Integration of Massive Open Online Course (MOOC) in Ophthalmic Skills Training for Medical Students: Outcomes and Perspectives : The Asia-Pacific Journal of Ophthalmology

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Original Study

Integration of Massive Open Online Course (MOOC) in Ophthalmic Skills Training for Medical Students: Outcomes and Perspectives

Huang, Zijing MD, PhD; Yang, Jianling MD; Wang, Hongxi MD; Chen, Binyao MD; Zheng, Dezhi MD; Chen, Haoyu MD, PhD

Author Information
Asia-Pacific Journal of Ophthalmology 11(6):p 543-548, November/December 2022. | DOI: 10.1097/APO.0000000000000548



Ophthalmology plays an important part in modern clinical medicine.1 However, ophthalmic education for medical students is facing difficulties in rigid teaching methods and limited time allocated.2 How to improve the transmission efficiency of knowledge and results of learning becomes the focuses of education sector.

In recent years, massive open online course (MOOC), an online course aimed at large-scale participation and free access via the internet, has emerged as a novel teaching pattern and earned its rapid popularity in all fields of education, including public health and medical care.3–6 Currently, MOOC is divided into connectivism-based “Connectivist” MOOC (cMOOC) and behaviorism-based “eXtended” MOOC (xMOOC). The cMOOC, based on the theory of connectivism, focuses on the construction and creation of knowledge and an open learning environment through resource sharing and interactive expansion, while xMOOC puts more emphasis on the copying and transfer of knowledge through videos and testing, which is closer to a traditional behaviorist model.7 In an age of digital learning, MOOC enables students to have an immersive experience and full engagement in the learning process, thus improving the efficiency of online teaching and gaining increasing popularity among young learners.8 Especially during the COVID-19 pandemic, MOOC offers a safe and effective way of providing training to large numbers of people and allows them to communicate and learn from each other.9

However, some people hold a wait-and-see attitude to the worth of MOOC. They argue that MOOC fails to provide direct contact between students, supervisors, and patients, and would be unable to replace more than a subset of didactic courses.10 In addition, although pilot studies suggest that MOOC was successful in engaging participants, delivering higher teaching satisfaction and easier understanding of concepts where relevant, whether they improve practical skills is uncertain.10

In this study, we integrated a MOOC with conventional clinical ophthalmic skill teaching and used a standardized assessment form-based grading system to semiquantify the impact of MOOC on promoting medical students’ skills, as well as the students’ perspective on MOOC.


Subjects and Study Design

This study followed the tenets of the Declaration of Helsinki and was approved by a local Research Ethics Committee in Joint Shantou International Eye Center (JSIEC) of Shantou University and The Chinese University of Hong Kong. All participants provided written informed consent.

This prospective and comparative study aimed to integrate MOOC into clinical ophthalmology teaching so as to achieve competency in the basic ocular examination. The flow chart of the study is demonstrated in Figure 1. Undergraduate medical students in year 4 of their 5-year curriculum of the ophthalmology course in JSIEC between October 2021 and December 2021 were recruited. All the students had attended didactic lectures on basic clinical ophthalmology before participation in this study, which covered external eye diseases, conjunctival and corneal disorders, cataracts, uveitis, and fundus diseases. A total of 76 medical students were enrolled. Students were arranged as the slitlamp microscopy MOOC (SLMM) group (n=39) and the visual acuity test MOOC (VATM) group (n=37) according to their student ID number before the study.

Flowchart of the study. MOOC indicates massive open online course; SLMM, slitlamp microscopy MOOC; VATM, visual acuity test MOOC.

Students in the SLMM group were asked to follow a MOOC for slitlamp microscope examination through computers or smartphones a couple of days before the clinical teaching but used textbook for preview of visual acuity test. Whereas those in the VATM group were required to take a MOOC for visual acuity test and previewed slitlamp microscopy using textbook. Students from both groups acted as controls for the respective group (Fig. 1).

The ophthalmology MOOC was designed and created by our teaching team from the JSIEC of Shantou University, which contained 15 modules and 31 sessions covering all basic and practical skills in ophthalmology, and was delivered online and accessible to all for free.11 The slitlamp microscopy and visual acuity test sessions were both around 10 minutes in length. According to the MOOC theory, our MOOC was considered an xMOOC, of which the prerecorded video lectures were based on traditional university courses, delivered by an instructor to the students, and appended with quizzes and tests.

The sample size was calculated using an unpaired 2-sample t test. The power (1−β) was set as 0.80 and α as 0.05. According to our preliminary data, the pooled SD (σ) for scoring methods was determined as 1.2. The least significant difference (δ) was set as 0.5. Q1=Q2=1. The sample size was calculated as: total n=[(Zα/2+Zβ)·σ/δ]2·(Q1−1+Q2−1)=71. According to this calculation, 76 participants in this study were deemed sufficient to obtain statistically significant results.

Slitlamp Microscopy Training and Evaluation

All participants were taught on a slitlamp microscope (BQ 900; Haag-Streit, Switzerland) connected to a digital camera system following standard teaching procedures by the tutors blinded to the grouping information. The slitlamp teaching session was 45 minutes in both groups, which included 20-minute demonstration of preparations, slitlamp examination techniques, and examination of the external eye, cornea, anterior chamber, lens, and anterior vitreous. Fundus examination was not included in this session. Then students spent 15 minutes practicing slitlamp examination. In the last 10 minutes of the teaching session, students were asked to perform a complete examination with the slitlamp, evaluated by the tutors blinded to the grouping information, using a nonvalidated assessment form developed from the Direct Observation of Procedural Skills (DOPS) Paper Form. The score was based on a numerical scale from 0 to 9 (0=worst and 9=best) for each examination procedure, including preparation and examinations of eyelid, conjunctiva, cornea, anterior chamber, iris, and lens.

Visual Acuity Test Training and Evaluation

All the students were taught visual acuity test by the tutors, who were blinded to the grouping information, using the Snellen eye chart with standard procedures (Supplemental Digital Content 1, The visual acuity test teaching session was 45 minutes in both groups, which included 20-minute demonstration of preparations, standard test procedures, and other points for attention. The students then practiced the visual acuity test for 15 minutes. In the final 10 minutes of the session, they were asked to perform a complete visual acuity test, evaluated by the tutor blinded to the grouping information, using a nonvalidated assessment form developed based on the DOPS. The score was based on a numerical scale from 0 to 9 (0=worst and 9=best): preparation, closely covering the fellow eye, adjustment for examination distance, proper length of exposure of the test object, checking corrected visual acuity, simulated test for counting fingers, hand motion and light perception, and results recording.


After finishing the evaluations, all the students in this study were asked to complete all the MOOC sessions and finish a questionnaire on their overall learning experience and comments about the MOOC. The questionnaire comprises 5 items: “The MOOC enhanced my learning outcomes in clinical ophthalmic skills”; “The MOOC boosted my interest and motivation in learning clinical ophthalmology”; “The MOOC was a useful tool additional to current clinical ophthalmology training”; “I preferred to learn ophthalmology in the MOOC format and for it to replace the traditional lectures and tutorials”; and “I would recommend the MOOC to my fellows and friends.” The questionnaire graded satisfaction on a numerical scale from 1 as the most unsatisfactory to 5 as the most satisfactory (Fig. 1).

Statistical Analysis

Data are presented as mean±SD and were analyzed using SPSS for Windows version 19.0 (SPSS Inc, Chicago, IL). The data used for analysis (eg, scoring of the DOPS assessment and questionnaires) were ranked and non-normal distributed. Therefore, nonparametric Mann-Whitney U test was used to compare the means between the 2 groups. χ2 test was used to compare the proportion between the 2 groups. P values of <0.05 were considered statistically significant.


A total of 76 students were included in this study, of which 31 (40.8%) were males and 45 (59.2%) were females. The average age of all subjects was 20.95±0.67 years old. The number of students was 39 in the SLMM group and 37 in the VATM group. No significant difference was found in gender (χ2=0.081, P=0.776) or age (20.92±0.70 vs 20.97±0.64, P=0.748) between the 2 groups.

Slitlamp Microscope Examination

Students in the SLMM group got overall higher scores than those in the VATM group (47.64±4.01 vs 44.68±5.99, P=0.013) in the slitlamp microscope examination (Supplemental Digital Content 1, Of note, the SLMM group attained significantly higher scores on the procedures of preparations (P=0.003) and examination of the eyelid (P=0.039) and cornea (P=0.009), compared with the VATM group. On examination of the conjunctiva, anterior chamber, iris, and lens, although the students in the SLMM group also gained higher average scores, no significant difference was found between the 2 groups (P>0.05) (Table 1).

TABLE 1 - Average Scores of Each Item in the Examination of Slitlamp Microscopy
Preparations* Eyelid Conjunctiva Cornea Anterior Chamber Iris Lens Total
SLMM group 6.92±1.13 7.44±0.85 7.18±1.07 6.97±0.90 6.77±1.06 6.44±0.91 5.92±0.93 47.64±4.01
VATM group 6.14±1.03 6.97±1.01 6.73±1.12 6.32±1.08 6.38±1.21 6.30±1.13 5.84±1.17 44.68±5.99
P value 0.003 0.039 0.066 0.009 0.152 0.490 0.662 0.013
SLMM indicates slitlamp microscopy MOOC (massive open online course); VATM, visual acuity test MOOC.
*Preparations include a brief explanation about the test, an adjustment for seat and height of working table, and alcohol-based disinfection of the device.
Nonparametric Mann-Whitney U test. P values of <0.05 were considered statistically significant.

Visual Acuity Test

Students in the VATM group achieved higher scores than those in the SLMM group (46.45±4.90 vs 43.78±4.94, P=0.040) in the visual acuity test. Specifically, they performed better in the preparations (P=0.008), showing the test object properly (P=0.003), and examination of counting fingers, hand motion, and light perception (P=0.037). The MOOC on VATM did not bring a marked improvement on other procedures such as adjustment of examination distance, checking corrected visual acuity, and results recording (P>0.05) (Table 2).

TABLE 2 - Average Scores of Each Item in the Examination of Visual Acuity
Preparations* Closely Covering the Fellow Eye Correct Examination Distance Proper Length of Exposure of the Test Objects Checking Corrected Visual Acuity Simulated Examination for Counting Fingers, Hand Motion and Light Perception Results Recording Total
SLMM group 6.27±0.99 6.82±1.32 6.23±1.18 5.64±1.50 6.82±1.21 5.13±1.54 6.87±1.03 43.78±4.94
VATM group 6.86±0.75 6.62±1.42 6.51±1.19 6.70±1.29 6.92±1.32 5.97±1.36 6.86±0.97 46.45±4.90
P Value 0.008 0.507 0.352 0.003 0.817 0.037 0.940 0.040
SLMM indicates slitlamp microscopy MOOC (massive open online course); VATM, visual acuity test MOOC.
*Preparations include a brief explanation about the test, an adjustment for seat and visual acuity chart illumination.
Nonparametric Mann-Whitney U test. P values of <0.05 were considered statistically significant.


All 76 students provided valid answers to the questionnaires. Most of the participants agreed that the MOOC could enhance their interests and motivation (4.13 of 5 points) and outcomes (4.01 of 5 points) in learning clinical ophthalmology. They also believed that the MOOC was a useful tool in additional to current traditional training (4.34 of 5 points). However, students gave relatively low scores (2.92 of 5 points) regarding to whether the current ophthalmology curriculum could be replaced with MOOC. Of note, 26 (34.2%) of students scored 2 points or lower for this question, indicating that they did not prefer to replace the traditional lectures and tutorials with MOOC. Finally, students scored 3.79 of 5 points for recommending the MOOC to others (Fig. 2).

A 5-item questionnaire for learning experience and comments with the ophthalmology MOOC. The scoring results was shown in the right panel, presented as mean±SD. MOOC indicates massive open online course.


Clinical skill training for medical undergraduates remains a challenging work.12,13 It is of great importance to optimize teaching patterns to boost learning interests and motivation, thus improving the outcomes and efficiency.14 In this study, we integrated MOOC-based e-learning into conventional ophthalmic skill training. The results showed that the students who had taken MOOC obtained overall higher scores in the corresponding skills compared to those taken textbook as a preview (47.64±4.01 vs 44.68±5.99, P=0.013 for slitlamp microscopy and 46.45±4.90 vs 43.78±4.94, P=0.004 for visual acuity test). The students agreed that MOOC increased learning interests (4.13 of 5 points) and motivation (4.01 of 5 points) but was more preferred as an additional tool to traditional teaching methods (4.34 of 5 points) rather than to replace them (2.92 of 5 points). They would like to recommend MOOC (3.75 of 5 points).

In recent years, MOOC has been developed and implemented for theoretical and practical skill training of undergraduate and postgraduate in broad aspects of medical education, including spinal cord injury,15,16 kidney transplant,17 radiology,18 cancer diagnosis,19 nursing education,20 antimicrobial stewardship,21 and others. These previous studies support that the MOOC was relevant and valuable in improving learning satisfaction, motivation and active learning, and interpersonal interaction.22 However, the hype surrounding MOOC is somewhat subsiding due to some of its inherent weakness. One major concern is that MOOC fails to provide face-to-face instruction between students and tutors in clinical settings, which is essential to the curriculum.9 The questionnaire results of our study support this argument. Despite its popularity and superiority, a significant number of participants would not prefer replacing traditional lectures and tutorials with MOOC. Therefore, a kind of blended learning that organically integrated face-to-face problem solving and video-based learning has emerged and gained increasing popularity, especially for niche subjects that have a short duration in the medical curriculum. Randomized controlled trial of blended learning showed that in-class problem instruction improved exam performance while video assignments increased attendance and satisfaction,23 suggesting a more effective teaching strategy in clinical medical education. We believe that MOOC should be integrated with the blended learning package.

In this study, students in the SLMM group attained higher scores in the slitlamp examination, particularly in the preparation and the examination of cornea and eyelid. On the other hand, participants in the VATM group performed better in the visual acuity test, particularly in examination of counting fingers, hand motion, and light perception, as compared with non-MOOC controls. These data implicated that MOOC, in a vivid video format, enables a standardized and comprehensive instruction to detailed procedures and relevant cautions, thus deepening students’ impression and understanding of ophthalmic practical skills. On the other hand, it was noted that students in the SLMM group were no better than the others on examination of specific ocular tissues with the slitlamp, such as the anterior chamber and lens. This may be because examining the tissues in a deep position has a highly technical requirement for undergraduate students, whereas the MOOC could not promote the real practice. Nevertheless, MOOC-based e-learning enhanced overall outcomes in promoting slitlamp and visual acuity test skills.

In recent years, more millennials and generation Z are entering medical colleges and institutions. There is a need for the rapid development and maturation of digital technologies to support these digital learners.24 Among them, artificial intelligence has the potential to reform clinical practice and is recommended to be incorporated into medical curriculum.25 Free online learning materials such as MOOC and open educational resources are of popularity with young people and undergoing further development to significantly impact clinical education.26 In an age of digital learning, MOOC and open educational resources complement, rather than replace, the set of learning resources available to digital learners and students.27 Other digital innovations in clinical ophthalmic training include slitlamp microscope connected with a digital camera display system28 and wireless smartphone,29 which is shown to enhance learning outcomes. The development of novel ophthalmic instruments is also important. We recently created an eye model to objectively evaluate the competency of ophthalmoscopy, which achieved certain effects in undergraduate students.30 These novel teaching strategies bring fresh vitality to medical education and are worth trying and popularizing.

This study has several limitations. First, the grouping was based on student ID number, which was nonrandomized and increased the selection bias. Besides, the assessment and grading of slitlamp and visual acuity test was performed by 3 independent tutors, which was subjective although standardized assessment forms were used. The third limitation is that only 2 outcomes were measured to evaluate the impact of MOOC on clinical skills. Last but not least, due to time constraints, only 15 minutes of practice were allowed for the slitlamp and visual acuity testing, which was a fairly short time for a student to practically learn a new skill, and that posterior segment examination was not taught as part of this curriculum. Further randomized control studies with a larger number of participants in different grades and comprehensive assessment on broader aspects of clinical skills are needed to validate the value of MOOC in clinical ophthalmic teaching.

In summary, we integrated MOOC-based e-learning into conventional ophthalmic skill teaching in undergraduate students and achieved overall, which enhanced learning satisfaction and promoted clinical skill acquisition. The MOOC is worth advocating as an additional tool for clinical ophthalmic skill training.


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undergraduate education; ophthalmology; massive open online courses; slitlamp examination; visual acuity test

Supplemental Digital Content

Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.