VITREO-RETINAL - SUBSPECIALTY CURRICULUM

PREAMBLE

COECSA Background

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

The College seeks to work in tandem with regional and global initiatives and to support international commitments including Sustainable Development Goals (SDGs), WHO Vision2020: The Right to Sight; WHO AFRO Road Map for scaling up HRH[KG1] ; 4th EAC Development Strategy; national eye care and development programmes in contributing to Universal Health Coverage (UHC).

COECSA’s expertise in research, curricula, standards, quality assessments, and policy reviews provide the basis to further programmatic interventions. COECSA, therefore, places a premium on partnerships and collaborations and further acts as a catalyst for action by many actors in the eye care space.

COECSA’s mandate is to:

· Support the development of human resource for health through quality training in ophthalmology;
· Set standards for professional ophthalmic practice;
· Facilitate continuing professional development;
· Contribute to health policy development;
· Advocate for relevant policy changes in the region;
· Promote research which advances ophthalmology practice in the region and ;
· Create a forum for the ophthalmic practitioners to promote the profession and exchange skills and knowledge.

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

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

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

ii. Curriculum Model

The subspecialty fellowship curriculum is a hybrid model that promotes the following tenets:

• Integration (horizontal & vertical)

• Thematic/systematic Courses

• Small group learning methods

• Student-centred & Student-directed Learning

• Optimum use of IT learning technologies

• Primary care models (& health promotion approaches)

iii. Curriculum Goal, Objectives and Outcomes

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

iv. Core Competences

Core competencies include:

· Patient Care

· Medical Knowledge

· Practice-based Learning and Improvement

· Communication Skills

· Professionalism

· Systems-based Practice

2. INTRODUCTION/RATIONALE

Vitreoretinal diseases are conditions that affect structures in the eye called the retina and the vitreous. The retina is the light-sensitive layer in the back of the eye that receives focused images and transmits that information to the brain via the optic nerve. The vitreous is a clear gel that fills the space between the lens (at the front of the eye) and the retina.

Because the retina and macula are integral to vision, any disease in this part of the eye can temporarily or permanently diminish vision. Therefore, any symptoms related to vitreoretinal disease need to be evaluated by a retinal specialist as quickly as possible.

To ensure the availability of retinal specialists in the ECSA region, COECSA with support from the Commonwealth Eye Health Consortium (CEHC) embarked on a project to roll out a regional Clinical Fellowship Programmes that will provide a well- defined clinical experience in Vitreo-Retina specialty with recognised competencies in both medical and surgical retina. The programme is aimed to forestall the challenge of long periods of training abroad and maximize on the available pool of resources, both human and hospitals that are available in the region.

3. STRUCTURE OF THE PROGRAMME

i. Goal

The goal of the VR Fellowship is to provide training/experience for the diagnosis, medical and surgical management of retinal and vitreous conditions using a regional, hospital based fellowship program.

ii. Objectives

History taking skills.

The fellow must have in-depth knowledge to take a comprehensive history about common and rare Vitreo-Retina clinical conditions that may be associated with worsening disease and/or vision loss

Clinical Investigation Skills

To acquire skills necessary to examine vitreo-retina pathology and related ocular and systemic conditions. In particular, the fellow will be required to be proficient with the use of the indirect ophthalmoscope along with skills of indentation to examine the peripheral retina.

Performing Technical VR diagnostic Tests and their Clinical interpretations.

To acquire knowledge and become proficient in identifying the indications for various diagnostic tests and interpretation of the results of such specialized diagnostic tests appropriate to the subspecialty of VR, including but not limited to the following:

o Should be able to do B Scan Ultrasonography (USG), evaluating and diagnosis of various posterior segment conditions. Give a concise and complete report on the USG findings. Should be proficient in various different USG examination techniques.

o Should understand the OCT testing modality and how to interpret the results and follow up on conditions such as DME, AMD, CSR, IPCV, CNVM etc . The fellow should be able to differentiate all the layers of the retina and determine the disease processes. The fellow should be able to use the OCT comfortably for anterior segment and disc evaluation along with RNFL/GCC interpretation.

o Evaluation of retina using wide field fundus photography

o Assessment of various vascular diseases using FFA/ICGA/OCT Angiography.

· Therapeutics Modalities and their limitations

To acquire knowledge related to management of various VR conditions as related to medical, radiological and surgical interventions.

The fellow must become familiar with the indications for and limitations of all important pharmacological, LASER, and surgical therapies that may be recommended for patients with VR and related conditions.

They must also be familiar with other systemic conditions whose management has direct or indirect impact on management of VR conditions. In case of drug interactions, they must be familiar with specific antidote or line of management for adverse effects from such interactions or from independent unwanted side effects.

· VR Clinical Experience

The fellow should become proficient in the diagnosis and clinical/surgical management of VR and related structures such as the uvea. Fellow should be proficient in dissemination of VR knowledge to the other medical cadres who are part of the eye care team.

To instill a deep-rooted sense of responsibility for VR patients who often require long term follow‐up and psychosocial care and support.
To demonstrate the highest ethical standards in treatment VR patients.
To understand the value of basic, clinical, and population-based research in furthering the understanding of etiology, diagnosis, and the treatment of VR conditions.
To participate in at least one VR‐related research project and present at resident/fellow research days, as well as at a major international ophthalmic meeting/ conference.
To participate in teaching of medical students and residents whenever possible.
To understand principles behind leadership and management roles related to the practice of VR (in an academic and community practice setting).
To appreciate considerations in the optimal utilization of limited resources.
To submit for publication at least one paper in a peer‐reviewed ophthalmic journal during the course of the fellowship.
To fulfill surgical competencies as outlined in the logbook requirements.

Delivery/Teaching Method

The program will take place in one center or multiple collaborating centers so long as there is an agreement between the centers. All centers must be accredited by COECSA. Where training is conducted in two training institutions:

the admitting institutions assumes full responsibility for the candidates training. This will include, but not limited to verification and documentation of such training undertaken at the partner institution.
If during the course of the training, any of the two institutions involved in the training decides to be accredited as a standalone training centre, a consideration will be made at the end of the training cycle.

The course shall have no lectures. However, the trainer shall be required to:

· Have 1 weekly presentation that may include:

- 1 diagnostics presentation

- 1 case presentation and OR

- 1 journal club presentation

· The trainee shall also be required to attend and present in at least 2 Ophthalmic conferences during the training period

ADMISSION REQUIREMENTS

The call for applications shall be made by the admitting institution and COECSA. In order for a consideration to be made for admission to the VR fellowship, a trainee shall be required to present the following documents when applying for the VR fellowship course:

The applicant must be a COECSA fellow or meet the following guidelines:

o The fellowship is primarily only open to fellows (1st Priority). Fellows will be admitted at a Subsidized rate.

o Second option is members of COECSA in good standing – These will be admitted at a Higher Fee agreed on in liaison with the Executive Committee.

o Third option – Licensed, Qualified Ophthalmologists outside the region at a Much Higher Fee as agreed on in liaison with the executive committee

ii. Motivation letter and duly filled application form[KG2] .

iii. Must have a log of 100 or more successful phacoemulsification cataract surgeries and an equivalent log of successful small incision cataract surgeries with accompanying audit of pre and post op outcomes and complication rates.

iv. Must have good depth perception (Stereopsis)

v. Must be proficient in indirect Ophthalmoscopy.

vi. Must have a medical license with the relevant board in the country of training.

vii. Must have evidence of upkeep either through a bank statement or scholarship.

viii. Must have health and indemnity insurance to cover the entire training duration.

ix. Must have a letter of commitment from the centre where he will be working to provide a VR unit, or proof of an existing VR unit that will absorb him/her upon VR fellowship training completion.

x. Must be proficient in English. An English proficiency certification may be required where the applicants medium of learning was not English.

xi. NOTE: Institutions with some candidates already in training at the time of accreditation, will be handled on a case by case basis as follows:

a. At the accreditation stage, the training institution will submit names of candidates in training.

b. The candidates will then be assessed against COECSA’s admission and exit criteria to ascertain if they meet the minimum requirements for a COECSA fellowship/specialist qualification.

SELECTION PROCESS

All applications shall be reviewed by a selection panel from COECSA and the defined members from the training institutions. The panel will consist of:

§ Representation from chair of the COECSA Education & Accreditation Committee,

§ 2 VR Specialists from the training institution(s) and

§ COECSA Education and Training Officer (ex-officio)

There is a veto by the two VR specialists if they both decline to approve the application.

COURSE DURATION

This training will take place for continuous minimum period of 18 months; and a maximum of 21 months in case the trainee does not meet the minimum requirements for qualification.

TRAINING ASSESSMENT AND EVALUATION

Training evaluation forms have been developed for training assessment purposes (see appendix B: Training Evaluation Forms). Using the Evaluation forms, there will be;

a) Monthly assessment of the trainee by the trainer which will be sent to COECSA Education Officer monthly.

b) A final evaluation that indicates whether the candidate has qualified or not. The program director must provide a written, final evaluation for each fellow who completes the program. The evaluation must include a review of the fellow’s performance during the period of training and should verify that the fellow has demonstrated sufficient professional ability to practice competently and independently. This final evaluation should be part of the fellow’s permanent record maintained by the institution.

EXIT CRITERIA

o Stage 1: Final Training Evaluation by the Training Institution/programme director, who will make recommendation to the COECSA subspecialty panel

o Stage 2: Evaluation by the COECSA subspecialty selection panel, who will make recommendation to the College Senate. The panel will consist of:

1. The COECSA Education &Accreditation Committee,

2. 2 Glaucoma Specialists, and

3. COECSA Education and Training Officer (ex-officio).

4. NOTE: The glaucoma specialists in the panel conducting the evaluation shall not be from the training institution.

o Stage 3: Validation and Approval by the College Senate

FELLOWSHIP AWARD

The award and title for the participant upon completion of the program, which will be given by COECSA in conjunction with the training institution is Vitreo Retina (VR) Specialist [COECSA]

UNSUCCESSFUL TRAINEE

In the event that a trainee does not meet the minimum requirements during the training period of 18 months;

a) There will be an extension of the training by 3 months in order to meet the requirements.

b) In the event that after the 3 months of extension the candidates does not meet the minimum requirements, training will be discontinued and this decision will be final.

FACULTY/TRAINER QUALIFICATIONS AND RESPONSIBILITIES

i. Qualifications

The following are the qualifications for a faculty member or trainer/director:

a) Must be a COECSA fellow in good standing or its equivalent[KG3] .

b) Must have undergone COECSA Train the Trainers (TTT)

c) Must have undergone VR Fellowship training and Must be a full time practicing VR surgeon with at least 100 unsupervised posterior segment surgeries per year.

d) Must have a minimum of 3 years working experience as a VR surgeon.

e) Must have a letter of reference from a COECSA recognised Vitreo- Retinal surgical trainer.

Requirements

a) Required to possess appropriate educational qualifications, including certification in ophthalmology and VR-fellowship training.

b) Required to have at least 3 years of clinical experience in VR following his/her fellowship training.

c) In rare circumstances, in regions where there may not be a fellowship trained program director, a senior ophthalmologist may have 8 or more years of experience in substantial (greater than 50%) VR practice, including contribution to the literature in the way of clinical or basic research. Such a clinician may be considered an appropriate primary supervisor.

d) Should be engaged in ongoing basic and/or clinical science research in the areas of VR, as demonstrated by regular publications in peer-reviewed journals and/or presentation of research material at national and international meetings.

e) Required to have a clinical practice with at least 50% of patients who have VR and related disorders.

f) Required to be licensed to practice medicine in the state or country where the institution that sponsors the program is located.

ii. Responsibilities of the fellowship trainer/director

a) Required to prepare a written statement outlining the educational goals of the program with respect to knowledge, skills and other attributes, and educational goals for each major rotation or other program assignments.

b) Should promote awareness of the fellowship opportunity by providing a training vacancy description and requesting applications via a public/COECSA website.

c) Required to develop and maintain documentation of institutional or inter-institutional agreements, the fellowship selection process, patient-care statistics, evaluations of faculty and the program, and assessment of the fellows’ performance.

d) Required to select fellows in accordance with COECSA and institutional l policies and procedures.

e) Required to designate and supervise the faculty through explicit descriptions of supervisory lines of responsibility.

f) Required to ensure the implementation of fair procedures and due process regarding academic discipline and fellow complaints or grievances, as established by the sponsoring institution.

g) Required to keep open lines of communication with their fellows and be sensitive to issues of professional and personal stress, which may interfere with the fellows’ interaction with patients and colleagues in medical and nonmedical departments. Further, the fellowship program director should be aware of issues that would interfere with the professional development of their fellows and be willing to facilitate timely provision of confidential counselling and psychological support services to fellows by professionals. Trainer should ensure that the training schedules are not producing undesirable stress on fellows. From time to time the training programme must be evaluated and modified when the need arises.

h) Required to ensure that accurate statistical and narrative descriptions of the training program developed is maintained up to date.

Note that any change in the fellowship director position is to be communicated to the COECSA education committee within 30 days.

12. COURSE DESCRIPTION (SYLLABUS/MINIMUM REQUIREMENTS FOR QUALIFICATION)

For a trainee to have qualified she/he must have done the following during the fellowship:

a) At least 3 full Scleral Buckles.

b) Vitrectomy – Must have done the following surgeries:

· 5 retinal detachments

· 2 Macular hole

· 1 ERMP

· 1 Posterior segment foreign body

· 1 dropped IOL

· 1 dropped Nucleus

· 2 posterior segment trauma

· 100 PRP Laser of which 50 must be with the LIO.

· 25 Macular Laser – Grid or sub-threshold.

· 50 Intra-vitreal Injections-

· 20 Posterior Subtenon injections

· 2 Scleral fixated IOLS

13. INSTITUTION FACILITIES AND RESOURCES (ACCREDITATION GUIDELINES)

Generally, the following guidelines shall apply for training institutions:

a) If training is done in a single centre, the centre must have at least 2 VR surgeons to enable the trainee gain as much exposure as possible.

b) If this is not the case, then the trainee should rotate in 2 or 3 Centres during the training period all of which must be COECSA accredited.

(See appendix C: Detailed accreditation guidelines)

14. TRAINING COSTS

See appendix D: VR Fellowship Training costs

15. APPENDIX

i. Appendix A: Acknowledgement

The College of Ophthalmology of Eastern, Central & Southern Africa (COECSA) leadership wishes to acknowledge the Education & Accreditation Committee for providing leadership in the overall development of the subspecialty training curriculum.

The curriculum has been developed through a participatory and consultative environment with significant contributions and support from various individuals and institutions. I therefore wish to extend my sincere appreciation to all those that contributed to the process of developing this curriculum.

I wish to pay special tribute to Dr. Amos Kibata Githeko, the Chair of the Vitreo-Retina Curriculum Subcommittee for the significant input and commitment to this process. I also acknowledge the tremendous contributions of the members of the subcommittee, in particular I wish to thank the following:

Dr. Petros Kayange
Dr. Muchai Gachago
Dr. Onyango Oscar
Dr. Kareko Catherine
Dr. Shafiq Jafferji
Dr. Ben Roberts
Dr. William Makupa
Dr. Emeritus Chibuga
Dr. P T Nyaga

The College extends special gratitude to the Commonwealth Eye Health Consortium (CEHC) for providing funding through the London School of Hygiene and Tropical Medicine (LSHTM), International Centre for Eye Health (ICEH) that made this process possible. We are particularly grateful to Ms. Sally Gillespie and Dr John Buchan of LSHTM for their unrelenting support.

Last but not least, we would like to acknowledge the secretarial and logistical support of the COECSA secretariat.

Yours Sincerely,

Dr. John Nkurikiye

President - COECSA

3^rd March, 2020

[KG1]What is this? Full word preferred.

[KG2]Yet to be designed.

a) [KG3]. DEFINE WHAT IS THE EQUIVALENT