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International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist: Chapter 1. Preamble


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Presented by the International Task Force on Ophthalmology for Resident and Specialist Training, on behalf of the International Council of Ophthalmology (ICO)

Introduction

An ophthalmologist is a doctor of medicine (MD or equivalent degree) who specializes in the eye and visual system.

As a licensed medical doctor, the ophthalmologist’s ethical and legal responsibilities include the care of individuals and populations suffering from diseases of the eye and visual system.

Such care requires not only core competencies for an ophthalmic physician, but also a set of specialized cognitive capabilities and an array of technical skills.

Specialist training is designed to provide a structured program of learning that facilitates the acquisition of knowledge, understanding, skills and attitudes to a level appropriate for an ophthalmic specialist who has been fully prepared to begin their career as an independent consultant in ophthalmology.

Goals

The curriculum provides an outline of essential intellectual and clinical information (cognitive and technical skills) that is necessary for a modern, comprehensive ophthalmologist.

The ICO curriculum is designed to provide a content outline for training. The precise details of the curricular learning plan should be modified by the readers of this curriculum to meet their local needs and available resources. These modifications should include:

1) when the learning will occur (i.e., duration, length, frequency, and timing of training)

2) where the learning will take place (i.e., location of learning, which rotations)

3) who will participate (i.e., who will teach, who will learn, who will assess learning and teaching)

4) how will the teaching and learning be measured (i.e., teaching and assessment methods) 

Core competencies and technical skills are described briefly in this preamble. Though not specifically addressed here, skills in epidemiology and research methodologies are important for the well-rounded ophthalmologist.

Blindness and reduced vision affect hundreds of millions of people throughout the world, and the causes vary widely.

The knowledge required to understand and treat the diseases commonly encountered in one part of the world may be entirely different from that required in other locations; for example, trachoma vs. age-related macular degeneration, or nutritional blindness vs. diabetic retinopathy, etc.

Accordingly, the curricular components deemed essential in one geographical locale or one cultural system may be relatively unimportant in other regions, depending upon prevalence of diseases, the medical infrastructure, and other factors. 

Levels of economic and social development also vary widely throughout the world. Treatments and techniques considered indispensable for one group of people might be unattainable or unimportant for others, due to lack of economic resources, unavailability of highly specialized personnel or equipment, and many other factors.

Thus, the standards proposed herein should be considered aspirational guidelines to be sought and attained as soon as practicable. They cannot be instantly achieved in all parts of the world, desirable as they might be.

Standards may need to be modified according to local priorities, goals, needs, culture, governmental policies, social systems, financial constraints, varying use of para-ophthalmic personnel, and differing tangible resources.

Even in highly developed societies, with large and well financed governmental systems of health care delivery, this document should be considered a "work in progress" and be revised and modified to suit local needs, as well as respond to expanding knowledge and technology.

In this regard, feedback to the ICO, with specific suggestions for changes and improvement in these guidelines, is earnestly solicited from the readers and will be greatly appreciated by the authors of this document and by the leadership of the ICO.

History of Task Force on Resident and Specialist Education in Ophthalmology

The ICO has had intense interest and commitment to ophthalmic education for many years.

Under the leadership of Professor Maurice H. Luntz, for example, the International Committee for Teaching and Continuing Educational Systems of the International Council of Ophthalmology has described training programs throughout the world and has offered guidelines for education of ophthalmologists on numerous occasions during the 1980’s and 1990’s, including presentations at the 14th, 24th and 26th quadrennial meetings of the ICO.

In 2001, the ICO and the Academia Ophthalmologica Internationalis (AOI) published "Vision for the Future," an international strategic plan to preserve and restore vision.  Within this plan, a task force on resident and specialist training in ophthalmology, under the direction of Professor Ronald E. Smith, noted the following:

  • Guidelines for ophthalmology training are not fixed and should not be viewed as rigid or mandatory.

  • Training should be provided through a combination of lectures, supervised patient care, and graduated, hands-on procedural and surgical experience, research, and independent study.

  • The focus should be on acquisition of knowledge and skills related to ophthalmology, and development of an appreciation for the importance of vision research, life-long learning, and the education of the public and other physicians.

  • The curriculum should be approximately 3-5 years in length, depending upon the individual country or region, and should prepare the graduating ophthalmologist for an examination or testing process that leads to licensure, registration, or a related certification system.

  • Facilities should include: up-to-date ophthalmic equipment and instruments, examining rooms dedicated to ophthalmic education, links to hospitals or other facilities for anesthesia, radiology, clinical testing laboratories, other diagnostic services, and modern surgical suites with appropriate equipment.

    In addition, repositories of library materials or Internet access to ophthalmic educational materials, such as journals, texts, tests, videotapes, and related resources, should be available, along with facilities for lectures and conferences (including audiovisual equipment).

  • A culture of learning and teaching should be established that includes modern facilities, and a committed and dedicated cadre of skilled educators.

  • Periodic audits and assessments of progress of individual trainees should include formal tests (oral or written).

    Examinations developed by Professor Peter Watson and a committee of specialists can be accessed by email at ICO.exam@btinternet.com; these examinations require extensive knowledge in both basic and clinical sciences.

    Review of case logbooks (surgical and non-surgical) should regularly occur at each stage of the training process. The logbook should be used for all laser and surgical procedures and might include preoperative indications, intraoperative complications, and postoperative complications. The logbook is an important educational, clinical, and administrative tool.

  • In addition, it is now considered desirable for supervised surgical training to begin as soon as possible after entry into the ophthalmic educational system. 

    Graduated levels of responsibility should occur, commensurate with a trainee’s education and set of skills.

    Various educational adjuncts should be available, including practice surgery on animal or outdated eye bank eyes, dissections of cadavers, videotapes, and web-based systems of instruction.

    Videotaping surgery performed by trainees is extremely useful, both for the surgeon in training and for the mentor.

    Assisting senior surgeons on a regular basis is a time-honored and helpful educational activity for the trainee.

    In addition to acquiring intraoperative skills, the ophthalmologist in training must acquire abilities for preoperative selection of suitable surgical candidates and in postoperative care.

    Details of surgical training (i.e., minimum requirements) are not included here, because local customs and legal requirements differ throughout the world.

    In some countries, limited standardized training programs are offered for surgical technicians who have been perceived as not fully trained ophthalmologists, but who are necessary for the care of populations having no access to such ophthalmologists.

    Guidelines for logbook requirements and minimum numbers of supervised surgical cases do vary from country to country. Valuable information on these issues can be obtained from: www.rcophth.ac.uk, www.acgme.org, www.ranzco.edu, and www.aao.org.
  • Periodic audits of individual training programs are also suggested.

The ICO Task Force on Resident and Specialist Training

In order to prepare a document having value for widely different nationalities, cultures, medical status, and socioeconomic developments, ophthalmic curricula were initially solicited and evaluated from national and local agencies throughout the world.

Representative documents were received and analyzed from over 30 countries.

Based upon these and related materials, the ICO Task Force on Ophthalmology for Resident and Specialist Training prepared the curricular guidelines and standards for international use.

In draft form, this document was initially reviewed by over 100 representatives of the ICO, the AOI, other transnational and national eye organizations, the American Academy of Ophthalmology, the Association of University Professors of Ophthalmology in the United States, and numerous university departments of ophthalmology throughout the world.

In addition, advice was received from ophthalmic leaders with different subspecialty skills and expertise in Africa, Asia, Australia and New Zealand, Europe, North America, Central America, South America, and the United Kingdom.

This review process took over 18 months to complete.

In addition, the draft document was placed on the website of the ICO for over six months in order to elicit feedback and suggestions before promulgating it in its present (and modifiable) form.

The draft was also presented in person to the Asia-Pacific Ophthalmology meeting in Bangkok, Thailand, 2003, and to the American University Professors of Ophthalmology meeting in Sarasota, Florida, 2003.

Format of the ICO Curriculum for Education of the Ophthalmic Specialist

The ICO curriculum presented here is an outline for three years of supervised ophthalmic training at progressively more advanced levels.

Following medical school graduation plus one year of post-graduate (non-ophthalmic) medical training, the  Basic Level of education corresponds to United States post-graduate year 2 (PGY2). The Standard Level corresponds to United States post-graduate year 3 (PGY3); and the Advanced Level corresponds to United States post-graduate year 4 (PGY4).

We only provide the corresponding levels of training for the United States for clarification purposes and not as a recommendation for duration or length of training which are subject to local custom and regulation.

As noted previously, local, national, or transnational cultural systems will require modification of this duration (and content) of training.

Indeed, in some locations, where clinical needs are urgent and pressing, marked abbreviations of the training program will be necessary in order to provide the region with sufficient numbers of practitioners, both medical and surgical (although at reduced levels of competence in certain areas of knowledge).

For each level within the curriculum presented here, both cognitive skills and technical skills are listed.

There is some planned repetition within the standard and advanced levels, because some areas are complex or important enough to deserve this emphasis.

The following categories of knowledge are included: optics; retinoscopy and refractions; cataract and lens; contact lens; cornea, external disease and refractive surgery; glaucoma; neuro-ophthalmology; ophthalmic histopathology; oculoplastic surgery and orbit; pediatric ophthalmology and strabismus; vitreoretinal disease; uveitis; ocular oncology; low vision rehabilitation; and ophthalmic practice and ethics. 

In some countries, ophthalmic training extends beyond the three-year curriculum offered here, so that exceptional mastery of select subspecialty areas (for example, cornea, retina, glaucoma, etc.) can be achieved. Graduates of such programs are designated by different titles (e.g., "fellows" in North America).

It is not the goal of the attached curricular outline to encompass all the knowledge and skills of such subspeciality areas, but mastery of the advanced level of this curriculum will provide introductory and transitional knowledge and skills leading towards even higher levels of sophistication.

Individuals at these subspecialty levels of training ordinarily should also have accomplished the goals of the attached three-year curricular outline that is offered here. 

A list of references is provided for the curriculum, but new information, which accrues regularly and rapidly, will need to be added to this list by the reader.

Evidence-based medicine, in which therapeutic decisions are based on documented, verifiable and validated information, is appropriately assuming increasing importance as an educational framework upon which individual physicians should make recommendations for their patients.

Whenever possible, those references and sources of knowledge providing such information should receive precedence and preference by both teachers and students of clinical ophthalmology.

Links to the practice of evidence-based medicine can be found at www.aao.org.

Core Competencies and Subcompetencies

In addition to the specialized cognitive and technical skills described in this curriculum, several generic core "competencies" are expected of ophthalmic, as well as other, medical specialists, as promulgated by the United States Accreditation Council for Graduate Medical Education (ACGME). Again, there are worldwide differences in nomenclature for the general competencies and we provide the United States version of these general competencies for all physicians for clarification purposes only. Local customs, practices, resources, and regulatory environments will dictate the application of these competencies for individual programs.The ACGME website is www.acgme.org.

These core competencies include:

  • Patient care.

  • Medical knowledge.

  • Practice-based learning and improvement.

  • Interpersonal and communication skills.

  • Professionalism.

  • Systems-based practice. 

Patient Care

Trainees ("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 are expected to:

  • communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families;

  • gather essential and accurate information about their patients;

  • make informed decisions about diagnostic and therapeutic interventions, based on patient information and preferences, up-to-date scientific evidence, and clinical judgment;

  • develop and carry out patient management plans;

  • counsel and educate patients and their families;

  • use information technology to support patient care decisions and patient education;

  • perform competently the medical and invasive procedures considered essential for the area of practice;

  • provide health care services aimed at preventing health problems or maintaining health;

  • work with health care professionals, including those from other disciplines, to provide patient-focused care. 

Medical Knowledge

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

Residents are expected to:

  • demonstrate an investigatory and analytic thinking approach to clinical situations;

  • know and apply the basic and clinically supportive sciences which are appropriate to ophthalmology.

Practice-based Learning and Improvement

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.

Residents are expected to:

  • analyze practice experience and perform practice-based improvement activities using a systematic methodology;

  • locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems;

  • obtain and use information about their own population of patients and the larger population from which their patients are drawn;

  • apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness;

  • use information technology to manage information, access on-line medical information; and support their own education; and

  • facilitate the learning of students and other health care professionals.

Interpersonal and Communication Skills

Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, patients’ families, and professional associates.

Residents are expected to:

  • create and sustain a therapeutic and ethically sound relationship with patients;

  • use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills; and

  • work effectively with others as a member or leader of a health care team or other professional group.

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Residents are expected to:

  • demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development;

  • demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices; and

  • demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

Systems-based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.

Residents are expected to:

  • understand how their patient care and other professional practices affect other health care professionals, the health care organization and the larger society, and how these elements of the system affect their own practice;

  • know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources;

  • practice cost-effective health care and resource allocation that do not compromise quality of care;

  • advocate for high quality patient care and assist patients in dealing with system complexities; and

  • know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.

Professional attitudes and conduct require that trainees must also have developed a style of care which is:

  • humane (reflecting compassion in providing bad news, if necessary; the management of the visually impaired; and recognition of the impact of visual impairment on the patient and society);

  • reflective  (including recognition of the limits of his/her knowledge, skills and understanding);

  • ethical;

  • integrative (including involvement in an inter-disciplinary team for the eye care of children, the handicapped, the systemically ill, and the elderly); and

  • scientific (including critical appraisal of the scientific literature, evidence-based practice and use of information technology and statistics). 

Basic, Standard, and Advanced Levels of the Curriculum

The suggested curriculum in all chapters is designed to serve as a content outline for a fund of knowledge.

The learning objectives are designed to emphasize recall of information understanding and application of basic sciences (e.g., anatomy, physiology, biochemistry, embryology, pharmacology), application of pathogenetic mechanisms to clinical problems, ordering and interpreting clinical, laboratory, imaging information, development of a differential diagnosis, implementation of a reasonable and appropriate therapeutic medical and/or surgical plan, and anticipation, recognition, and treatment of complications.

This curriculum is not designed to be all-inclusive, and individual programs should modify and apply the content as deemed appropriate to meet local, regional, and national priorities.

It is intended solely as a guideline for the training of ophthalmic specialists.

We recognize that certain specialized and expensive techniques of diagnosis and therapy are not universally available.

All of the goals cannot invariably be achieved, but they should serve as aspirational guidelines towards achieving modern methods of diagnosis and care of common eye problems.

It should be noted that parenthetical listings preceded by "e.g." represent examples only, and do not comprise a complete listing of items in the category.

BASIC LEVEL GOALS: PGY-2

A. Describe the basic principles of optics and refraction.

B. List the indications for and prescribe the most common low vision aids.

C. Perform the basic anterior segment (e.g., basic refraction, basic retinoscopy, slit lamp biomicroscopy) and posterior segment examination skills (e.g., dilated fundus examination, use of magnification and lenses, Hruby lens, 90 Diopter lens, three-mirror Goldmann contact lens) and to understand and use basic ophthalmic instruments (e.g., tonometer, lensometer).

D. Triage and manage ocular emergencies (e.g., central retinal artery occlusion, giant cell arteritis, chemical burn, acute angle closure glaucoma, endophthalmitis, traumatically open globe).

E. Perform minor external and adnexal surgical procedures (e.g., chalazion excision, corneal foreign body removal, use of foreign body corneal drill for removal of a rust ring, conjunctival biopsy, corneal scraping, isolated entropion).

F. Identify the key examination techniques and management of basic and most common medical problems in the subspecialty areas of glaucoma (e.g., primary open angle glaucoma), cornea (e.g., dry eye, microbial keratitis), orbit and oculoplastics (e.g., common lid lesions, ptosis), retina (e.g., macular disorders, retinal detachment, diabetic retinopathy), and neuro-ophthalmology (e.g., optic neuropathy, ocular motor neuropathy, pupillary abnormalities, visual field defects).

G. Describe indications for, performance of, and complications of common anterior segment surgery, (e.g., cataract extraction, trabeculectomy, peripheral iridectomy) and to assist at surgery.

H. Describe the common but serious genetic ocular disorders (e.g., retinal and macular dystrophies).

I. Recognize the most common ophthalmic histopathology findings and recognize basic histopathology of common ocular lesions (e.g., retinal detachment, pterygium, corneal button removed at keratoplasty).

STANDARD LEVEL GOALS: PGY-3

A. Describe the more advanced principles of optics and refraction.

B. List the indications for and uses of more advanced low vision aids.

C. Perform more advanced anterior segment (e.g., more complex refractions, including contact lens and postoperative refractions, intermediate retinoscopy, including moderate astigmatism, examination of young children, intermediate techniques of slit lamp biomicroscopy) and posterior segment examination skills (e.g., more advanced techniques of dilated fundus examination, including scleral depression, use of magnification and lenses to diagram and describe retinal lesions).

D. Recognize and treat ocular emergencies (e.g., central retinal artery occlusion, giant cell arteritis, chemical burn, acute angle closure glaucoma, endophthalmitis, traumatically open globe), as well as the short and long-term complications of these disorders.

E. Perform more advanced external and adnexal surgical procedures (e.g., isolated ectropion and isolated entropion repair, removal of small, localized, and benign lid lesions, pterygium excision).

F. Identify the key examination techniques and management of the less common surgical problems in the subspecialty areas of glaucoma (e.g., secondary open angle and closed angle glaucoma), cornea (e.g., fungal and other less common microbial keratitis, corneal transplantation), ophthalmic plastic surgery (e.g., extensive benign and common lid lesions, ptosis), retina (e.g., primary retinal detachment, mild to moderate proliferative and non-proliferative diabetic retinopathy and laser treatments), and neuro-ophthalmology (e.g., less common optic neuropathy, supranuclear palsies, myasthenia gravis, more complex visual field defects).

G. Perform common anterior segment surgery (e.g., cataract extraction, trabeculectomy, peripheral iridectomy).

H. Recognize, and refer if indicated, some major genetic ocular disorders (e.g., neurofibromatosis I and II, tuberous sclerosis, von Hippel-Lindau disease, retinoblastoma, retinitis pigmentosa, macular dystrophy).

I. Recognize more complex and difficult ophthalmic histopathology findings.

ADVANCED LEVEL GOALS: PGY-4

A. Describe the advanced principles of optics and refraction (e.g., pre- and post-refractive surgery, higher order aberrations).

B. List the indications for and uses of advanced low vision aids.

C. Perform the most advanced anterior segment (e.g., complex refractions, advanced retinoscopy, advanced slit lamp biomicroscopy) and posterior segment examination skills (e.g., drawings of retinal detachments and scleral depressions, interpretation of macular disorders with slit lamp biomicroscopy).

D. Manage or supervise the more junior trainees (e.g., medical students or medical residents) in the management of ocular emergencies (e.g, central retinal artery occlusion, giant cell arteritis, chemical burn, angle closure glaucoma, endophthalmitis).

E. Perform more advanced external and adnexal surgical procedures (e.g., lacrimal gland procedures, complex lid laceration repair, (e.g., canalicular and lacrimal apparatus involvement).

F. Identify the key examination techniques and management of complex but common medical and surgical problems in the subspecialty areas of glaucoma (e.g., complicated or postoperative primary and secondary open and closed angle glaucoma), cornea (e.g., unusual or rare types of microbial keratitis), ophthalmic plastic surgery (e.g., less common and more complex lid lesions, reoperation or complex or recurrent ptosis), retina (e.g., complex retinal detachment, tractional retinal detachments and severe proliferative diabetic retinopathy, proliferative vitreoretinopathy), and neuro-ophthalmology (e.g., unusual optic neuropathy, neuroimaging, supranuclear palsies, uncommon visual field defects).

G. Perform and treat complications of common anterior segment surgery, (e.g., cataract extraction, trabeculectomy, peripheral iridectomy).

H. Recognize, evaluate, and treat, if possible, the major genetic ocular disorders (e.g., neurofibromatosis I and II, tuberous sclerosis, von Hippel-Lindau disease, retinoblastoma, retinitis pigmentosa, macular degenerations).

I. Recognize uncommon or rare but classic ophthalmic histopathology findings.

Trainees at all levels of training should be able to describe the key features and apply in clinical practice the results of evidence-based medicine in ophthalmology, including, but not limited to, the results of the following clinical trials: (see Appendix 1 for full references)


Next: Chapter 2. Optics

Also see: Table of Contents of the Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist

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