India is home to a quarter of the world’s blind population. In India, more than 51% of blindness is attributed to cataract, with total number of blind due to cataract estimated to increase to 8.25 million by 2020. Over the last several decades, the Government of India has taken robust steps in combating this disease, with India being the first country to adopt the National Prevention of Control of Blindness (NPCB) and has formulated actionable plans to increase cataract surgical rates (CSR) and reduce the prevailing blindness. The proposed national CSR of 3000 by 2020 has been comfortably achieved, with most large states performing more than 4000 cataract surgeries per million population. This has been a multilayered plan, which has involved understanding the situation, acquiring data, setting up infrastructure, delivering eye care, and following up patients. The core to this entire process is having well-trained ophthalmologists who are confident in performing independent, high-quality cataract surgery and are able to deliver consistent results in terms of good visual acuity with minimal complications.
Challenges in ophthalmic residency training have been highlighted not only in India, but also in other neighboring countries of Sri Lanka and Pakistan as well. While the western residency programs have moved towards ‘appraisal based approach’, the countries of Asian subcontinent still follow the traditional apprenticeship model. Also, lack of integration of International Council of Ophthalmology (ICO) curriculums and core competencies described by Accreditation Council for Graduate Medical Education (ACGME) in South Asian programs, has called for education reforms, especially in India. Most of the residency programs focus on basic cataract surgery, which includes Extra Capsular Cataract Surgery (ECCE), and Manual Small Incision Cataract Surgery (MSICS), and the All India Ophthalmic Society (AIOS) is working towards streamlining residency curriculums. Very few offer phacoemulsification training, and even if they do, it is usually inadequate for the resident to perform independent phacoemulsification once the residency program finishes.
To bridge this gap, Alcon (Alcon Inc. headquarters in Geneva, Switzerland), introduced the Phaco Development Program (PDP) in 2010, which is a unique collaborative initiative between Alcon and various teaching ophthalmic institutes across India. Its aim is to support ophthalmologists in their endeavor to enhance their surgical skills, in dealing nuances of phacoemulsification surgery and to establish phacoemulsification as the standard cataract care procedure across the country.
In this paper, we reviewed the training methodology applied, the number of ophthalmologists trained by this initiative since 2010 and the number of surgeries performed by them following their training. This will help to better assess the role of the PDP program in creating sufficient, successful, and sustainable cataract services across the country as well as pave the way forward.
Alcon Initiative and program details
In 2010, Alcon (Alcon Inc. headquarters in Geneva, Switzerland), started the Phaco Development Program (PDP) as a unique collaborative initiative between Alcon and various tertiary eye care institutes all across India.
Tertiary Eye Care Institutes were identified all over India and contacted. These institutes were ophthalmic Centers of Excellence and some of them were already been involved in various training programs. The host hospitals called as Phaco Development Centre of Excellence (PD-CoE) supported the participants for wet laboratory facilities as well as hands-on surgical training on patients on their premises. While identifying the PD-CoE, mutual discussion between hospital authorities and the Alcon team was done to understand hospital resources, wet laboratory, surgical trainers, and patient availability for the program. A Memorandum of Understanding (MOU) was signed between Alcon and the institute for 2 week PD training course. Alcon contributed in providing the support team, surgical equipments in wet lab and consumables for the learning.
Alcon designated one technical person who supported the participant at the PD-CoE throughout the period of the program. This technical support person was trained by Alcon for the specific requirements of this program and was referred to as Phaco Development Specialist (PDS). The PDSs were from various backgrounds like optometry, biomedical engineering, and ophthalmic para-medical staff. Once they enrolled as PDS, he/she underwent exhaustive training and mentoring in phacodynamics, phacoemulsification surgical techniques, and phacoemulsification machine understanding, followed by regular assessment of their knowledge and skill. Alcon-PDP Medical Director, Program Director, and Country Training Manager were involved in assessing the PDS before they were deemed competent to support the participating surgeons during and after PDP. The role of PDS is crucial to the success of this program. The PDS starts visiting the training institutes even before the start of the training program at that particular PD-CoE. They are also involved in a lot of background work where they build relationship with the PD-CoE, spend time at the facility checking equipment, and ensuring smooth conduction of the program. The PDS is also the first point of contact for the participant, where they start communications before the program starts and understand participant requirement from the program. This helped the PDS and trainers at the CoE to better tailor the program to each individual participant. Educational material, both written and video-based, were shared with the participants. In order to facilitate the surgical progress of the participant, the participants were provided with a logbook to enter case details as well as postoperative outcomes.
The two-week program schedule is depicted in Supplementary Table 1. The participants had access to goat eyes in the wet laboratory every day and were assisted by the PDS in using the phacoemulsification machine. Supervised phacoemulsification steps were practiced on goat`s eye in the wet lab and surgeries in the operating room (OR) with constant guidance from the trainers at the CoE. In the OR, the participants were given surgeries in a stepwise manner. They started with incision, followed by anterior continuous curvilinear capsulorhexis (ACCC), and subsequently progressed along in a stepwise manner. Although Supplementary Table 1 mentions the proposed schedule in which the surgeons were given surgical steps, individual adjustments were made based on participant comfort level as well as trainers’ discretion. The participants were allowed to perform a complete phacoemulsification case by day 7 of the program, although this could be variable on a case-to-case basis. Along with this, there were arrangements made for the participant to spend time with the training faculty and have case-based discussions, didactic lectures and video-assisted teaching; this ensured a more holistic learning experience for the participant.
Participating Institutes and candidate selection
The PDP is being conducted at 10 different host institutes or PD-CoE all over India over the last 10 years. Three out of these ten hospitals use PDP to train their in-house trainees (post-graduate residents, long-term fellows) and do not host short-term external candidates. These three hospitals were not included in this paper. The remaining seven hospitals accept applications from out of hospital candidates for the two-week program. The program was advertised via ophthalmic discussion portals, and by word-of-mouth. The seven participating hospitals were-
- Dr. Shroff’s Charity Eye Hospital, New Delhi
- I CARE Eye Hospital, Noida, Uttar Pradesh
- Susrut Eye Foundation and Research Center, Kolkata
- Shri Sadguru Seva Sangh Trust, Chitrakoot
- Chandraprabha Eye Hospital, Jorhat
- Comtrust Charitable Hospital, Calicut
- Dr. Thakorbhai V. Patel Eye Institute, Baroda.
Participant selection was flexible and dependent on availability of training slots. Participants were selected as per their surgical skill development need after mutual discussion between the participant and Alcon PDS using the International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR) score, following which PD CoE faculty reviewed their surgical video along with OSCAR score & finalized the candidates. The selection criteria were flexible in terms of candidate’s age and years of practice; however, there were few minimum criteria that were expected from the participants- being a practicing cataract surgeon, being willing to incorporate phacoemulsification surgery as the primary modality of cataract care in his/her practice, and to have access to infrastructure that supports phacoemulsification surgery.
Before starting the course, there were extensive discussions between the PDS and the participant highlighting the surgeon’s need and surgical areas of improvement.
Participants were expected to fill out self-evaluation forms developed by the Alcon PDP team before the start of the program. Also, all participants were asked to share their cataract surgery videos with the host institute before start of the program facilitated by Alcon PDS.
One PDS was assigned to the participant for the entire duration of two weeks. Not only did the PDS act as a bridge between the participant and the host CoE, he also helped the candidate with daily wet laboratory sessions, understanding phacoemulsification equipment, facilitating faculty lectures and faculty training during surgeries. After course completion, the same PDS supported the participant in his/her practice for a period of at least 12 months.
PD Course curriculum
The PD course emphasized on mastering the basic steps of phacoemulsification. Participants were first trained in patient selection and biometry. All patients undergoing cataract surgery signed an informed surgical consent prior to the surgery. The surgery was registered under a designated faculty’s name, who was the training surgeon. Exemption was sought from one of the participating Institute’s Review Board (IRB) and the study was conducted in adherence to tenets of the Declaration of Helsinki. Trained and designated faculty at respective CoE supervised all surgeries. The participants started with uncomplicated cataract cases or basic steps of cataract surgery initially and graduated to performing the entire surgery towards the end of their course. Some participants would get an opportunity to operate even on a few challenging cases depending upon their skill level.
Every surgery was scored at the end by the training faculty using International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR) in discussion with the participant. Post-operative rounds and surgical video discussion were an integral part of this training. The faculty delivered didactic lectures on relevant topics as and when possible. Case details and post operative findings were filled in a logbook at the end of every day.
Dedicated time was also spent in the wet-laboratory practicing steps of phacoemulsification on enucleated goat eyes under PDS’s supervision. Nuances of the phacoemulsification machine, fluidics, and phacodynamics were discussed regularly. Participants also got a chance to practice anterior vitrectomy, use of iris hooks, and capsular tension rings depending upon their need and expertise.
Post-program, the progress of each participant was followed by the PDS who was assigned to that participant during the two weeks. The PDS followed up the participant for a minimum of 1 year, initially by visiting their facility 2 times every month for the first three months, then every month for next 3 months, then 3 monthly for the following 6 months. In case the PDS could not travel to the participant’s facility in person, telephonic updates were received and next possible visit was scheduled. All the surgical details were discussed in these visits. Continuous support was provided to the participants during the entire year including support in understanding & application of technology, phacodynamics & parameters for different cataract cases, biometry, and overall development of the participants practice. If required, with the help of the PDS, the guidance of the training faculty at the CoE was also taken for any particular difficulty that the participant surgeons faced during their phacoemulsification procedures.
Study design, data collection, and statistical analysis
The surgical data of the participants enrolled between June 2010 to August 2018 was shared by the participant doctors with the Alcon Phaco Development Specialist and was retrospectively analyzed. All participants were followed up for a minimum of one year. Participants’ demographics, type of institute and phacoemulsification surgeries performed by them till August 2019 was noted. Statistical analysis was carried out using SPSS statistical software (SPSS version 21. Inc., Chicago, IL, USA). Statistical significance was defined at a level of 5% (P < 0.05).
A total of 989 Indian Ophthalmologists from 27 Indian states and 4 Union Territories were trained at the 7 training institutes over a period of eight years (June 2010 till August 2018). Maximum number of participants were from the states of Uttar Pradesh (148) and West Bengal (130). Fig. 1a shows the geographic location of various training institutes (PDCoE) and Fig. 1b shows number of participants enrolled from each state. The mean age of the participants was 40.6 years (+ 8.2 years, standard deviation (SD)) and 641 (64.8%) were males. More than half of (501 surgeons, 50.66%) the participants who were trained were individual practitioners, working independently. Rest of the participants came either from Government Hospitals (GH), Non-Government Organizations (NGO) or from Private Eye Hospitals (PEH). All participants were followed up for a mean duration of 4.3 years (SD of 2.4 years) after the course finished. A total of 1,022,508 phacoemulsification surgeries were performed by these participants, after finishing their PDP, all over the country over a period of 9 years and 2 months. Fig. 2a shows total number of phacoemulsification surgeries performed year on year by the participants till August 2019 and Fig. 2b shows the indirect contribution of different centers in the number of surgeries performed by their trainees. Table 1 shows the baseline characteristics of participants enrolled in seven training centers over the last eight years and 2 months.
On following up the participants, it was noted that 92.11% and 88.77% of the surgeons were performing phacoemulsification at the end of 1 year and at final follow-up, respectively, in their practice. Out of 518 participants in the age group of 31 to 40 years, 480 (92.66%) were performing phacoemulsification at end of 1 year (P = 0.8), and 464 (89.58%) were performing phacoemulsification at the final follow-up (P = 0.08), constituting the highest number in this group. Also, 94.23% of doctors working with NGOs were found to be performing phacoemulsification at the final follow-up, which was the highest, compared to their counterparts working in GH, PEH or as individual practitioners. In comparison, 84.69% doctors working in Private Eye Hospitals were performing phacoemulsification at final follow-up (P = 0.03) [Table 2].
Comparisons were also made after grouping participants as those performing only manual small incision cataract surgery (MSICS), performing <30% phacoemulsification, performing 30%-50% phacoemulsification, performing 50%- 70% phacoemulsification, Performing >70% phacoemulsification at the time of enrollment. Out of the 551 doctors only performing MSICS (and no phacoemulsification) before the PDP, 501 (90.93%) doctors were performing phacoemulsification at the end of one year and 446 (86.39%) were performing phacoemulsification at final follow-up [Table 3].
The Indian medical education system requires approximately ten years to produce a specialist. With the minimum age to start medical school being 17 years, the average age of an ophthalmologist finishing residency has been noted to be 32 years. However, it takes a few additional years of supervised clinics and surgeries that make an ophthalmologist confident to manage and operate on patients independently. Out of the 1285 annual ophthalmology residency seats on offer, and roughly 900 ophthalmologists being trained every year, residency training varies considerably from program to program. Uneven nature of training, lack of standardized curriculum and variable quality of academic programs have all been earlier documented and discussed. Although efforts are being made to standardize residency programs across the country, those reforms will take time. Currently, there are residency programs where residents perform no more than 30 phacoemulsification, as compared to an average of 324 phacoemulsification performed by their Canadian counterparts. Other studies have reported nearly 50% of trainees not getting any chance to perform phacoemulsification surgery, neither under supervision nor independently.
It is not possible for every graduating ophthalmologist to commit to a long-term fellowship at a modest stipend due to several underlying reasons. The magnitude of this problem can be understood by the fact that cataract surgery complications are now reported to be the third most common cause of blindness in Indians above 50 years of age, accounting for 7.2% of blindness. Therefore, there clearly is a huge unmet need for standardized and monitored training for ophthalmic surgeons.
The Phaco Development Program was started for ophthalmologists to upgrade their surgical skills in a safe and monitored environment. Most of the trainees were in the 31-40 years age group (52.38%). This was expected, as this program is most popular amongst mid-career ophthalmologists wanting to learn or sharpen their skills of phacoemulsification. This is most favorable as these doctors still have many years to perform good quality cataract surgeries in their practice, and in a way contribute to country’s cataract surgical rate. Only a small proportion of our participants were above the age of 60 years (2.43%). At final follow-up, there was no statistical difference between participants of different age groups performing phacoemulsification, with the lowest understandably being performed in the above 60 years age group (79.17%).
A very efficient by-product of our two-week program was the cumulative number of surgeries performed by doctors trained by this initiative. A combined 1,022,508 phacoemulsification surgeries were performed all over India over the last 9 years and 2 months, This re-iterates the idea that training and service go hand in hand. We would also like to highlight that at the time of joining the program, 551 doctors (55.7%) were not performing any phacoemulsification at all. For the training institutes, having got the opportunity to be involved in their training and to note that 88.78% of them were performing phacoemulsification at final follow-up was very gratifying. To the best of our knowledge, this is the largest series of ophthalmologists trained within a single program with longest follow-up.
Applicants enrolled in the Phaco Development Program from all over the country. This shows that they were motivated to learn and were willing to take a break from their work and travel for 2 weeks to upgrade their skill and knowledge.
The decrease in the percentage of phacoemulsification surgeries being performed at final follow-up as compared to 1 year follow-up was the least among surgeons working in NGOs as compared to their counterparts working in GH, PEH or as individual practitioners. This could be because the number of surgeries performed at NGOs is usually high and at a subsidized rate, giving the surgeon an opportunity to keep performing phacoemulsification. On the other hand, the Private Eye Hospitals usually work on a ‘fee-for-service’ model, where the patients pay for the surgery. In models such as these, the doctors may not, sometimes, get a chance to operate as per their will. Hence, it is important to ensure thatthe doctor has an arrangement, in terms of patients and support of the hospital management where he/she can continue performing phacoemulsification even after the training is over.
Most of the young ophthalmologists are focused on securing a long-term sub specialty fellowship at premier institutes. But with limited training opportunities, much larger number of applicants, and several limitations that may prevent surgeons from opting for a long-term fellowship, we feel that there is definitely a larger role for more short-term training courses. This way, more number of ophthalmologists can be trained, and focus could shift towards mid-career ophthalmologists wanting to enhance their basic skills and becoming good comprehensive ophthalmologists. Such short-term yet monitored courses would add immense value in a country like ours, where resources and good opportunities are often missing. This paper also brings to focus the lack of opportunity, which exists in our system for skill up gradation for practicing ophthalmologists. The PDP has in a way set up a role model for similar courses should in other subspecialties, which could provide support and supervision for ophthalmologists in practice interested in learning newer treatment modalities. ‘Sandwich’ training programs could be arranged for ophthalmologists who are busy in their respective practice and cannot take breaks for a long duration training program. A ‘Sandwich Program’ would comprise of digital training platforms, where the ophthalmologist could do part of his/her training remotely without physically being present for the course; this could be followed up with shorter, more intensive hands-on time at the hospital. These efforts would help them in providing good ophthalmic care to the community and at a grass root level. We hope other organizations and institutes working in ophthalmic education can organize similar short-term training programs in various sub specialties and contribute not only to education but also indirect patient care.
What is unique about this program, however, is the mutually beneficial partnership of the training ophthalmologists, trainee ophthalmologists and the ophthalmic industry. Also, the idea of maintaining a logbook gives credibility to the program and allows the surgeons as well as the trainers to objectively analyze the outcomes of the training. Success of this course also is attributed to the constant follow-up and support provided by the team of dedicated and committed PDS as well as the entire team of the Alcon PDP. Detailed 2-week break up of the program, meticulous planning, careful participant selection and long-term follow-up of the participant is the backbone of PDP. These activities will not only contribute to the training of the estimated 23,500 ophthalmologists in the country (10,000 ophthalmologists in 2005 and an average of 900 graduating every year), but also help reduce the incidence of blindness. Most importantly, this analysis shows us that the quality of surgery can be improved drastically, and that most modern surgical techniques can be applied even at the community level, when the trainee surgeon returns back to his/her hometown in different parts of India.
During this time of global medical emergency, where there are talks of greater investment in medical technologies and as we expect global health policies to be re-written in the coming months, we should not forget the importance of investing in training doctors as well. National and global efforts are required where doctors, including ophthalmologists, receive standardized training platforms, so that we do not have a shortfall of skilled personnel. This particular program is one such example of how partnership model between industry and ophthalmologists can go hand in hand for training and skill development of doctors contributing to patient care across societies. It also brings a novel concept of pre training assessment, standardized course curriculum with post course follow-up support, which can be replicated all over the country and may be other countries as well will ensure that the learning from the program is furthered and is practiced for a long time to come.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
We would like to acknowledge the contribution of entire Phaco Development India team for their great efforts in consolidating the data, Mr. Larry Fay (Retired & Earlier head of ASIA Phaco Development) and Mr. Ravindran Sreekanth International Director, Phaco Development for their guidance and support in building the framework and structure of Phaco Development.
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Last accessed on 2020 May 01