purpose of the test and how it will be carried out.  They ensure that the patient is comfortable and that adequate privacy is maintained. Poor trainees fail to introduce themselves and do not identify the patient.  They appear to hurry or ignore what the patient is saying. They do not explain the test in an appropriate manner.  They pay little or no attention to confirmation of patient comfort or privacy.
	Poor	Fair	Good	V Good	n/a
Introduction and explanation of examination
Rapport with patient, empathy and sensitivity to age and context
Respect for patient and their comfort

Gonioscopy (Technique: indirect, dynamic, corneal light wedge)
V good trainees ensure adequate disinfection of the gonioscopy lens before and after use. They anesthetize the eye. They do not cause corneal abrasions.  They record angle findings to within 1 grade of the assessor’s findings. They can identify all major angle landmarks, perform the corneal light wedge technique and dynamic gonioscopy when indicated.  They are conversant with the different types of grading systems and understand the advantages and disadvantages of each. Poor trainees have to be prompted to ensure disinfection of gonioscopy lens before and after use. They insert inappropriate quantities of anaesthetic drops or use inappropriate drops.  They push roughly on the patient’s eye with the lens and frequently cause trauma to the corneal epithelium.  They have difficulty identifying and interpreting the angle. They do not know when or how to perform the corneal light wedge technique or dynamic gonioscopy.  They are not conversant with the major grading systems of the angle nor are they able to explain the advantages and disadvantages of each.
	Poor	Fair	Good	V Good	n/a
Consent for test
Application of anaesthesia
Stabilisation of lids and eye
Use of the gonioscopy lens
Accurate angle recording within 1 grade of assessor
Interpretation of result
Corneal appearance after examination
Care of gonioscopy lens
Infection control

Overall performance in this assessment	Poor	Fair	Good	V Good

Outcome (Delete as appropriate)                              Pass/Fail

NB The following boxes MUST be completed:

                               

Please note any aspects which were especially good:

Please note any suggestions for improvement and action points:

Signature of assessor:                                                                                           Signature of trainee:

Case-based Discussion (CbD)

Competence in patient investigation, patient management, and community eye health, and some aspects of best practice domain is assessed using a CbD form. These forms can be completed by trainers in the following circumstances:

• During an out-patient clinic. Trainers and trainees may wish to allocate 5-10 minutes to discuss the management of a patient seen during an out-patient clinic. Case selection would be determined by either the trainee or trainer. The trainee should have had some direct clinical role with the patient e.g. history taking, clinical examination, investigations ordered or interpreted, management decisions, management of complications, critical incidents etc.
• At the end of an out-patient clinic. Trainers and trainees may wish to allocate some time at the end of clinic to review a small number of case notes where the trainee has had a significant role in the management of the patient.
• Case presentations during postgraduate teaching. Trainees are often asked to present cases at local or regional postgraduate teaching sessions. A nominated trainer should complete a CbD form after the presentation.
• During a designated teaching session. Trainers and trainees may wish to allocate a period of one-to-one teaching or small group teaching where cases are discussed and a CbD form completed.

A list of Clinical Scenarios (approximately 40) that cover most of the COECSA curriculum is provided in the Study Guide  link. Trainees should aim to cover all these scenarios in their case based discussions if possible so that their portfolio reflects a wide range of clinical management situations.

It is recommended that about half the cases for CbD are chosen by the trainee and half by the trainer.

Trainees need to complete 10 CbDs during each year of training and these should be suitably spread throughout the year. By the end of training a trainee's portfolio should contain at least 40 CbD forms. Case based discussion is an important way to show that a trainee is developing her or his patient management skills and that he/she is able to relate his/her knowledge and skills to everyday ophthalmic practice. It is therefore appropriate that the level of competence documented on the CbD forms during Yr1 and Yr2 is at a lower level than during Yr3 and Yr4.

Clinical Scenarios

As an ophthalmologist you will be expected to manage a range of clinical scenarios. This may involve referrals from other health professionals, patient self-referrals or screening for ophthalmic disease.

Below is a list of typical problems that may present to an ophthalmologist.

Symptoms	Signs
Decreased Vision Transient Sudden Gradual Painful Diplopia Distortion Dry Eyes Floaters Headache Night Blindness Pain Ocular Periocular Red Eye Trauma Visual Disturbance Watery	Ametropia Corneal Opacities Conjunctival Pigmentation Dysgenesis/Colobomata Lens Opacities Lid Lumps Lid Malposition Macular Exudation Nystagmus Ocular Tumours Optic Disc Atrophy/Swelling Proptosis Pupil Abnormalities Raised Intraocular Pressure Retinal Haemorrhages Retinal Pigmentation Strabismus Visual Field Defects Visual Handicap in a Child Vasculature abnormalities

During your training you will be expected to discuss the management of patients with seniors in the form of a Case-Based Discussion. You should ensure that during your training all these common clinical presentations have been covered in at least one case-based discussion.

In addition, these clinical scenarios may form a focus for learning. Using these commonly encountered scenarios enhances the value of on-the-job learning, increasing learning efficiency and relevancy.

Whilst learning about a patient with one of the above clinical problems you should consider which learning outcomes may be addressed. By thinking of the patient's problem in terms of the 10 learning outcome domains, you can integrate your knowledge (basic science and clinical), skills and attitudes.

The scenarios may be used in a variety of learning situations e.g. clinics, theatre, small / large group teaching, independent study.

Case-based Discussion (CbD) assessment form

                                                                                                                                                                                                                                                                                                                     

Trainee’s Name                                                                                                                                                                                         Date (dd/mm/year)

   

     YEAR1                           YEAR2                                             YEAR 3                            YEAR 4                                   Other (specify)

Assessor's name:

Assessor's status:         Consultant                                               AHP                           Other (Specify)

Clinical Scenario (see Study Guide )

Diagnosis

Overall difficulty of case                Simple                                                        Intermediate                                                                 Difficult

Subspecialty: Plastics/Lac/Orbits      Cornea/Ext       Cataract/Ref          Glaucoma       Retina/Uvea/Onco       Neuro        Paeds/Strab

(if identifiable)

Please grade the trainee’s performance under the curricular domains as listed below.

Topic	Poor	Fair	Good	V Good	n/a
Medical Record Keeping
Clinical Assessment
Investigation and Referrals
Treatment
Follow-up and Future Planning
Professionalism
Clinical Judgment
Leadership/Manager Issues

Overall performance in this assessment	Poor	Fair	Good	V Good

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

Please note any aspects which were especially good (assessor):	Please note any suggestions for improvement and action points (assessor):
What have I learnt (Trainee):

Now associate this to the 3 most relevant Learning Outcomes consider choosing one from each Curriculum theme

Signature of assessor:                                                         Signature of trainee:

_______________________                                                          _____________________________

Direct Observation of Procedural Skills (DOPS)

Competence in 19 of the 14 practical skills (PS) listed in the COECSA curriculum, and in surgical skills (SS13, SS14 and SS15) is assessed using a modified version of the F2 DOPS rating scale. [PS1 (refraction) is assessed by CRSretPS1a for adults, CRSret, Retinoscopy paediatric and formal COECSA examination.

How a practical procedure is taught will be determined by the individual trainer and informed by an appropriate training the trainers course. When trainees have the opportunity to perform the procedure themselves they must do so under appropriate supervision. The supervisor will be able to complete a DOPS at the end of the procedure. If there are aspects of the procedure that are not performed satisfactorily the completed DOPS will act as a guide for training and inform the next attempt. It is expected that for some of the more complex practical procedures e.g. PS2 "Drug administration", a trainee will require assessment on more than one occasion (heir portfolio will reflect  this). Where possible a trainee will arrange to have at least 2 satisfactory DOPS for each of the relevant Learning Outcomes. Where opportunities to perform a procedure are scarce e.g. PS11"Corneal glue", it may be appropriate for the portfolio to contain only one DOPS. The ultimate decision as to how many are appropriate will be the responsibility institution examination committee.

Where appropriate it is useful for initial DOPS to be completed using any simulators that are available e.g. in a clinical skills centre. The DOPS form must make it clear that the assessment has been carried out using a simulator.

Trainees should also maintain a logbook of procedures performed with reflective comments where appropriate as part of their portfolio.

Where a trainee has an opportunity to perform a practical procedure that is not included in the curriculum e.g. as part of sub-specialty training, she/he is encouraged to ask the trainer to complete a DOPS for inclusion in the portfolio.

The following practical skills Learning Outcomes are assessed by DOPS:

Learning Outcome(Click here for DOPS form)		Target Year (TYA)*	Comments
PS8	Ocular surface FB	1	DOPS can be completed by an appropriately trained nurse or senior resident
PS5	Tear film	2	DOPS can be completed by senior Resident
PS6	Lacrimal drainage		DOPS can be completed by senior Resident
PS7	Corneal scrape	2
PS9	Removal of sutures	2	DOPS can be completed by an appropriately trained nurse
PS14	Perform/teach hand hygiene	2	DOPS can be completed by an appropriately trained nurse
PS2	Local anaesthesia	3	May require several DOPS for different LA techniques
PS10	Fit a bandage contact lens	3	DOPS can be completed by an appropriately trained nurse
SS13	Laser to the lens capsule	3
SS14	Laser for raised intraocular pressure	3/4 (annual review)	May require several DOPS for different laser therapies
S15	Laser for retinal problems	3/4 (annual review)	May require several DOPS for different laser therapies
PS3	Diathermy	3	May be incorporated with a surgical OSATS
PS2	Intraocular/periocular drugs	¾	May require several DOPS for different LA techniques
PS4	Cryotherapy	¾	May be incorporated with a surgical OSATS
PS11	Corneal glue	¾	.
PS13	Ocular /orbital ultrasound	¾	.
SS16	AC/vitreous tap	¾	.
SS10	Prepare biopsy	¾	.
PS12	Forced duction test	¾	.

* The TYA represents the latest year that a trainee should normally achieve the specified LO. Trainees are encouraged to seek assessment using DOPS when an opportunity arises and not wait until the target year.

By completion of training a trainee's portfolio may contain around 60 satisfactory DOPS forms

Direct Observation of Procedural Skills (DOPS) form

COECSA Workplace Based Assessment and Feedback Form

Direct Observation of Procedural Skills (DOPS)

 

Trainee’s Name                                                                                                                                                                                         Date (dd/mm/yyyy)                  

Trainee's year:            Year1                       Year 2                   Year 3            Year4                                Other (specify)

Assessor's name

 

Assessor's status           Consultant                      Senior Trainee                                Other (Specify)                                  

 

Learning Outcome     Title                                                                                                                                                                                      Code

                                 

Brief description of procedure

Overall difficulty of case                                        Simple                                                        Intermediate                                                                 Difficult

Number of times procedure performed before One                                                   Two to four                      Five to nine                                  More than nine          

Procedure performed on                                      Simulator                           Wet lab                       Volunteer                 Patient

Please grade the following areas using the scale below (use tick or cross)

	Poor	Fair	Good	V Good	n/a
1       Demonstrates understanding of indications, relevant anatomy,          techniques of procedure
2       Obtains informed consent
3       Demonstrates appropriate preparation pre-procedure
4       Appropriate analgesia
5       Technical ability
6       Aseptic technique
7       Seeks help where appropriate
8       Awareness of potential complications and how to avoid them
9       Post procedure management
10     Communication skills
11     Consideration to patient/professionalism

Overall performance in this assessment	Poor	Fair	Good	V Good

Outcome (Delete as appropriate)            Meets Expectations/Does not meet Expectations     (for stage of training)

Please use the boxes below/overleaf for free-text comments and recommendations for further training.

Anything especially good? (assessor)	Suggestions for development (assessor)
What have I learnt? (trainee)

Signature of assessor:                                                        Signature of trainee:

Multi-Source Feedback (MSF)

Whilst several of the other Work-Based Assessments (WBA) will require a trainer to assess the trainee's attitude to the patient, some of the "Best Practice" (BP) and Communication (COM) learning outcomes will be assessed using MSF. (BP17 is actually achieved by taking part in MSF.) The MSF will be performed electronically via the on-line portfolio or by paper format. The process for obtaining MSF, which will be required on at least an annual basis, will resemble the following:

• The trainee identifies 15 people who can be approached to give feedback. The list should include consultant supervisors and trainers, other trainees, Rota organizer, allied health professionals (nurses, orthoptists, optometrists), clerical/secretarial/administrative staff.
• The trainee enters the details of these chosen assessors into the on-line or paper format portfolio
• The list is approved on-line/or paper by the trainee's educational supervisor
• The staff on the trainee's list are contacted by email by letter and asked to complete an on-line or paper feedback form that will cover the appropriate areas of the curriculum. The trainee will not see individual responses.
• The results of feedback are collated and a report is produced.
• The trainee completes a self-assessment
• The MSF report is sent to the trainee's educational supervisor who arranges to meet with the trainee to discuss the contents and any action required.

The following LO will be assessed using MSF:

Learning Outcome (LO)		Typical question	Feedback likely from*
PS21 SS3 CEH3	Hand hygiene Asepsis X-infection	Follows local guidelines on general cleanliness and avoidance of cross infection	MS, AHP
COM1	Rapport	Establishes a trusting clinical relationship with patients	MS, AHP
COM2	Listen	Listens effectively to patients	MS, AHP
COM3	Deliver	Provides information to patients in an appropriate and sensitive manner	MS, AHP
COM5	Consent	Obtains valid consent in an appropriate manner	MS, AHP
COM6	Breaking bad news	Communicates potentially upsetting information in an appropriate and sensitive manner	MS, AHP
COM7	Language	Makes allowances/provisions for difficulties in communication that may affect the patient	MS, AHP
COM8	Body language	Uses body language to good effect in communication	MS, AHP, S&C
COM10	Professionals	Communicates well with clinical and non-clinical colleagues	MS, AHP, S&C
COM11 COM12	Written notes	The doctor writes notes and dictates letters clearly	MS, AHP, S&C
COM14	Leave	Complies with local policies for the approval of leave and makes appropriate arrangements for cover	MS, AHP, S&C
BP10	Compassion	Has a compassionate approach to patient care	MS, AHP
BP11	Autonomy	Respects the patient's wishes when making clinical decisions	MS, AHP
BP12	Considerate	Behaves in a considerate and sensitive manner towards all patients	MS, AHP, S&C
BP13	Empathy	Shows appropriate empathy with patients	MS, AHP, S&C
BP14	Confidentiality	Respects the confidential nature of clinical information obtained from patients	MS, AHP, S&C
BP15	Limits	Works within the limits of her/his clinical competence	MS, AHP
BP16	Help	Seeks help and advice from clinical colleagues when appropriate	MS, AHP
BP18	Equality	Treats all patients equally, avoiding discrimination	MS, AHP, S&C
BP20	Legal	Practices according to the National medical and dental practitioners council's guidelines for doctors	MS
BP24	Prioritize	Prioritizes tasks appropriately, ensuring urgent and important matters are dealt with promptly	MS, AHP, S&C
BP30	Stress	Copes well when under stress	MS, AHP, S&C

* Feedback from:

• MS=medical staff
• AHP=allied health professional (nurse, optometrist, orthoptists)
• S&C= secretarial and clerical staff

Multi-Source Feedback (MSF) form

                             

Trainee’s Name                                                                                                                         Date (dd/mm/year)                      

Trainee's year: Year 1          Year 2           Year 3          Year 4                      Other (specify)

Assessor's name:

Assessor's status:         Consultant                                               AHP                           Other (Specify)

Please grade the trainee’s performance against the statements as listed below

(Indicate “n/a” if you are unable to comment on any particular statement)

(*Note: This is an anonymous assessment but comments may inevitably provide a clue to their origin. If you have anxieties about making particular comments in writing please indicate “will discuss” and do so as soon as possible with an appropriate consultant supervisor in your unit.)

Curricular Codes	Statement	They perform to a high standard in this area of practice (Tick)	I have no concerns in this area of practice (Tick)	I have some Concerns in this area of practice (Tick)	n/a (Tick)	Comments* (Essential if concerns exist) (Continue overleaf if necessary)
PS21/ SS3	Follows local guidelines on general cleanliness and avoidance of cross infection
COM1	Establishes a trusting clinical relationship with patients
COM2	Listens effectively to patients
COM3	Provides information to patients in an appropriate and sensitive manner
COM5	Obtains valid consent in an appropriate manner
COM6	Communicates potentially upsetting information in an appropriate and sensitive manner
COM7	Makes allowances/provisions for difficulties in communication that may affect the patient
COM8	Uses body language to good effect in communication
COM10	Communicates well with clinical and non-clinical colleagues
COM11 COM12	The doctor writes notes and dictates letters clearly
COM14	Complies with local policies for the approval of leave and makes appropriate arrangements for cover
BP10	Has a compassionate approach to patient care
BP11	Respects the patient’s wishes when making clinical decisions
BP12	Behaves in a considerate and sensitive manner towards all patients
BP13	Shows appropriate empathy with patients
Curricular Codes	Statement	They perform to a high standard in this area of practice (tick)	I have no concerns in this area of practice (Tick)	I have some Concerns in this area of practice (Tick)	n/a (Tick)	Comments* (Essential if concerns exist) (Continue overleaf if necessary)
BP14	Respects the confidential nature of clinical information obtained from patients
BP15	Works within the limits of her/his clinical competence
BP16	Seeks help and advice from clinical colleagues when appropriate
BP18	Treats all patients equally, avoiding discrimination
BP20	Practises according to the National medical and dental practitioner’s council's guidelines for doctors
BP24	Prioritizes tasks appropriately, ensuring urgent and important matters are dealt with promptly
BP30	Copes well when under stress

Space for further comments (please indicate Curricular Code to which comments refer, e.g. “BP10” etc.)

Objectively Structured Assessment Of Technical Skills (OSATS)

How a surgical procedure is taught will be determined by the individual trainer and informed by an appropriate training the trainers course (where available). When trainees have the opportunity to perform the procedure themselves they must do so under appropriate supervision. The supervisor will be able to complete an OSATS at the end of the procedure. If there are aspects of the procedure that are not performed satisfactorily the completed OSATS will act as a guide for training and inform the next attempt. Where possible a trainee will arrange to have at least 2 satisfactory OSATS for each of the Surgical Skills Learning Outcomes.

It is expected that several OSATS will be completed and kept in the trainee's portfolio, before the first satisfactory OSATS is achieved for an individual Learning Outcome. It is important that a trainee and trainer understand that this is an important part of training and does not represent a problem with a trainee.

Trainees should also maintain a logbook of surgical and laser procedures performed with reflective comments where appropriate as part of their portfolio.

Where appropriate it is useful for initial OSATS to be completed using any simulators that are available e.g. in a wet lab. The OSATS form must make it clear that the assessment has been carried out using a simulator.

The following surgical Learning Outcomes are assessed by OSATS:

WpBA	Learning Outcome (LO)		Target Year (TYA)*	Comments
OSATS2	SS2	Operating microscope	1	This LO can be assessed by a senior resident (year   3 or 4)
OSATS3	SS3	Aseptic technique	1	This LO can be assessed by an appropriately trained theatre nurse
OSATS1	SS1	Microsurgical skills	2	OSATS after initial TYA should reflect an increase in complexity of cases
OSATS1	SS7	Lid surgery	¾
OSATS1	SS4	Cataract surgery	¾
OSATS1	SS11	Temporal artery biopsy	2
OSATS1	SS5	Procedures to lower IOP	¾
OSATS1	SS6	Ocular and adnexal trauma	2
OSATS1	SS8	Ocular surface protection	1
OSATS1	SS9	Lateral canthotomy/cantholysis	2
OSATS1	SS10	Biopsy ocular and adnexal tissue	2
OSATS1	SS12	Extraocular muscle surgery	¾
OSATS1	SS13	Removal of the eye	2	This LO can be assessed by a senior resident (year   3 or 4)
OSATS1	SS17	Anterior Vitrectomy	¾

* The TYA represents the latest year that a trainee must achieve the specified LO. Trainees are encouraged to seek assessment using OSATS when an opportunity arises and not wait until the target year.

The COECSA MSICS-OSCAR

The COECSA MSICS-OSCAR

This should be completed at the end of the case and immediately discussed with the student to provide timely, structured, specific performance feedback. Circle the appropriate cells and if previous MSICS-OSCARS are available review them in order to develop a plan for improvement

COECSA Manual Small Incision Cataract Surgery -Ophthalmology Surgical Competency Assessment Rubric: (COECSA MSICS-OSCAR)
Date ___________ Resident _______ Evaluator _______		Novice (score = 2)	Beginner (score = 3)	Advanced Beginner (score = 4)	Competent (score = 5)	Not applicable. Done by consultant or senior resident (score= 0)
1	Draping:	Unable to start draping without help.	Drapes with minimal verbal instruction. Incomplete lash coverage.	Lashes mostly covered, drape at most minimally obstructing view.	Lashes completely covered and clear of incision site, drape not obstructing view.
2	Scleral access & Cauterization	Unable to successfully access sclera. Cauterization insufficient or excessive both in intensity and localization.	Accesses sclera but with difficulty and hesitation. Cauterization insufficient or excessive in location or intensity.	Achieves good scleral access with mild difficulty. Adequate cauterization.	Precisely and deftly accesses sclera. Appropriate and precise cauterization.
3	Sclerocorneal Tunnel	Inappropriate incision depth, location, and size, hesitant dissection. Iris prolapse may occur	One of the following correct: incision depth, location or size.  Able to dissect forward but not able to perceive depth	Two of the following are correct: incision depth, location or size. Understands that tunnel depth is incorrect but unable to correct.	Good incision depth, location and size. Tunnel constructed at right plane, if inappropriate plane, able to rectify.
4	Corneal entry	Hesitant keratome entry into AC. Unable to extend the internal valve. Significant shallowing of anterior chamber. Require wound extension or suturing.	Enters into AC but difficulty in extension. Follows a different plane. Entry either anterior or posterior to dissection site. Mild AC shallowing. Require wound extension or suturing.	Entry at right plane. Able to extend but with repeated use of viscoelastic. Internal valve irregular. Require wound extension or suturing.	Fluently enters in right plane. Wound length adequate with no further need for extension. Retains viscoelastic during extension. Self-sealing, provides good access for surgical maneuvering.
5	Paracentesis & Viscoelastic insertion	Chamber collapses on performing paracentesis. Inappropriate width, length and location. Pierces anterior capsule on entry. Unsure of when, what type and how much viscoelastic to use. Has difficulty accessing anterior chamber through paracentesis.	Appropriate incision width, location or length. Anterior chamber shallows mildly. Requires minimal instruction. Knows when to use but administers incorrect amount or type of viscoelastic.	Inappropriate location, width or length. Anterior chamber almost stable Requires no instruction. Administers viscoelastic at appropriate time, amount, type, and cannula position.	Wound of adequate length, width, and correct location. Viscoelastics administered in appropriate amount, at appropriate time, with cannula tip clear of lens capsule and endothelium.
6	Capsulorrhexis: Commencement of Flap & follow-through.	Instruction required, tentative, chases rather than controls rhexis, cortex disruption may occur.	Minimal instruction, occasional loss of control of rhexis, cortex disruption may occur.	In control, few awkward or repositioning movements, no cortex disruption.	Delicate approach and confident control of the rhexis, no cortex disruption.
7	Capsulorrhexis: Formation and Circular Completion	Size and position are inadequate for nucleus density, tear may occur.	Size and position are barely adequate for nucleus density, difficulty achieving circular rhexis, tear may occur.	Size and position are almost exact for nucleus density, shows control, and requires only minimal instruction.	Adequate size and position for nucleus density, no tears, rapid, unaided control of radialization, maintains control of the flap and AC depth throughout the capsulorrhexis.
8	Hydrodissection: Visible Fluid Wave and Free prolapse of one pole of nucleus	Hydrodissection fluid not injected in quantity or place to achieve nucleus rotation or prolapse.	Multiple attempts required, able to prolapse nuclear pole after multiple efforts. Manually forces nucleus prolapse before adequate hydrodissection; cheese wiring.	Fluid injected in appropriate location, able to prolapse one pole of nucleus but encounters more than minimal resistance.	Ideally see free fluid wave, adequate for free nuclear hydroprolapse or mechanical prolapse with minimal resistance. Aware of contraindications to hydrodissection.
9	Prolapse of nucleus completely into AC	Unable to dial nucleus into AC. Hooks anterior or posterior nuclear surface, nucleus rotates in the bag, iris and corneal touch, pupillary constriction, may damage capsule or zonules.	Prolapses nucleus after repeated awkward attempts, needs instruction, churns cortex causing reduced visibility; iris or corneal touch; no damage to capsule or zonules.	Prolapses nucleus into AC with more than minimal resistance. No corneal touch.	Prolapse with minimal resistance. No damage to pupil and iris.
10	Nucleus extraction	Damages endothelium, iris or capsule, unable to hold and extract nucleus, movements not coordinated.	Movements coordinated but unable to extract nucleus, iris or corneal damage, unable to assess wound size in relation to nuclear density.	Removes nucleus after repeated attempts, more than one piece, might need wound extension prior to extraction.	Extracts nucleus with one or two attempts; proper wound size in relation to nuclear density.
11	Irrigation and Aspiration Technique with Adequate Removal of Cortex	Great difficulty introducing the aspiration tip under the capsulorrhexis border, aspiration hole position not controlled, cannot regulate aspiration flow as needed, cannot peel cortical material adequately, engages capsule or iris with aspiration port.	Moderate difficulty introducing aspiration tip under capsulorrhexis and maintaining hole up position, attempts to aspirate without occluding tip, shows poor comprehension of aspiration dynamics, cortical peeling is not well controlled, jerky and slow, capsule potentially compromised. Prolonged attempts result in minimal residual cortical material.	Minimal difficulty introducing the aspiration tip under the capsulorrhexis, aspiration hole usually up, cortex will engaged for 360 degrees, cortical peeling slow, few technical errors, minimal residual cortical material. Some difficulty in removing sub incisional cortex	Aspiration tip is introduced under the free border of the capsulorrhexis in irrigation mode with the aspiration hole up, Aspiration is activated in just enough flow as to occlude the tip, efficiently removes all cortex. The cortical material is peeled gently towards the center of the pupil, tangentially in cases of zonular weakness. No difficulty in removing subincisional cortex
12	Lens Insertion, Rotation, and Final Position of Intraocular Lens	Unable to insert IOL.	Difficult insertion, manipulation of IOL, rough handling, unstable anterior chamber. Repeated hesitant attempts placing lower haptic in capsule, repeated attempts rotate upper haptic d into place with excessive force.	Insertion and manipulation of IOL accomplished with minimal anterior chamber instability, the lower haptic is placed with some difficulty, upper haptic is rotated with some stress.	Insertion and manipulation of IOL is performed in a deep, and stable anterior chamber and capsular bag, with incision appropriate for implant type.  The lower haptic is smoothly placed inside the capsular bag; the upper haptic is rotated or gently bent and inserted into place without exerting excessive stress to the capsulorrhexis or the zonule fibers.
13	Wound Closure (Including Suturing, Hydration, and Checking Security as Required)	If suturing is needed, instruction is required and stitches are placed in an awkward, slow fashion with much difficulty, astigmatism, bent needles, incomplete suture rotation and wound leakage may result, unable to remove viscoelastics thoroughly. unable to make incision watertight or does not check wound for seal.  Improper final IOP.	If suturing is needed, stitches are placed with some difficulty, resuturing may be needed, questionable wound closure with probable astigmatism, instruction may be needed, questionable whether all viscoelastics are thoroughly removed, Extra maneuvers are required to make the incision water tight at the end of the surgery. May have improper IOP.	If suturing is needed, stitches are placed with minimal difficulty tight enough to maintain the wound closed, may have slight astigmatism, viscoelastics are adequately removed after this step with some difficulty, The incision is checked and is water tight or needs minimal adjustment at the end of the surgery. May have improper IOP.	If suturing is needed, stitches are placed tight enough to maintain the wound closed, but not too tight as to induce astigmatism, viscoelastics are thoroughly removed after this step, the incision is checked and is water tight at the end of the surgery. Proper final IOP.
	Global Indices
14	Wound Neutrality and Minimizing Eye Rolling and Corneal Distortion	Nearly constant eye movement and corneal distortion.	Eye often not in primary position, frequent distortion folds.	Eye usually in primary position, mild corneal distortion folds occur.	The eye is kept in primary position during the surgery. No distortion folds are produced. The length and location of incisions prevents distortion of the cornea.
15	Eye Positioned Centrally Within Microscope View	Constantly requires repositioning.	Occasional repositioning required.	Mild fluctuation in pupil position.	The pupil is kept centered during the surgery.
16	Conjunctival and Corneal Tissue Handling	Tissue handling is rough and damage occurs.	Tissue handling borderline, minimal damage occurs.	Tissue handling decent but potential for damage exists.	Tissue is not damaged nor at risk by handling.
17	Intraocular Spatial Awareness	Instruments often in contact with capsule, iris, corneal endothelium; blunt second instrument not kept in appropriate position.	Occasional contact with capsule, iris, corneal endothelium; sometimes has blunt second instrument in appropriate position.	Rare contact with capsule, iris, endothelium. Often has blunt second hand instrument in appropriate position.	No accidental contact with capsule, iris, corneal endothelium. Blunt, second hand instrument, is kept in appropriate position.
18	Iris Protection	Iris constantly at risk, handled roughly.	Iris occasionally at risk. Needs help in deciding when and how to use hooks, ring or other methods of iris protection.	Iris generally well protected. Slight difficulty with iris hooks, ring or other methods of iris protection.	Iris is uninjured. Iris hooks, ring, or other methods are used as needed to protect the iris.
19	Overall Speed and Fluidity of Procedure	Hesitant, frequent starts and stops, not at all fluid.	Occasional starts and stops, inefficient and unnecessary manipulations common, case duration about 60 minutes.	Occasional inefficient and/or unnecessary manipulations occur, case duration about 45 minutes.	Inefficient and/or unnecessary manipulations are avoided, case duration is appropriate for case difficulty. In general, 30 minutes should be adequate.

Overall difficulty of procedure (circle):           Simple             Intermediate                Difficult

Good points: _______________________________________________________________________________________________________________________

Suggestions for development: _______________________________________________________________________________________________________________________

Agreed action: ­­­­­­

Signature of Assessor: __________________________________        Signature of Trainee: ____________________________________

The COECSA TRAB-OSCAR

This should be completed at the end of the case and immediately discussed with the student to provide timely, structured, specific performance feedback. Circle the appropriate cells and if previous MSICS-OSCARS are available review them in order to develop a plan for improvement

COECSA Trabeculectomy-Ophthalmology Surgical Competency Assessment Rubric (COECSATRAB-OSCAR)

Resident: __________________  Assessor: ____________________         Year of Training:  __________    Date: ____________

Surgical Step		Novice (score = 2)	Beginner (score = 3)		Advanced Beginner (score = 4)	Competent (score = 5)	Not applicable. Done by consultant or senior resident (score= 0)
1	Universal precautions	Has not heard of universal precautions.	Aware of time-out process but not confident to perform. May perform with guidance/ prompting, but misses some information.		Able to perform team time-out but needs prompting to do so.	Independently initiates team time-out at beginning of case, identifies correct patient, procedure and side. Team members have been introduced. Alerts / allergies noted.
2	Draping and placement of speculum	Unable to start draping without help.	Drapes with minimal verbal instruction. Incomplete lash coverage.		Lashes mostly covered, drape at most minimally obstructing view.  Attains proper head position.	Lashes completely covered and clear of incision site, drape not obstructing view.
3	Corneal Traction Suture	Unable to describe purpose and method of inserting corneal traction suture.	Difficulty loading needle, needs instruction for correct needle placement and completion of suture placement.		Able to load and handle needle appropriately. Some difficulty in finding correct depth of suture, needs instruction, needle track too deep or too shallow or bite not of ideal size.	Is able to consistently perform the step with the appropriate length of bite, depth of suture and achieve the desired rotation of the eye for exposure.
4	Conjunctival incision and dissection	Is able to describe but not able to perform limbal or fornix conjunctival incision for trabeculectomy surgery.	Is able to perform limbal or fornix conjunctival incision but is inefficient and requires guidance.  Has difficulty with judging appropriate length of incision, dissection down to sclera of both conjunctiva and Tenon’s and the necessary force to apply to the tissue.  Has difficulty avoiding damage to the superior rectus muscle with limbal-based conjunctival flap.		Is able to perform limbal or fornix conjunctival incisions but is inefficient or tentative and requires guidance with technique and/or position and size of incision.	Performs conjunctival incision without creating buttonholes and with no disruption of adjacent tissues. Incision is of correct size (i.e. enough to give proper exposure for performance of posterior subTenon’s dissection and formation of scleral flap.
5	Hemostasis	Is unable to describe the need for hemostasis, type of cautery required, appropriate technique. Is unable to perform.	Is able to describe the need for hemostasis, type of cautery required, appropriate technique. Has difficulty performing proper technique.		Is able to apply cautery but has difficulty with scleral burns, shrinkage of tissue, obtaining hemostasis.	Is able to efficiently and precisely apply hemostasis without significant scleral burns, shrinkage of tissues and obtains hemostasis. Understands advantages and disadvantages of different types of cautery tips.
6	Application of antimetabolite	Is unable to accurately describe role of antimetabolites in trabeculectomy, types of antimetabolites and the relative indication for use of each type, safety considerations and use of pledget material.	Is able to accurately describe role of antimetabolites in trabeculectomy, types of antimetabolites and the relative indication for use of each type, safety considerations and use of pledget material. Needs guidance for choice of anti-metabolite and exposure time. Needs guidance for fashioning of sponges. Inefficient or inappropriate placement of sponges. Needs to be reminded to keep surgical count. Does not protect conjunctival edge. Inefficient removal of sponges and /or irrigation.		Is able to safely apply antimetabolite onto eye but may have difficulty creating pledget material to appropriate size and thickness. Appropriately discards materials into toxic waste and rinses eye of residual antimetabolite material.	Is able to safely, efficiently and accurately, apply antimetabolite onto eye and has no difficulty creating pledget material to appropriate size and thickness. Appropriately discards materials into toxic waste and thoroughly rinses eye of residual antimetabolite material. Keeps surgical count of pledgets used.
7	Creation of scleral flap	Is unable to describe dissection technique for flap creation.	Is able to describe dissection technique for flap creation but requires constant guidance to perform the basic steps. Needs reminding to grasp sclera outside flap construction area.		Is able to perform basic flap creation but is inefficient and/or creates flaps that may be too thin, deep, small, or posterior or at risk of avulsion.	Is able to efficiently create flap to the appropriate size and depth without constant guidance. Able to describe the complications and management of faulty scleral flap creation including buttonholing and avulsion of the flap.
8	Paracentesis	Puts anterior lens capsule or iris at risk when entering anterior chamber Inappropriate incision architecture, location, and size.	Needs instruction on how to perform. Leakage and/or iris prolapse with local pressure, provides poor surgical access.		Incision not in correct position or leaks.	Incision parallel to iris, self-sealing, adequate size, provides good access for surgical maneuvering.
9 (a)	Sclerostomy (with Kelly punch)	Has difficulty with entry into anterior chamber, either ineffective or trauma to ocular tissue. Uncontrolled entry into AC. Difficulty using Kelly punch.	Is able to create an entry plane into anterior chamber but has significant difficulty with using Kelly punch. Damages scleral flap. Makes sclerostomy too large /small or too anterior/posterior for appropriate filtration.		Is able to use the Kelly punch, but may be prone to creating a shelving wound with the punch. Makes sclerostomy too large or too small for appropriate filtration.	Is able to create an appropriate entry plane into the anterior chamber and is able to use Kelly punch with dexterity. Sclerostomy appropriate size for filtration.
9 (b)	Sclerostomy (without Kelly punch)	Needs constant direction. Size of sclerostomy inappropriate or not in correct position	Difficulty outlining and dissecting deep scleral flap. There may be damage to surrounding tissues.		Able to outline deep scleral flap and perform dissection, but has difficulty performing this smoothly, needs direction, unable to cleanly remove deeper scleral tissue.	Outlines deep scleral flap with ease, dissects flap sclera from underyling tissue without trauma to other structures, excises deep scleral flap cleanly. Deep scleral flap/ sclerostomy of appropriate size and correctly positioned. Avoids damage to the underlying ciliary body.
10	Peripheral iridectomy (PI)	Cannot grasp iris tissue, damages surrounding structures.	Needs direction in grasping iris tissue and performing iridectomy. Unable to control size of PI.		Able to grasp iris tissue without damage to intraocular structures, but PI either too large or too small. May need more than one attempt	Able to grasp iris tissue without damage to surrounding structures, PI is of correct size.
11	Scleral flap suturing	Instruction is required and stitches are placed in an awkward, slow fashion with multiple passes to sclera or tear of flap, bends needles, incomplete suture rotation.	Stitches are placed with some difficulty, re-suturing may be needed, instruction needed. Difficulty achieving proper IOP at end of case.		Stitches are placed with minimal difficulty; tight enough to achieve wound closure and allow for appropriate filtration.	Stitches are placed with correct tension to allow for appropriate filtration. Able to place both fixed and releasable sutures proficiently. Appropriate final IOP.
12	Anterior chamber reformation	Cannot cannulate anterior chamber via paracentesis. Unable to assess whether anterior chamber of appropriate depth. Unable to assess whether IOP is satisfactory to proceed to next step.	Has difficulty cannulating anterior chamber via paracentesis to reform anterior chamber. Needs guidance.		Cannulates anterior chamber with ease to reform anterior chamber, but has difficulty assessing ideal AC depth/IOP.	Cannulates AC with ease and is able to assess correct AC depth/ IOP for eye
13	Conjunctival closure	Is unable to close conjunctiva. Unable to differentiate Tenon’s capsule from conjunctiva.	Is able to perform basic conjunctival closure technique but is inefficient and requires significant guidance. Additional sutures are required. Significant bleb leak at the end of surgery with unstable, shallow anterior chamber. May have buttonhole of conjunctiva.		Is able to safely close conjunctiva with good tissue approximation but is inefficient. Requires guidance to ensure closure is effective without a leak. Placement of additional sutures or replacement of loose sutures required before closure is complete and Seidel negative.	Is able to safely and efficiently close conjunctiva with good tissue approximation, no bleb leak and stable anterior chamber. Has good understanding of various suture types, appropriate needles and different closure techniques.
Global Indices
1	Maintaining hemostasis	Is unable to describe types of cautery, settings for cautery and/or unable to describe electrocautery technique.		Can describe techniques for avoiding and controlling bleeding but requires significant guidance to perform proper cautery to minimize bleeding.	Usually applies proper tissue technique to avoid bleeding and is able to control bleeding using cautery but requires multiple attempts to cauterize and may leave burnt carbon marks.	Consistently applies proper tissue technique to avoid bleeding and is able to efficiently control bleeding using cautery.
2	Tissue handling	Is excessively aggressive or timid in manipulating tissue. Inadvertent tissue damage occurs to conjunctiva or sclera. Needs direction to grasp sclera outside margins of intended scleral flap.		Aware of techniques for avoidance of tissue damage and bleeding but needs supervision to accomplish proper handling.  Needs direction to grasp sclera outside margins of intended scleral flap. Conjunctival buttonholes present.	Tissue handling is safe but sometimes requires multiple attempts to achieve desired manipulation of tissue.  No direction required to avoid grasping sclera within margins of intended scleral flap. Conjunctiva is intact but manipulated aggressively/unsafely e.g. toothed forceps.	Tissue handling is efficient, fluid and almost always achieves desired tissue manipulation on first attempt. No conjunctival buttonholes present.
3	Knowledge of instruments	Can only identify instruments in simple terms such as “scissors” and “forceps” but no knowledge of necessary sutures or needle types.		Can identify some but not most of the surgical instruments by proper names and can identify necessary suture sizes and materials but not needle types.	Can identify most but not all of the surgical instruments by proper name and can identify necessary suture sizes/materials but not needle types.	Can identify all surgical instruments by proper names and can identify necessary suture sizes/materials and needle types.
4	Technique of holding suture needle in needle holder	Frequently loads needle incorrectly.		Loads needle in proper direction for a forehand pass but sometimes loads incorrectly for backhand pass. Loads too close or too far from the swaged end of the needle.	Loads needle properly for forehand and backhand needle pass but is inefficient and often requires multiple attempts.	Loads needle properly and efficiently for forehand and backhand needle passes.
5	Technique of surgical knot tying	Unable to tie knots.		Require multiple extra hand maneuvers to make first throw lay flat and/or loosens first throw while attempting to perform the second throw.	Is able to tie a flat surgeon’s knot first throw but second and third throws are inefficient. Does not inadvertently loosen the first throw.	Is able to efficiently tie a flat, square surgeon’s knot.
6	Communication with surgical team	Does not know role of surgical team members. Lacks confidence or has too much. Does not establish good rapport with team. Unable to request instruments from scrub nurse using proper instrument and suture names and/or instructions to surgical assistant are vague or nonexistent.		Knows role of most surgical team members. Lacks confidence. Has difficulty establishing good rapport with team members. Able to request most instruments from scrub nurse using proper instrument and suture names but instructions to surgical assistant are inadequate to perform procedure safely.	Knows role of each surgical team member. Is somewhat confident and usually treats team with respect. Establishes good working relationship. Able to request most instruments from scrub nurse using proper instrument and suture names in correct order. Instructions to surgical assistant are adequate for a skilled assistant but inadequate for an unskilled assistant.	Knows role of each surgical team member. Is confident and treats team with respect. Establishes good working relationship. Able to efficiently request instruments from scrub nurse using proper names in correct order. Able to consistently give clear instructions to surgical assistant. Communicates with anesthetist, if present.

Overall difficulty of procedure (circle):           Simple             Intermediate                Difficult

Good points: _______________________________________________________________________________________________________________________

Suggestions for development: __________________________________________________________________________________________________________

Agreed action: _____________________________________________________________________________________________________________________

Signature of Assessor: ___________________________________        Signature of Trainee: ____________________________________The COECSA PAEDIATRIC CATARACT-OSCAR

The COECSA PAEDIATRIC CATARACT-OSCAR

This should be completed at the end of the case and immediately discussed with the student to provide timely, structured, specific performance feedback. Circle the appropriate cells and if previous PAED CAT-OSCARS are available review them in order to develop a plan for improvement

COECSA PAEDIATRIC CATARACT SURGERY-Ophthalmology Surgical Competency Assessment Rubric (COECSA PAED CAT-OSCAR)
Date ______ Resident ___________ Evaluator __________		Novice (score = 2)	Beginner (score = 3)	Advanced Beginner (score = 4)	Competent (score = 5)	Not applicable. Done by consultant or senior resident (score= 0)
1	Draping:	Unable to start draping without help.	Drapes with minimal verbal instruction. Incomplete lash coverage.	Lashes mostly covered, drape at most minimally obstructing view.	Lashes completely covered and clear of incision site, drape not obstructing the view.
2	Incision (corneal or corneo-scleral) &Paracentesis: Formation& Technique	Inappropriate incision architecture, location, and size.	Leakage and/or iris prolapse with local pressure, provides poor surgical access to and visibility of capsule and bag.	Incision either valvular or of good internal length not both.	Incision parallel to iris, valvular and of good internal length provides good access for surgical maneuvering.
	Staining of the anterior capsule	Unsure about the technique of injecting 0.1%Trypan Blue dye, the amount to be injected and the waiting time before washing off the dye to stain the anterior capsule.	Knows the technique but requires instruction on injecting, waiting time. Anterior chamber fluctuates while injecting the dye. Does not use sterile air to protect the corneal endothelium. Administers incorrect amount or washes off the dye too quickly.	Requires no instruction. Uses adequate sterile air bubble to protect the corneal endothelium. Administers adequate amount and waits for adequate time. Washes off the dye with saline a little too early causing improper and patchy staining of the capsule. May cause endothelial staining due to excess trypan or inadequate air bubble.	Administers adequate amount. . Uses adequate sterile air bubble to protect the corneal endothelium Waits for one minute and or wait for the dye to stain the anterior capsule uniformly and then washes away the dye with saline. The anterior chamber remains stable during the whole process. There is no staining of the corneal endothelium.
4	Viscoelastic: Appropriate Use and Safe Insertion	Unsure of when, what type and how much OVDto use. Has difficulty accessing anterior chamber through paracentesis. .	Requires minimal instruction. Knows when to use but administers incorrect amount or type.	Requires no instruction. Uses at appropriate time. Administers adequate amount and type. Cannula tip in good position. Unsure of correct OVD if multiple types available.	OVDs are administered in appropriate amount and at the appropriate time with cannula tip clear of lens capsule and endothelium. Appropriate OVDs used if multiple types of OVD are available.
5	Anterior Capsulorrhexis: Commencement of Flap& follow-through.	With Forceps: Instruction required, tentative, chases rather than controls rhexis, lens matter disruption may occur. With Vitrector: Instruction required for initiation of capsulorrhexis, unsure of vitrectomy settings, anterior chamber (AC) fluctuates frequently.	With Forceps: Minimal instruction, predominantly in control with occasional loss of control of rhexis, lens matter disruption may occur. With Vitrector: Minimal instruction needed, has knowledge of machine settings for capsulotomy, AC is stable throughout.	With Forceps: In control, few awkward or repositioning movements, no lens matter disruption. With Vitrector:  In control, No lens matter disruption or AC fluctuation, Few awkward movements noticed.	With Forceps: Delicate approach and confident control of the rhexis, no lens matter disruption. With Vitrector:  Has a sound knowledge of vitrector machine settings for capsulotomy, well controlled initiation and completion of rhexis.
6	Anterior Capsulorrhexis: Formation and Circular Completion	With Forceps or vitrector: Size and position are inadequate for a paediatric cataract.	With Forceps or vitrector: Size and position are barely adequate, difficulty achieving circular rhexis, tear may occur.	With Forceps or vitrector: Size and position are almost exact, shows control, and requires only minimal instruction. Nearly all of the optic edge covered by the capsule edge.	With Forceps or vitrector: Adequate size (5-6 mm) and position for paediatric cataract, no tears, rapid, unaided control of radialization, maintains control of the flap and AC depth throughout the capsulorrhexis.
7	Hydrodissection:	Hydrodissection fluid not injected in sufficient quantity or place to achieve desired displacement of the soft nucleus. Unaware of contraindications to hydrodissection such as posterior polar cataract or a suspected pre-existing posterior capsule dehiscence.	Multiple attempts required to achieve the desired displacement of the soft nucleus.	Fluid injected in appropriate location, has sound knowledge of contraindications to hydrodissection.	Adequate if free nuclear rotation with minimal resistance is achieved or adequate separation of nucleus and epinucleus from the cortex is obtained. Aware of contraindications to hydrodissection.
8(a)	Aspiration Probe and Second Instrument: Insertion Into Eye	Has great difficulty inserting the probe or second instrument, AC collapses, may damage wound, capsule or Descemet’s membrane	Inserts the probe or second instrument after some failed attempts, may damage wound, capsule or Descemet’s membrane.	Inserts probe and second instrument on first attempt with mild difficulty, no damage to wound, capsule or Descemet’s membrane.	Smoothly inserts instruments into the eye without damaging the wound or Descemet's membrane.
8(b)	Aspiration Probe and Second Instrument: Effective Use and Stability	Tip frequently not visible, has much difficulty keeping the eye in primary position and uses excessive force to do so.	Tip often not visible, often requires manipulation to keep eye in primary position.	Maintains visibility of tip at most times, eye is generally kept in primary position with mild depression or pulling on the globe.	Maintains visibility of instrument tips at all times, keeps the eye in primary position without depressing or pulling up the globe.
9	Management of Lens: Aspiration Technique	Great difficulty in aspirating the nucleus, introducing the tip under the capsulorrhexis border, position of aspiration hole not controlled, cannot regulate aspiration flow as needed, cannot peel cortical material adequately, and engages capsule or iris with aspiration port.	Moderate difficulty introducing aspiration tip under capsulorrhexis and maintaining hole up position, attempts to aspirate without occluding tip, shows poor comprehension of aspiration dynamics, cortical peeling is not well controlled, jerky and slow, capsule potentially compromised. Prolonged attempts result in minimal residual cortical material.	Minimal difficulty introducing the aspiration tip under the capsulorrhexis, aspiration hole usually up, cortex well engaged for 360 degrees, cortical peeling slow, few technical errors, minimal residual cortical material.	Aspiration tip is introduced into the nucleus to aspirate and then under the free border of the capsulorrhexis in irrigation mode with the aspiration hole up, Aspiration is activated in just enough flow as to occlude the tip, efficiently removes all cortex, The cortical material is peeled gently towards the center of the pupil, tangentially in cases of zonular weakness
10	Primary Posterior Capsulorrhexis (PPC) initiation	Tentative, needs instructions, unable to clearly visualize the posterior capsule. With Forceps: Not sure if a nick has been made in the posterior capsule. Unable to grasp the lifted posterior capsule with forceps. With Vitrector: Struggles while making a sclerotomy site and inserting the irrigating cannula, Anterior chamber (AC) keeps fluctuating. Wrong site for initiating posterior capsulotomy.	Requires minimal instructions With Forceps: Able to clearly appreciate the posterior capsule and nick made with a cystitome and initiate PPC, moderate vitreous disturbance. Able to grasp the posterior capsule with minimal difficulty. With Vitrector: Needs minimal instructions while deciding the site and technique of sclerotomy, AC remains stable. Site of initiating the capsulotomy is correct.	With Forceps: In control, few awkward movements while making the nick and trying to grasp the posterior capsule, no vitreous disruption. With Vitrector: Performs proper sclerotomy and inserts infusion cannula with ease, AC does not fluctuate, visualizes the vitrector probe in the centre before starting capsulotomy, requires minimal instructions for initiating capsulotomy.	With Forceps: Able to grasp the posterior capsule with ease and at will. Delicate approach and confident control of the rhexis, no vitreous disruption. With Vitrector: Understands the difference in surgical anatomy of pars plana for age, makes a proper sclerotomy at the desired distance with an MVR blade, properly places the infusion port to maintain the AC, Starts posterior capsulotomy from the centre.
11	Primary Posterior Capsulorrhexis(PPC) formation and completion	With Forceps: Poor control when proceeding with the capsulotomy. Vitreous disturbance occurs. Inadequate size and position of PPC. With Vitrector: Does not have knowledge of machine settings while performing capsulotomy and vitrectomy. Improper technique and inadequate size of capsulotomy. Peripheral extension of posterior capsular tear may occur.	With Forceps: predominantly in control with occasional loss of control of rhexis. Size and position are barely adequate, difficulty achieving circular rhexis, tear may occur. With Vitrector: Moderate difficulty in performing capsulotomy and vitrectomy, unable to decide if size of capsulotomy is adequate. Knowledge on machine settings not complete. Difficulty in achieving circular rhexis and may cause peripheral tears.	With Forceps: Able to proceed and complete capsulotomy with minimal instructions. Size and position are almost exact, shows good control. Needs minimal instructions if capsulotomy starts extending peripherally. Able to use appropriate OVD to help facilitate PPC at appropriate stage With Vitrector: Able to perform adequate capsulotomy with ease. Has a sound knowledge on the change in settings while performing capsulotomy. Needs minimal instructions if capsulotomy starts extending peripherally.	With Forceps: Adequate size and position for age, no tears, rapid, unaided control of radialization, maintains control throughout. Able to manage independently if posterior capsulotomy starts extending peripherally. Able to use appropriate OVD to help facilitate PPC at appropriate stage With Vitrector: Adequate size (4-5 mm) and position for age, no tears. Has a sound knowledge on the change in settings while performing capsulotomy. Able to manage independently if posterior capsulotomy starts extending peripherally.
12	Anterior Vitrectomy	Needs Instruction, Difficulty in appreciating vitreous in anterior chamber or the bag, Technique of holding the bimanual irrigation cannula and vitrector is wrong, not sure of settings for vitrectomy. May cut the posterior capsule inadvertently.	Requires minimal instructions, holds the vitrector properly, minimal fluctuation in the anterior chamber during vitrectomy, able to appreciate the presence of vitreous. Unable to perform complete vitrectomy, stays too anterior in vitreous cavity. May cut the posterior capsule inadvertently.	Performs anterior vitrectomy with control, able to clear the anterior and posterior chamber free of vitreous but unable to judge if adequate vitrectomy has been performed, maintains the anterior chamber during vitrectomy. Maintains the posterior Capsulorrhexis margins intact. Peaking of posterior capsule due to inadequate vitrectomy may be noted.	Knows the goals of performing anterior vitrectomy in paediatric age. Knows the end point of complete anterior vitrectomy, Anterior and posterior chamber completely cleared of vitreous, adequate depth of vitrectomy performed in vitreous cavity all around the posterior Capsulorrhexis. Maintains the anterior chamber throughout.
13	IOL Insertion, Rotation, and Final Position of Intraocular Lens	Unable to insert IOL, unable to produce adequate incision for implant FOLDABLE:   unable to load IOL into injector or forceps, no control of lens injection, doesn't control tip placement, lens is not in the capsular bag or is injected upside down.	Insertion and manipulation of IOL is difficult, eye handled roughly, anterior chamber not stable, repeated attempts result in borderline incision for implant type FOLDABLE:  difficulty loading IOL into  injector or forceps, hesitant, poor control of lens injection, difficulty controlling tip placement, excessive manipulation required to get both haptics into capsular bag.	Insertion and manipulation of IOL is accomplished with minimal anterior chamber instability, incision just adequate for implant FOLDABLE:  minimal difficulty loading IOL into injector of forceps, hesitant but good control of lens injection, minimal difficulty controlling tip placement,  both haptics are in the capsular bag.	Insertion and manipulation of IOL is performed in a deep and stable anterior chamber and capsular bag, with incision appropriate for implant type. FOLDABLE: Able to load IOL into injector or forceps, lens is injected in a controlled fashion, fixation of IOL is symmetric; the optic and both haptics are inside the capsular bag.
14	Wound Closure (Including Suturing, Hydration, and Checking Security as Required)	When suturing is needed, instruction is required and stitches are placed in an awkward, slow fashion with much difficulty, astigmatism, bent needles, incomplete suture rotation and wound leakage may result, unable to remove OVDs thoroughly. Unable to make incision water tight or does not check wound for seal.  Improper final chamber depth IOP	When suturing is needed, stitches are placed with some difficulty, resuturing may be needed, questionable wound closure with probable astigmatism, instruction may be needed, questionable whether all viscoelastics are thoroughly removed, Extra manoeuvres are required to make the incision water tight at the end of the surgery. May have improper IOP.	When suturing is needed, stitches are placed with minimal difficulty tight enough to maintain the wound closed, may have slight astigmatism, viscoelastics are adequately removed after this step with some difficulty, The incision is checked and is water tight or needs minimal adjustment at the end of the surgery. May have improper IOP.	When suturing is needed, stitches are placed tight enough to maintain the wound closed, but not too tight as to induce astigmatism, OVDs are adequately removed, and the incision is checked and is water tight at the end of the surgery. Proper final IOP.

Global Indices
15	Wound Neutrality and minimizing Eye Rolling and Corneal Distortion	Nearly constant eye movement and corneal distortion.	Eye often not in primary position, frequent distortion folds.	Eye usually in primary position, mild corneal distortion folds occur.	The eye is kept in primary position during the surgery. No distortion folds are produced. The length and location of incisions prevents distortion of the cornea.
16	Use of dilating agents and devices	Does not have knowledge of dilating agents or devices	Has a good knowledge of dilating agents or devices but unsure of dose and technique.	Has adequate knowledge of dilating agents, of dose and devices but needs minimal instructions while usage	Has adequate knowledge of dilating agents, of dose and devices. Needs no instructions while performing the technique.
17	Eye Positioned Centrally Within Microscope View	Constantly requires repositioning.	Occasional repositioning required.	Mild fluctuation in pupil position.	The pupil is kept centered during the surgery.
18	Conjunctival and corneal Tissue Handling	Tissue handling is rough and damage occurs.	Tissue handling borderline, minimal damage occurs.	Tissue handling decent but potential for damage exists.	Tissue is not damaged nor at risk by handling.
19	Intraocular Spatial Awareness	Instruments often in contact with capsule, iris and corneal endothelium,	Occasional accidental contact with capsule, iris and corneal endothelium.	Rare accidental contact with capsule, iris and corneal endothelium	No accidental contact with capsule, iris and corneal endothelium, when appropriate,
20	Iris Protection	Iris constantly at risk, handled roughly.	Iris occasionally at risk. Needs help in deciding when and how to use hooks, ring or other methods of iris protection.	Iris generally well protected. Slight difficulty with iris hooks, ring, or other methods of iris protection.	Iris is uninjured. Iris hooks, ring, or other methods are used as needed to protect the iris.
21	Overall Speed and Fluidity of Procedure	Hesitant, frequent starts and stops, not at all fluid.	Occasional starts and stops, inefficient and unnecessary manipulations common, case duration about 60 minutes.	Occasional inefficient and/or unnecessary manipulations occur, case duration about 45 minutes.	Inefficient and/or unnecessary manipulations are avoided, case duration is appropriate for case difficulty. In general, 30 minutes should be adequate.
22	Communication with surgical team	Does not know role of surgical team members. Lacks confidence or has too much. Does not establish good rapport with team. Unable to request instruments from scrub nurse using proper instrument and suture names and/or instructions to surgical assistant are vague or nonexistent.	Knows role of most surgical team members. Lacks confidence. Has difficulty establishing good rapport with team members. Able to request most instruments from scrub nurse using proper instrument and suture names but instructions to surgical assistant are inadequate to perform procedure safely.	Knows role of each surgical team member. Is somewhat confident and usually treats team with respect. Establishes good working relationship. Able to request most instruments from scrub nurse using proper instrument and suture names in correct order. Instructions to surgical assistant are adequate for a skilled assistant but inadequate for an unskilled assistant.	Knows role of each surgical team member. Is confident and treats team with respect. Establishes good working relationship. Able to efficiently request instruments from scrub nurse using proper names in correct order. Able to consistently give clear instructions to surgical assistant.

Overall difficulty of procedure (circle):           Simple             Intermediate                Difficult

Good points: _______________________________________________________________________________________________________________________

Suggestions for development: __________________________________________________________________________________________________________

Agreed action: _____________________________________________________________________________________________________________________

Signature of Assessor: ___________________________________        Signature of Trainee: ____________________________________

The COECSA STRABISMUS-OSCAR

This should be completed at the end of the case and immediately discussed with the student to provide timely, structured, specific performance feedback. Circle the appropriate cells and if previous STARBISMUS-OSCARS are available review them in order to develop a plan for improvement

COECSA Strabismus -Ophthalmology Surgical Competency Assessment Rubric: (COECSA STRABISMUS-OSCAR)

Resident: __________________  Evaluator: ____________________                     Date: ____________

	Surgical Step	Novice (score = 2)	Beginner (score = 3)	Advanced Beginner (score = 4)	Competent (score = 5)	Not applicable. Done by consultant or senior resident (score= 0)
1	Draping	Is unable to prepare or drape the patient using sterile technique without instruction. Unaware of importance of identifying correct eye and muscle prior to draping.	Is able to prepare and drape the patient but sterile technique is inconsistent. Difficulty attaining proper head position.	Is able to consistently prepare and drape patients using sterile technique however steps are performed inefficiently. Attains proper head position.	Is able to consistently and efficiently prepare and drape patients with appropriate head position.
2	Forced duction test	Is unaware of forced duction testing for muscle restriction.	Is familiar with the test but is unaware of its relevance, timing and is unable to perform it.	Is able to state the purpose of the test and is able to perform the test at the appropriate time(s) and detect moderate to severe restriction.	When appropriate, is able to consistently detect and describe all degrees of rectus muscle restriction and comment on relevance to surgical options.
3	Globe stabilization	Is able to describe one method of globe stabilization but is unable to perform it.	Is able to describe one method of globe stabilization but needs assistance to perform it.	Is able to perform one method of globe stabilization with minimal verbal supervision.	Is able to perform one method of globe stabilization without verbal supervision and with ease.
4	Conjunctival incision & Tenon’s dissection	Is unable to describe limbal or fornix conjunctival incision for rectus muscle surgery.	Is able to describe but not able to perform limbal or fornix conjunctival incision for rectus muscle surgery.	Is able to perform limbal or fornix conjunctival incisions but is inefficient and requires guidance.	Is able to efficiently perform either limbal or fornix conjunctival incision.
5	Hooking rectus muscle	Is unable to describe proper technique of hooking the muscle and is unable to perform technique.	Is able to describe proper technique but unable to hook muscle on first attempt.	Usually hooks the muscle on first attempt but is inefficient.	Is able to efficiently and precisely hook the muscle on first attempt.
6	Exposure of rectus muscle	Is unable to describe proper dissection technique to expose rectus muscle.	Is able to describe dissection technique for muscle exposure but requires constant guidance to perform the basic steps.	Is able to perform basic exposure but is inefficient and/or occasionally disrupts multiple tissue planes or branches of the anterior ciliary arteries.	Is able to efficiently expose muscle using a combination of sharp and blunt dissection as appropriate and avoids branches of anterior ciliary arteries.
7	Placement of suture in muscle	Is unable to accurately describe muscle suture technique.	Is able to describe muscle suture technique. Multiple attempts required to load or unload the needle-holder. Suture placement inaccurate. Requires assistance to properly place suture.	Is able to safely secure muscle with suture but is inefficient. May cause bleeding and muscle fiber cuts. Needs supervision for locking bites at two ends of muscle.	Is able to safely, efficiently and accurately secure the muscle with minimal tissue trauma without supervision.
8	Disinsertion of rectus muscle	Is unable to describe technique for rectus muscle disinsertion.	Is able to describe but attempts to disinsert the muscle results in inadvertently cutting or nearly cutting the muscle suture or sclera.	Is able to perform disinsertion but occasionally causes inappropriate bleeding or leaves muscle tissue attached to sclera. Requires some verbal instruction.	Is able to safely and efficiently disinsert rectus muscle.
9	Use of caliper/scleral ruler	Is unable to mark the sclera with calipers or does not check the caliper setting to confirm planned action or is too aggressive with indenting the sclera with caliper. Does not understand the potential discrepancy between arc-length and chord-length measurement.	Is able to mark sclera with calipers or scleral ruler but measurement is often not perpendicular to the original rectus insertion. Checks caliper for correct measurement. Understands arc-length vs. chord length measurements.	Is able to accurately mark sclera with calipers and/or scleral ruler but marks fade because not prepared to make needle pass.	Is able to efficiently and accurately mark sclera with calipers and/or scleral ruler and is prepared to make needle pass immediately after marking sclera.
10	Reattachment of muscle:  Intrascleral needle pass.	Is unable to describe safe technique for intrascleral pass.	Is able to describe safe technique for intrascleral pass but does not approach the globe with needle directed tangentially or does not unlock needle holder before starting the intrascleral pass. Unable to accurately obtain correct needle depth or length.	Safely approaches the globe with needle tip directed tangential to the globe. Visualizes needle tip after entering the sclera and has no difficulty exiting the sclera but intrascleral passes are frequently too short or too shallow. Minimal muscle belly sagging.	Approaches the globe with needle directed tangentially and intrascleral passes are consistently of correct length and depth. No muscle belly sagging.
11	Conjunctival closure (when appropriate)	Is unable to close conjunctiva. Unable to differentiate Tenon’s capsule from conjunctiva.	Is able to perform basic conjunctival closure technique but is inefficient and requires significant guidance. Additional sutures are required.	Is able to safely close conjunctiva with good tissue approximation but is inefficient. .	Is able to safely and efficiently close conjunctiva with good tissue approximation.
	Global Indices
12	Maintaining hemostasis	Is unable to describe proper rectus muscle dissection, suture placement and disinsertion to avoid bleeding and/or unable to describe electrocautery technique.	Can describe techniques for avoiding and controlling bleeding but requires significant guidance to perform proper dissection, suture placement, muscle disinsertion and electrocautery to minimize bleeding.	Usually applies proper tissue technique to avoid bleeding and is able to control bleeding using electrocautery but requires multiple attempts to cauterize and may leave burnt carbon marks.	Consistently applies proper tissue technique to avoid bleeding and is able to efficiently control bleeding using electrocautery.
13	Tissue handling	Is excessively aggressive or timid in manipulating tissue. Inadvertent tissue damage occurs (including significant corneal epithelium disruption).	Aware of techniques for avoidance of tissue damage and bleeding but needs supervision to accomplish proper handling. Mild corneal epithelium disruption may occur.	Tissue handling is safe but sometimes requires multiple attempts to achieve desired manipulation of tissue. Minimal corneal epithelium disruption may occur.	Tissue handling is efficient, fluid and almost always achieves desired tissue manipulation on first attempt.
14	Knowledge of instruments	Can only identify instruments in simple terms such as “muscle hook” and “forceps” but no knowledge of necessary sutures or needle types.	Can identify some but not most of the surgical instruments by proper names and can identify necessary suture sizes and materials but not needle types.	Can identify most but not all of the surgical instruments by proper name and can identify necessary suture sizes/materials but not needle types.	Can identify all surgical instruments by proper names and can identify necessary suture sizes/materials and needle types.
15	Technique of holding suture needle in needle holder	Frequently loads needle incorrectly.	Loads needle in proper direction for a forehand pass but sometimes loads incorrectly for backhand pass. Loads too close or too far from the swaged end of the needle.	Loads needle properly for forehand and backhand needle pass but is inefficient and often requires multiple attempts.	Loads needle properly and efficiently for forehand and backhand needle passes.
16	Technique of surgical knot tying	Unable to tie knots.	Require multiple extra hand maneuvers to make first throw lay flat and/or loosens first throw while attempting to perform the second throw.	Is able to tie a flat surgeon’s knot first throw but second and third throws are inefficient. Does not inadvertently loosen the first throw.	Is able to efficiently tie a flat, square surgeon’s knot.
17	Communication with surgical team	Does not know role of surgical team members. Lacks confidence or has too much. Does not establish good rapport with team. Unable to request instruments from scrub nurse using proper instrument and suture names and/or instructions to surgical assistant are vague or nonexistent.	Knows role of most surgical team members. Lacks confidence. Has difficulty establishing good rapport with team members. Able to request most instruments from scrub nurse using proper instrument and suture names but instructions to surgical assistant are inadequate to perform procedure safely.	Knows role of each surgical team member. Is somewhat confident and usually treats team with respect. Establishes good working relationship. Able to request most instruments from scrub nurse using proper instrument and suture names in correct order. Instructions to surgical assistant are adequate for a skilled assistant but inadequate for an unskilled assistant.	Knows role of each surgical team member. Is confident and treats team with respect. Establishes good working relationship. Able to efficiently request instruments from scrub nurse using proper names in correct order. Able to consistently give clear instructions to surgical assistant.

Overall difficulty of procedure (circle):           Simple             Intermediate                Difficult

Good points: _______________________________________________________________________________________________________________________

 

Suggestions for development: _______________________________________________________________________________________________________________________

Agreed action: _______________________________________________________________________________________________________________________

Signature of Assessor: ___________________________________        Signature of Trainee: ____________________________________

The COECSA PHACO-OSCAR

The COECSA PHACO-OSCAR is adapted from the ICO-OSCARs available at icoph.org/ico-oscar.  It should be completed at the end of the case and immediately discussed with the student to provide timely, structured, specific performance feedback. Circle the appropriate cells and if previous PHACO-OSCARS are available review them in order to develop a plan for improvement

COECSA PHACO-Ophthalmology Surgical Competency Assessment Rubric: Phacoemulsification (COECSA PHACO -OSCAR)
Date ______ Resident _______ Evaluator _______		Novice (score = 2)	Beginner (score = 3)	Advanced Beginner (score = 4)	Competent (score = 5)	Not applicable. Done by consultant or senior resident (score= 0)
1	Draping:	Unable to start draping without help.	Drapes with minimal verbal instruction. Incomplete lash coverage.	Lashes mostly covered, drape at most minimally obstructing view.	Lashes completely covered and clear of incision site, drape not obstructing view.
2	Incision & Paracentesis: Formation & Technique	Inappropriate incision architecture, location, and size.	Leakage and/or iris prolapse with local pressure, provides poor surgical access to and visibility of capsule and bag.	Incision either well-placed or non-leaking but not both.	Incision parallel to iris, self sealing, adequate size, provides good access for surgical maneuvering.
3	Viscoelastic: Appropriate Use and Safe Insertion	Unsure of when, what type and how much viscoelastic to use. Has difficulty accessing anterior chamber through paracentesis. .	Requires minimal instruction. Knows when to use but administers incorrect amount or type.	Requires no instruction. Uses at appropriate time. Administers adequate amount and type. Cannula tip in good position. Unsure of correct viscoelastic if multiple types available.	Viscoelastics are administered in appropriate amount and at the appropriate time with cannula tip clear of lens capsule and endothelium. Appropriate viscoelastic is used if multiple types of viscoelastics are available.
4	Capsulorrhexis: Commencement of Flap & follow-through.	Instruction required, tentative, chases rather than controls rhexis, cortex disruption may occur.	Minimal instruction, predominantly in control with occasional loss of control of rhexis, cortex disruption may occur.	In control, few awkward or repositioning movements, no cortex disruption.	Delicate approach and confident control of the rhexis, no cortex disruption.
5	Capsulorrhexis: Formation and Circular Completion	Size and position are inadequate for nucleus density & type of implant, tear may occur.	Size and position are barely adequate for nucleus density and implant type, difficulty achieving circular rhexis, tear may occur.	Size and position are almost exact for nucleus density and implant type, shows control, requires only minimal instruction.	Adequate size and position for nucleus density & type of implant, no tears, rapid, unaided control of radialization, maintains control of the flap and AC depth throughout the capsulorrhexis.
6	Hydrodissection: Visible Fluid Wave and Free Nuclear Rotation	Hydrodissection fluid not injected in quantity nor place to achieve nucleus rotation.	Multiple attempts required, able to rotate nucleus somewhat but not completely. Tries to manually force rotation before adequate hydrodissection.	Fluid injected in appropriate location, able to rotate nucleus but encounters more than minimal resistance.	Ideally see free fluid wave but adequate if free nuclear rotation with minimal resistance is achieved. Aware of contraindications to hydrodissection.
7	Phacoemulsification Probe and Second Instrument: Insertion Into Eye	Has great difficulty inserting the probe or second instrument, AC collapses, may damage wound, capsule or Descemet’s membrane	Inserts the probe or second instrument after some failed attempts, may damage wound, capsule or Descemet’s membrane.	Inserts probe and second instrument on first attempt with mild difficulty, no damage to wound, capsule or Descemet’s membrane.	Smoothly inserts instruments into the eye without damaging the wound or Descemet's membrane.
8	Phacoemulsification Probe and Second Instrument: Effective Use and Stability	Tip frequently not visible, has much difficulty keeping the eye in primary position and uses excessive force to do so.	Tip often not visible, often requires manipulation to keep eye in primary position.	Maintains visibility of tip at most times, eye is generally kept in primary position with mild depression or pulling on the globe.	Maintains visibility of instrument tips at all times, keeps the eye in primary position without depressing or pulling up the globe.
9	Nucleus: Sculpting or Primary Chop	Frequently incorrect power used during sculpting, applies power at inappropriate times, excessive phaco probe movement causes constant eye/nucleus movement, unable to engage nucleus (chop method) or the groove is of inadequate depth or width (divide and conquer), cannot control Phacodynamics. Unable to correctly work foot pedals.	Moderate error in power used while sculpting, tentative, frequent eye/nucleus movement produced by phaco tip, difficult to engage nucleus (chop technique) or groove adequately after many attempts (divide and conquer), poor control of phacodynamics with frequent anterior chamber depth fluctuations. Has difficulty working foot pedals.	Uses correct power with minimal error when sculpting, occasional eye/nucleus movement caused by phaco tip, some difficulty in engaging or holding nucleus (chop method) or groove adequate  with minimal repeat attempts,  fairly good control of phacodynamics with occasional anterior chamber depth change. Minimal mistakes using foot pedals.	Sculpting is performed using adequate ultrasound power regulated by the pedal, with forward movements that do not change the eye position or push the nucleus, the nucleus is safely engaged (with chop method) or the groove is appropriate in depth and width (divide and conquer technique), phacodynamics are controlled as evidenced by the internal anterior chamber environment. Adept at foot pedal control.
10	Nucleus: Rotation and Manipulation	Unable to rotate nucleus.	Able to rotate nucleus partially and with zonular stress.	Able to rotate nucleus fully but with zonular stress.	Nucleus is safely and efficiently manipulated producing minimal stress on zonules and globe.
11	Nucleus: Cracking or Chopping With Safe Phacoemulsification of Segments	CRACKING: Grooves are not centered or deep enough and go into epinucleus, nucleus is constantly displaced from central position, unable to crack nucleus at all, eye constantly moving. CHOPPING: Always endangers or engages adjacent tissue, unable to accomplish chop of any piece. SEGMENT PHACOEMULSIFICATION: produces significant wound burn, great difficulty pursuing fragments around the anterior chamber and into the bag, poor awareness of second instrument tip and difficulty keeping the second hand instrument under the phaco tip,	CRACKING: Some grooves are centered and deep enough and some go into epinucleus, displaces nucleus in most grooves, attempts to split nucleus with instruments too shallow in groove, able to crack portion of nucleus, eye often moving. CHOPPING: endangers or engages adjacent tissue in most chops, able to accomplish chop of some pieces. SEGMENT PHACOEMULSIFICATION: produces light wound burn, pursues most fragments around the AC and into the bag, the second hand instrument is sometimes under the phaco tip	CRACKING: Most grooves are centered and deep enough, rarely goes into epinucleus, rarely displaces nucleus, sometimes attempts to split in mid-nucleus but succeeds, eye usually in primary position. CHOPPING: endangers or engages adjacent tissue in some chops, able to accomplish chop of most pieces. SEGMENT PHACOEMULSIFICATION: produces minimal wound burn, pursues some fragments around the AC and into the bag, the second hand instrument is usually under the phaco tip	CRACKING: Grooves are centered, deep enough to ensure cracking, length does not reach epinucleus, nucleus is not displaced from central position, places instruments deep enough to easily and successfully crack nucleus, eye stays in primary position. CHOPPING: Nucleus engaged and vertical or horizontal chop technique undertaken with no inadvertent engagement of adjacent tissue (especially capsule). Full thickness nuclear chop of all pieces in a controlled and fluid manner. SEGMENT PHACOEMULSIFICATION: No wound burns, Pieces are "floated" to the tip without "pursuing" the fragments around the anterior chamber and the bag, The second hand instrument is kept under the phaco tip to prevent posterior capsule contact if surge arises.
12	Irrigation and Aspiration Technique With Adequate Removal of Cortex	Great difficulty introducing the aspiration tip under the capsulorrhexis border, aspiration hole position not controlled, cannot regulate aspiration flow as needed, cannot peel cortical material adequately, engages capsule or iris with aspiration port.	Moderate difficulty introducing aspiration tip under capsulorrhexis and maintaining hole up position, attempts to aspirate without occluding tip, shows poor comprehension of aspiration dynamics, cortical peeling  is not well controlled, jerky and slow, capsule potentially compromised. prolonged attempts result in minimal residual cortical material.	Minimal difficulty introducing the aspiration tip under the capsulorrhexis, aspiration hole usually up, cortex will engaged for 360 degrees, cortical peeling slow, few technical errors, minimal residual cortical material.	Aspiration tip is introduced under the free border of the capsulorrhexis in irrigation mode with the aspiration hole up, Aspiration is activated in just enough flow as to occlude the tip, efficiently removes all cortex, The cortical material is peeled gently towards the center of the pupil, tangentially in cases of zonular weakness.
13	Lens Insertion, Rotation, and Final Position of Intraocular Lens	Unable to insert IOL, unable to produce adequate incision for implant type NON-FOLDABLE: unable to place the lower haptic in the capsular bag, unable to rotate the upper haptic into place FOLDABLE:   unable to load IOL into injector or forcep, no control of lens injection, doesn't control tip placement, lens is not in the capsular bag or is injected upside down.	Insertion and manipulation of IOL is difficult, eye handled roughly, anterior chamber  not stable, repeated attempts result in borderline incision for implant type NON-FOLDABLE: repeated hesitant attempts result in lower haptic in the capsular bag, upper haptic is rotated into place but with excessive force on capsulorrhexis and zonules and repeated attempts are necessary FOLDABLE:  difficulty loading IOL into  injector or forcep,, hesitant, poor control of lens injection, difficulty controlling tip placement, excessive manipulation required to get both haptics into capsular bag.	Insertion and manipulation of IOL is accomplished with minimal anterior chamber instability, incision just adequate for implant type NON-FOLDABLE: the lower haptic is placed inside the capsular bag with some difficulty, upper haptic is rotated into place with some stress on the capsulorrhexis and zonule fibers FOLDABLE: , minimal difficulty loading IOL into injector of forcep, hesitant but good control of lens injection, minimal difficulty controlling tip placement,  both haptics are in the capsular bag.	Insertion and manipulation of IOL is performed in a deep and stable anterior chamber and capsular bag, with incision appropriate for implant type.  NON-FOLDABLE: The lower haptic is smoothly placed inside the capsular bag; the upper haptic is rotated into place without exerting excessive stress to the capsulorrhexis or the zonule fibers.  FOLDABLE: Able to load IOL into injector or forcep, lens is injected in a controlled fashion, fixation of IOL is symmetric; the optic and both haptics are inside the capsular bag.
14	Wound Closure (Including Suturing, Hydration, and Checking Security as Required)	If suturing is needed, instruction is required and stitches are placed in an awkward, slow fashion with much difficulty, astigmatism, bent needles, incomplete suture rotation and wound leakage may result, unable to remove viscoelastics thoroughly. unable to make incision water tight or does not check wound for seal.  Improper final IOP.	If suturing is needed, stitches are placed with some difficulty, resuturing may be needed, questionable wound closure with probable astigmatism, instruction may be needed, questionable whether all viscoelastics are thoroughly removed, Extra maneuvers are required to make the incision water tight at the end of the surgery. May have improper IOP.	If suturing is needed, stitches are placed with minimal difficulty  tight enough to maintain the wound closed, may have slight astigmatism, viscoelastics are adequately removed after this step with some difficulty, The incision is checked and is water tight or needs minimal adjustment at the end of the surgery. May have improper IOP.	If suturing is needed, stitches are placed tight enough to maintain the wound closed, but not too tight as to induce astigmatism, viscoelastics are thoroughly removed after this step, the incision is checked and is water tight at the end of the surgery.  Proper final IOP.
	Global Indices
15	Wound Neutrality and Minimizing Eye Rolling and Corneal Distortion	Nearly constant eye movement and corneal distortion.	Eye often not in primary position, frequent distortion folds.	Eye usually in primary position, mild corneal distortion folds occur.	The eye is kept in primary position during the surgery. No distortion folds are produced. The length and location of incisions prevents distortion of the cornea.
16	Eye Positioned Centrally Within Microscope View	Constantly requires repositioning.	Occasional repositioning required.	Mild fluctuation in pupil position.	The pupil is kept centered during the surgery.
17	Conjunctival and Corneal Tissue Handling	Tissue handling is rough and damage occurs.	Tissue handling borderline, minimal damage occurs.	Tissue handling decent but potential for damage exists.	Tissue is not damaged nor at risk by handling.
18	Intraocular Spatial Awareness	instruments often in contact with capsule, iris and corneal endothelium’, blunt second hand instrument not kept in appropriate position.	Occasional accidental contact with capsule, iris and corneal endothelium, sometimes has blunt second hand instrument between the posterior capsule and the activated phaco tip.	Rare accidental contact with capsule, iris and corneal endothelium. Often has blunt second hand instrument between the posterior capsule and the activated phaco tip.	No accidental contact with capsule, iris and corneal endothelium, when appropriate, a blunt, second hand instrument, is always kept between the posterior capsule and the tip of the phaco when the phaco is activated.
19	Iris Protection	Iris constantly at risk, handled roughly.	Iris occasionally at risk. Needs help in deciding when and how to use hooks, ring or other methods of iris protection.	Iris generally well protected. Slight difficulty with iris hooks, ring, or other methods of iris protection.	Iris is uninjured. Iris hooks, ring, or other methods are used as needed to protect the iris.
20	Overall Speed and Fluidity of Procedure	Hesitant, frequent starts and stops, not at all fluid.	Occasional starts and stops, inefficient and unnecessary manipulations common, case duration about 60 minutes.	Occasional inefficient and/or unnecessary manipulations occur, case duration about 45 minutes.	Inefficient and/or unnecessary manipulations are avoided, case duration is appropriate for case difficulty. In general, 30 minutes should be adequate.

Overall difficulty of procedure (circle):           Simple             Intermediate                Difficult

Good points: _______________________________________________________________________________________________________________________

 

Suggestions for development: _______________________________________________________________________________________________________________________

Agreed action: _______________________________________________________________________________________________________________________

Signature of Assessor: ___________________________________        Signature of Trainee: ____________________________________

Rubric for ocex

	Rubric for   OCEX                                                                                                        OCEX Scoring Rubric
			1 Does not meet		2 Meets some expectations		3 Meets all expectations	4 Exceeds Expectations
	Interview Skills
	Introduction		Does not introduce him/her self			Introduces self as Dr. not as resident	Introduces self as resident physician	Introduces self to patient & family and shakes hands
	Chief Complaint		Does not elicit a CC			Elicits CC but lacks relevant details.	Elicits CC & details	Elicits CC and subtle, relevant details
	HPI		Does not elicit HPI			HPI lacks relevant details	HPI includes most important details	HPI includes all relevant details
	Pertinent Negatives		Does not elicit pertinent negatives			Elicits some pertinent negatives	Elicits important pertinent negatives	Elicits even subtle pertinent negatives
	Pain Inquiry		Does not elicit.			Pain is elicited, not characterized	Elicits scaled rating of pain (0-10)	Elicits scaled rating/ relieving/exacerbating factors
	Allergies		Does not elicit.			Elicits medical allergies without symptom detail	Elicits medical allergies with symptom detail	Elicits medical & environmental allergies/symptoms
	ROS		Does not elicit.			Elicits incomplete ROS	Elicits most important items in ROS	Leaves no stone unturned
	Medication List		Does not elicit.			Obtains list, no dosages/frequency	Obtains list with dosages/frequency	Obtains list of meds/ & herbal remedies
	Social History		Does not elicit.			Omits important details	Obtains important details	Elicits even subtle relevant details
	Family History		Does not elicit.			Omits important details	Obtains important details	Obtains subtle relevant details of family tree
	Hand Washing		Does not wash hands.			Washes his/her hands, no soap	Washes hands with soap	Washes hands before and after encounter
	Exam
	Visual Acuity		Does not check			Checks, but not best corrected	Checks best corrected	Does additional, appropriate testing relevant to patient’s history/exam
	Pupils		Does not check			Checks light reaction, does not swing light	Checks light reaction and for RAPD	Does additional, appropriate testing relevant to patient’s history/exam
	Visual Field		Does not check			Confrontational VF done but incompletely	Confrontational visual fields done correctly	Does additional, appropriate testing relevant to patient’s history/exam
	Motility		Does not check			Checks ductions or versions	Checks ductions / versions and alignment in primary position	Does additional, appropriate testing relevant to patient’s history/exam
	External		Does not check			Observes without measurements	Checks lid fissures & for proptosis	Does additional, appropriate testing relevant to patient’s history/exam
	SLE		Does not check			Doesn’t check all depths of AC and/or checks only 1 eye	Checks both eyes, entire anterior segment	Does additional, appropriate testing relevant to patient’s history/exam
	IOP		Does not check			Poor applanation technique	Checks IOP correctly OU	Does additional, appropriate testing relevant to patient’s history/exam
	Fundus		Does not check			Indirect or slit lamp biomicroscopy	Indirect and slit lamp biomicroscopy	Does additional appropriate testing relevant to patient’s history/exam
Interpersonal Skills
		1 Does not meet		2 Meets some expectations			3 Meets all expectations	4 Exceeds all expectations
Respectful		Disrespectful		Curt, does not listen to all of patient’s questions/concerns			Listens to patient, responds to patient questions/concerns	Extremely attentive to patient’s questions, concerns
Understandable		Constantly uses medical jargon the patient doesn’t understand		Occasionally uses medical jargon the patient doesn’t understand			Avoids or explains medical terms when used	Avoids or explains medical terms when used and frequently asks whether they are understood
Explained Findings		No explanation		Cursory explanation			Thoroughly explained all pertinent findings	Thoroughly explained all findings and used models/photos
Explained Diagnosis		No explanation		Cursory explanation			Thoroughly explained diagnosis	Thoroughly explained diagnosis and used models/photos
Explained Plan		No explanation		Cursory explanation			Thoroughly explained plan	Thoroughly explained plan and scheduled tests
Asked if Patient Had Questions.		Does not ask		Asked if patient had questions but didn’t answer completely			Asked if patient had questions and answered questions thoroughly	Asked if patient & family had questions. And answered thoroughly. Gave phone # for patient to call with questions
Case Presentation
Concise/Clarity		Unintelligible		Somewhat Disorganized			Clear, concise, organized	Meticulous, exact, succinct but complete
Pertinent Facts		Omits pertinent facts		Omits minor supporting facts			Covers all pertinent facts	Covers all pertinent facts and omits all irrelevant data
Pertinent Positives & Negatives		Does not mention		Mentions some pertinent positives & negatives			Covers all pertinent positives & negatives	Covers all pertinent positives & negatives, and omits irrelevant data
Differential Diagnosis		Does not mention		Provides basic but incomplete differential Dx			Provides appropriate differential Dx	Exhaustive differential Dx and cites literature
Appropriate Plan		Does not mention		Provides basic but incomplete plan			Provides appropriate plan	Provides detailed plan and cites literature
Response to Attending		Inappropriate		Listens but little response			Listens and responds appropriately	Responds appropriately and cites relevant literature

Coecsa-ocex

COECSA Ophthalmic Clinical Evaluation Exercise (COECSA-OCEX)

The OCEX is an observed encounter between a resident and a new patient. The evaluator should be present in the exam room for the entire interaction. The intent is to rate the resident in all the categories listed below compared to a graduating resident and then provide immediate performance feedback. The rating system is:     1 -  Does Not Meet Expectations     2 – Meets Some Expectations       3 - Meets All Expectations                      4 – Exceeds Expectations                   na -  Not Applicable

Elicits medical & environmental allergies/symptoms Elicits medical & environmental allergies/symptoms

Interview Skills
1. Introduced self	1	2	3	4	na		7. Review of systems	1	2	3	4	na
2. Obtained chief complaint	1	2	3	4	na		8. Med list	1	2	3	4	na
3. History of present illness	1	2	3	4	na		9. Past medical history	1	2	3	4	na
4. Pertinent negatives	1	2	3	4	na		10. Social history	1	2	3	4	na
5. Pain inquiry	1	2	3	4	na		11. Family history	1	2	3	4	Na
6. Allergies	1	2	3	4	na		12. Washed hands	1	2	3	4	Na
Examination
1. Best corrected Va	1	2	3	4	na		5. External	1	2	3	4	na
2. Pupils / RAPD	1	2	3	4	na		6. SLE	1	2	3	4	na
3. Visual Fields	1	2	3	4	na		7. IOP (+/- gonioscopy)	1	2	3	4	na
4. Motility	1	2	3	4	na		8. Funduscopy	1	2	3	4	na
Interpersonal Skills / Professionalism
1. Empathetic	1	2	3	4	na		5. Explained diagnosis	1	2	3	4	na
2. Respectful & courteous	1	2	3	4	na		6. Explained plan/options	1	2	3	4	na
3. Used language the pt Understands	1	2	3	4	na		7. Asked if patient had questions	1	2	3	4	na
4. Explained findings	1	2	3	4	na
Case Presentation
1. Concise & clear	1	2	3	4	na		4. Appropriate differential Dx	1	2	3	4	na
2. Pertinent facts	1	2	3	4	na		5. Appropriate plan	1	2	3	4	na
3. Pertinent pos & negs	1	2	3	4	na		6. Response to attending’s questions/suggestions	1	2	3	4	na

Comments:                                                                                                                                                                    

                                                                                                                                                                                       

                                                                                                                                                                               

We have reviewed this OCEX together.                 Resident initials:                        Date:          

Evaluator initials: