OptimEYEzing Emergency Skills: A Novel Model for Ocular Procedural Education for Emergency Medicine Residents

This model for ocular procedural education is designed to instruct emergency medicine residents of all levels of training.

Ocular complaints are a common presentation to the emergency department (ED) with some studies quoting as many as two to three million ocular-related visits annually.1,2 These complaints can range from minor issues, such as corneal abrasions, to more serious conditions that require prompt evaluation and management, such as retrobulbar hematomas. Emergency medicine physicians are often the first-line providers assessing these complaints, so it is imperative that they feel adept in recognizing and managing these complaints.2Despite the frequency of ocular-related visits, ophthalmologic training among emergency medicine residents is often limited. Studies have reported that residents receive less than ten hours of formal ophthalmology training throughout their residency.2,3 One study revealed that many emergency medicine physicians in the United States are not confident in using basic ophthalmic tools, conducting eye exams, diagnosing ophthalmic complaints, or performing vision-saving procedures.2 This lack of formal training makes it difficult for residents to confidently diagnose and manage ocular conditions in the emergency department, both during residency and in their future practice. On review of the literature, there have been developments of procedural models for the practice of ophthalmology skills including removal of corneal foreign bodies utilizing swine eyes, tonometry using water balloons, and lateral canthotomy using a cadaver eye.4.5 However, cadavers can be very difficult to obtain, and expensive and swine eyes are not reusable or easy to store.There is a need for cost-effective, hands-on, ocular training models to help bridge this learning gap and increase residents' comfort with common ocular complaints and procedures - including foreign body removal, lateral canthotomy, fluorescein staining, and intraocular pressure (IOP) measurements. Integrating hands-on ocular training models into medical education can ultimately lead to better patient outcomes.

By the end of this session, learners will be able to: 1) identify signs and symptoms of ocular emergencies, 2) appraise for indications to perform ocular procedures, 3) demonstrate procedural competence in ocular foreign body removal, fluorescein staining, lateral canthotomy, and intraocular pressure (IOP) measurements, 4) relate increased procedural confidence with ocular procedures.

We developed two gelatin-based eye models that are low-cost and can be easily replicated. The first was created with Knox^® gelatin which can be easily made at home. The second was made with Humimic Medical™ synthetic gelatin which can be easily melted down and re-used. The gelatin base mimics the eye and allows for practice of foreign body removal techniques. Different concentrations of gelatin can be used to simulate different IOPs to practice IOP measurement. Fluorescein stain can be applied to the gelatin models to mimic corneal abrasions/ulcerations with use of a Woods lamp. Finally, the gelatin eye models can be placed into an existing 3D printed face model for lateral canthotomy procedural practice, utilizing rubber bands as the ligaments.6 Our institution provides access to a 3D printer for both students and faculty. The average total time to create all material for this ocular session was about 20 hours, though many elements of this model can be utilized multiple times. Utilizing low-cost material, the total cost of one reusable model is about 30 United States Dollars (USD).

Twenty-one residents, ranging from their first year of training to their third year of training, participated in the session. A pre-survey was administered to all participants (supplemental materials). The pre-survey was broken down into each ocular procedure listed above, and the participants were asked if 1) they had ever performed the procedure, 2) if they had ever consulted ophthalmology for assistance with the procedure, and 3) to rate their comfort level with the procedure using a Likert scale (1=not at all comfortable to 5=very comfortable). After completion of the session, a post-survey (supplemental materials) was administered to participants, again broken down by each ocular procedure, asking 1) to rate their comfort level with the procedure using the same Likert scale and 2) if they would plan to consult ophthalmology for assistance with the procedure in the future.Variables were summarized using percentages and frequencies for categorical variables, and means and ranges for continuous variables were presented. Using an α-value of 0.05, a T-test for independent samples was performed to determine if a difference between comfort levels before and after each activity exists.

Twenty-one participants took part in the learning session; all participants were emergency medicine residents, ranging from post-graduate year (PGY)1s to PGY-3s. Of the participants, 100% had performed fluorescein staining, 24% had performed ocular foreign body removal, 95% had performed IOP measurements utilizing a Tono-Pen,^® and 14% had performed a lateral canthotomy (all in conjunction with ophthalmology) prior to this activity. There was a statistically significant increase in self-reported comfort level with each of these procedures after the activity: for fluorescein staining, comfort level increased from 4.1 to 4.6 (p-value 0.04); for ocular foreign body removal, comfort level increased from 2.3 to 3.9 (p-value <0.01); for IOP measurements utilizing a Tono-Pen,^® comfort level increased from 4.1 to 4.8 (p-value 0.01); for lateral canthotomy, comfort level increased from 1.7 to 3.5 (p-value <0.01). Please see Table 3 for details. Resident comments included: "Great simulations," "Helpful, want slit lamp," "Amazing!" and "Great sims!"

Feedback from residents was favorable, and their comfort level with each of these ocular procedures improved after the activity. We believe this tool can offer simulation of these procedures at a relatively low cost with reusable materials to improve both comfort level and procedural competence in emergency medicine residents.

Ocular procedures, lateral canthotomy, Tono-Pen,^® IOP measurement, ocular foreign body removal, fluorescein staining, Wood's lamp.