DNB Ophthalmology in India: Check out NBE released Curriculum

The National Board of Examinations (NBE) has released the Curriculum for DNB Ophthalmology.

I. OBJECTIVES OF THE PROGRAMME:

1. PROGRAMME GOAL

• The purpose of this program is to standardize Ophthalmology teaching at Post Graduate level so that it will achieve uniformity in postgraduate teaching, and create competent ophthalmic surgeons with appropriate expertise.

• Adequate current knowledge of the subject with sufficient diagnostic and surgical skills.

• Good knowledge of the blindness control programs to help eradicate blindness from our country.

2. PROGRAMME OBJECTIVES

A candidate upon successfully qualifying in the DNB (Ophthalmology) examination shall be able to:

• Offer to the community the current quality of 'standard of care in ophthalmic diagnosis as well as therapeutics (medical or surgical) in most of the common and easily managed situations at all levels of health services.

• Periodically self-assess his or her performance, keep abreast with ongoing advances in the field, and apply the same in his/her practice.

• Apply research and epidemiological methods during his/her practice. The candidate shall be able to present or publish work done by him/her.

• Contribute as an individual/group towards the fulfillment of national objectives about the prevention of blindness.

• Effectively communicate with patients and relatives to educate them sufficiently and give them the full benefit of informed consent for treatment, and ensure compliance.

• Acquire the basic skills of teaching medical and paramedical professionals.

3. OVERALL OBJECTIVES:

The clinical postgraduate training program is intended at developing in the student a blend of qualities of a clinical specialist, a teacher, a researcher, and a surgeon. A postgraduate should possess the following qualities, knowledge, and skills:

• Basic Sciences: Resident should possess basic knowledge of the structure, function, and development of the human body as related to ophthalmology, and of the factors which may disturb these, the mechanisms of such disturbances, and the disorders of structure and function which may result.

• Clinical Knowledge: Resident should be able to practice and handle most day-to-day ophthalmic problems independently, should recognize the limitations of his clinical knowledge, and know when to seek further help.

• Environment and Health: The resident should understand the effect of the environment on health and be familiar with the epidemiology and common diseases in the field of ophthalmology. He/she should be able to integrate the preventive and promotive methods with the curative and rehabilitative measures in the treatment of disease.

• Community Ophthalmology: The resident should be able to integrate the preventive and promotive methods with the curative and rehabilitative measures in the treatment of ophthalmic disease. He should be familiar with common eye problems occurring in communities and be able to deal with them effectively. The student should be able to organize and conduct surveys in rural, urban, and industrial communities and special group populations.

• Recent Advances: Resident should be familiar with the current developments in Ophthalmic Sciences.

• Teaching: Resident should be able to plan educational programs in ophthalmology in association with senior colleagues, and be familiar with modern methods of teaching and evaluation.

• Research: The resident should be able to identify a problem for research of a clinical experimental nature, clearly state the objective, plan a rational approach to its solution, execute it, and critically evaluate the data in the light of existing knowledge.

• Scientific Method: Resident should know that conclusions should be reached by logical deduction; he/she should be able to assess evidence both as to its reliability and its relevance.

• Medico-legal aspects: Resident should have basic knowledge of medico-legal aspects of medicine.

II. TEACHING AND TRAINING ACTIVITIES:

The fundamental components of the teaching program should include:

1. Case presentations & discussion- once a week

2. Seminar - Once a week

3. Journal club- Once a week

4. Grand round presentation (by rotation departments and subspecialties)- once a week

5. Faculty lecture teaching- once a month

6. Clinical Audit-Once a Month

7. A poster and one oral presentation at least once during their training period in a recognized conference.

The rounds should include bedside sessions, file rounds & documentation of case history and examination, progress notes, round discussions, investigations, and management plan) interesting and difficult case unit discussions.

The training program would focus on knowledge, skills, and attitudes (behavior), all essential components of education. It is divided into theoretical, clinical, and practical into all aspects of the delivery of rehabilitative care, including the methodology of research and teaching.

• Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia, and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary given inadequate exposure to the subject in the undergraduate curriculum.

• Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in three years to the combined class of teachers and students. A free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

• Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing, and management in rehabilitation practice.

• Bedside: The trainee would work up cases, and learn the management of cases by discussing them with the faculty of the department.

• Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation from other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

• Research: The student would carry out the research project and write a thesis/ dissertation by NBE guidelines. He/ she would also be given exposure to partake in the research projects going on in the departments to learn their planning, methodology, and execution to learn various aspects of research.

III. SYLLABUS:

1. The Basic Sciences:

• Orbital and ocular anatomy

a) Gross anatomy

b) Histology

c) Embryology

• Ocular Physiology

• Ocular Pathology

• Ocular Biochemistry-Biochemistry applicable to the ocular function

• Ocular Microbiology-Specific microbiology applicable to the eye

• Immunology with particular reference to ocular immunology.

• Ocular Pharmacology

• Genetics

2. Optics:

• Basic physics of optics

• Applied ophthalmic optics

• Applied optics including optical devices

• Disorders of Refraction

• Low Vision Aids

3. Clinical Ophthalmology:

• Disorders of the lids

• Disorders of the lacrimal system

• Disorders of the Conjunctiva

• Disorders of the Sclera

• Disorders of the Cornea

• Disorders of the UvealTract

• Disorders of the Lens

• Disorders of the Vitreo Retina

• Disorders of the Optic Nerve & Visual Pathway

• Disorders of the Orbit

• Glaucoma

• Neuroo ophthalmology

• Pediatric ophthalmology

• Ocular involvement in systemic disease

• Immune ocular disorders

• Strabismus & Amblyopia

• Community Ophthalmology

Biostatistics, Research Methodology, and Clinical Epidemiology Ethics Medico-legal aspects relevant to the discipline

Health Policy issues may apply to the discipline

IV. COMPETENCIES:

1. Basic medical science:

• Attain an understanding of the structure and function of the eye and its parts in health and disease including Anatomy, Physiology, Genetics, Biochemistry, Microbiology, Pharmacology, etc., and its relevance to ophthalmology

• Attain understanding and application of knowledge of CNS and other systems of the body that influence or control the structure and function of the eye.

• Attain understanding of, and develop competence in, executing common general laboratory procedures employed in diagnosis and research in Ophthalmology.

2. Clinical Ophthalmology:

The student will be given adequate opportunity to work, based on graded responsibilities, in outpatients, inpatient, and operation theaters (on a rotational basis). Thus, from the day of entry to the completion of the training program, the student shall be able to:

• Acquire a scientific and rational approach to the diagnosis of ophthalmic cases.

• Acquire an understanding of, and develop inquisitiveness to investigate, the cause and effect of diseases.

• Manage and treat all types of ophthalmic cases

• Competently handle all ophthalmic medical and surgical emergencies

• Competently handle and execute safely all routine surgical procedures on the lens, glaucoma, lid, sac, adnexa, retina, extraocular muscles, etc.

• Be familiar with micro-surgery and special surgical techniques

• Demonstrate knowledge of the pharmacological aspects (including toxicity) of drugs used in ophthalmic practice, and of drugs commonly used in general diseases that affect the eyes.

• To understand the principles, perform observe all routine and special ophthalmic investigations, for example, Slit lamp examination Gonioscopy, Perimetry, Tonometry, Darkroom procedures, Electrophysiological Tests (ERG, EOG, VER), OCT, etc.

3. Refraction:

• Acquire competence in the assessment of refractive errors and prescription of glasses for all types of refraction problems.

• Acquire basic knowledge of the manufacture and fitting of glasses and competence in judging the accuracy and defects of the dispensed glasses.

4. Medical and Surgical Management

• To demonstrate the knowledge of the pharmacology (including toxic) aspects of drugs used in ophthalmic practice and drugs commonly used in general diseases affecting the eyes.

• To exhibit competence in the medical management of ophthalmic cases.

• To competently handle and execute safely common surgical procedures on the lens, glaucoma, lid, sac, adnexa, the ocular surface including conjunctiva, cornea and sclera and extraocular muscle, etc.

• To competently handle all ophthalmic medical and surgical emergencies.

5. Ophthalmic sub-specialties:

The student will be allowed to work on a rotational basis in various special clinics of sub-specialties of ophthalmology. The student shall be able to:

• Examine, diagnose and demonstrate understanding of the management of the problems of neuro-ophthalmology, and refer appropriate cases to neurology and neuro-surgery.

• Examine, diagnose and demonstrate understanding of the management of (medical and surgical) complicated problems in the field of an (a) lens, (b) uvea, (c) ocular surface including conjunctiva cornea and sclera including transplant (d) vitreo retina (e) pediatric ophthalmology and squint (f) eyelid orbital and lacrimal diseases of the eye (g) glaucoma (h) plastic surgery of eye (i) genetic problems in ophthalmology, (j) principles of refractive surgery.

• To demonstrate understanding of the manufacture, and competence in prescribing and dispensing of contact lenses, low vision aids, and ocular prosthesis

6. Ophthalmic pathological/microbiological/biochemical sciences:

• The student should be able to interpret the relevant pathological/microbiological/biochemical data and correlate it with clinical data.

7. Imaging Techniques in Ophthalmology

• X-Rays, USG, CT scan MRI, etc.

8. Community Ophthalmology:

• Postgraduate students may be able to assist or carry out eye camps; community and school surveys.

• They may be allowed to participate in surveys, and to be a part of rehabilitation teams.

• They shall be able to guide rehabilitation workers in the organization and training of the blind in the art of daily living, and in the vocational training of the blind, leading to their gainful employment.

9. Should be able to identify systemic emergencies of acute nature and carry out an effective emergency management

10. Research:

• The student shall be able to:

• Recognize a research problem.

• State the objectives in terms of what is expected to be achieved in the end.

• Plan a rational approach, with appropriate controls, with full awareness of the statistical validity of the size of the material.

• Spell out the methodology and carry out most of the technical procedures required for the study.

• Accurately, systematically, and objectively record results and observations made.

• Analyze the data with the aid of appropriate statistical analysis.

• Interpret the observations in the light of existing knowledge, and highlight in what ways the study has advanced the existing knowledge on the subject and what further remains to be done.

• Resident should be encouraged to write at least one scientific paper on National/ International Standards from the material of this thesis.

• Resident should know the ethical issues involved in research and publication.

11. Teaching

• To write Symposiums / Seminars and critically discuss them

• To methodically summarize internationally published articles according to prescribed instructions and critically evaluate and discuss each selected article

• To discuss symposia and journals with his colleague and guide his juniors in the groups

• To present cases at clinical conferences, discuss them with his colleagues and guide his juniors in groups in evaluation & discussion of these cases.

12. Learning Methods

A. Theoretical methods:

• Lectures, and demonstrations: Didactic teaching in clinical, applied, pre-clinical, Paraclinical, and allied sciences (like forensic medicine, radiology, microbiology, pharmacology, pathology, biochemistry, biostatistics, etc). These may be imparted by the members of the staff in respective disciplines or by clinicians themselves.

• Seminars: seminars should be conducted regularly. The topics selected should be repeated once in 3 years to cover as wide a range of topics as possible. Seminars could be individual presentations or a continuum (large topic), with many students participating.

• Journal Clubs: The selected articles from the journals should be reviewed by the resident and these shall be presented by the student under the following headings, 1) Aim 2) Methods 3) Observations 4) Discussion, and 5) Conclusions.

• Case Discussion:

i. Bedside discussion, outpatient teaching, and clinical case discussion should form part of a department's schedule. This could range from 1-2hours.

ii. Clinical case presentations of the resident should be evaluated as per Annexure I.

iii. Case presentations at other in-hospital multidisciplinary forums should be couraged.

iv. Webinars and e-learning methods incorporated into the teaching program of residents

B. Clinical Ophthalmology:

The training should be given inwards, in out-patients departments, specialty clinics, and operation theatres.

• Out Patients: For the first six months of the training program, students may be attached to a faculty member to be able to pick up methods of history taking and ocular examination in ophthalmic practice. During this period the student may also be oriented to common ophthalmic problems. After 6 months, the student may work independently, where the resident receives new and old cases including refractions and prescribes for them. The students are attached to a senior resident and faculty member whom they can consult in case of difficulty.

• Wards: Each student may be allotted beds in the in-patient section depending upon the total bed capacity and the number of postgraduate students. The whole concept is to provide the student with an increased opportunity to work with increasing responsibility according to seniority. A detailed history and case record are to be maintained by the resident.

• Specialty clinics: The student must rotate in the various subspecialty clinics run by the department.

The following practical skills shall be acquired:

a) Examination techniques along with interpretation

i. Slit-lamp Examination

• Diffuse Examination / Focal Examination / Retrollumination-direct & indirect / Sclerotic scatter / Specular reflection / Staining modalities and interpretation

ii. Fundus evaluation

• Direct & Indirect ophthalmoscopy with fundus drawing

• 3-mirror, 78-D/90-D/60-D Examination

b) Basic Investigations along with their interpretation

i. Tonometry

• Applanation / Indentation / Non-contact tonometry

ii. Gonioscopy- grading of the angle

iii. Tear/ Lacrimal function test

• Staining- fluorescein, Rose Bengal / Schirmer's tests/ Break up time /Syringing / Dacrocystography

iv. Corneal Evaluation

• Corneal scraping and cauterization

• Smear preparation and interpretation (Gram'sstain/KOH)

• Keratometry- performance & Interpretation

• Corneal topography and Scheimpflugprinciple

• Pachymetry

v. Colour Vision Evaluation

• Ishihara pseudoisochromatic plates / Farnsworth Munsell 100 hue test

vi. Refraction

• Retinoscopy- streak/ Priestley Smith

• Use of Jackson'scross-cylinder

• Subjective and objective refraction

• Prescription of glasses

vii. Diagnosis & Assessment of squint

• Ocular position and motility examination

• Synaptophoreusage

• Lees / Hess screen usage

• Diplopia charting

• Assessment of strabismus - cover tests/ prism bars/synaptosome

• Amblyopia diagnosis and treatment

• Assessment of convergence, accommodation, stereopsis, suppression

viii. Exophthalmometry

• Usage of Hertel's Exophthalmometry- roptosismeasurement

ix. Contact lenses:

• Fitting and assessment of RGP and soft lenses

• Subjective verification of over-refraction

• Common complications arising from contact lens use

• Educating the patient regarding CL usage, and complications

x. Low Vision Aids

• Knowledge of basic optical devices available and the relative advantages and disadvantages of each.

• The basics of fitting, with knowledge of availability cost

xi. Community Ophthalmology

• Ability to organize an institutional screening

• Ability to organize peripheral eye screening camps

• Knowledge and ability to execute guidelines of the National program for the prevention of Blindness.

• Eye checkup Camps

C. Essential investigative skills: the postgraduate student should be able to perform/interpret the following tests:

i. Fundus Photography

ii. Fluorosceinangiography

iii. Ophthalmic ultrasound: A-scan/B-scan

iv. Automated perimetry for glaucoma and neurological lesions

v. OCT and basic knowledge of UBM

vi. ERG, EOG, VER

vii. Specular Microscopy

viii. New modalities of glaucoma investigation

ix. Radiological tests

• X rays

• Localization of ocular and intraorbital Foreign Bodies

• Interpretation of - CT scan /MRI

• Operations: The resident shall be provided with an opportunity to perform operations, both extra-ocular and intra-ocular, with the assistance of the senior residents and/or under the direct supervision of a faculty member. Resident shall be provided with an opportunity to learn special and complicated operations by assisting the Senior Residents or the Senior Surgeon, in these operations. The resident shall be responsible for the post-operative care of these cases. The student should be able to perform independently/under guidance various surgeries; the thrust areas include cataract, glaucoma, squint, lacrimal sac, entropion, and enucleation /evisceration.

• To provide surgical training, a phased program may be chalked out. In the first phase, the student is given training in the wet lab. He is also exposed to regional anesthetic block, preparations of cases for operation, and premedication.

• In the next phase, the student shall assist the operating surgeon during the operation. In the third phase, the student operates independently assisted by a senior resident or a faculty member.

The resident surgery should be evaluated by available tools like OSCAR, and CEX

a) Minor surgical procedures: The student must know and be able to perform independently:

i. Conjunctival and corneal foreign body removal on the slitlamp

ii. Pterygium excision with recent techniques

iii. Suture removal- skin / conjunctival/ corneal /corneoscleral

iv. Subconjunctivalinjection

v. Posterior Sub-Tenon'sinjections

vi. Repair of corneal / corner - scleral perforations

vii. Chalazion incision and curettage

viii. Biopsy of small lid tumors

ix. Tarsorrhaphy

b) Major Surgical Procedures:

i. The student must know and be able to perform independently:

Ocular Anesthesia

• Peribulbar / Retrobulbar anesthesia

• Facial nerve blocks- O'Brien / Atkinson/ Van lint &modifications

• Frontal nerve blocks

• Infraorbital nerve blocks

• Blocks for sac surgery

ii. The student must be able to perform independently / under supervision/assistance and deal with complications arising from the following surgeries:

Lid Surgery

• Tasorrhaphy

• Ectropion & entropion (simple procedures)

• Lid repair following trauma - including lid margin tears

• Epilation, electroepilation

Destructive procedures

• Evisceration with or without implant

• Enucleation with or without implant

• Enucleation for eye donation

• Cyclocryotherapy Sac surgery

• Dacryocystectomy /Dacryocystorhinostomy

• Probing for congenital obstruction of nasolacrimal duct Strabismus surgery

• Recession and resection procedures on the horizontal recti

iii. The student shall be well conversant with the use of an Operating microscope and must be able to perform the following surgeries competently using the microscope:

Cataract surgery

• Standard ECCE with IOL implantation

• Small incision Cataract surgery with IO Limplantation

• Resident should have performed under the guidance/assistance of the following

• Secondary AC or PC IO Limplantation

• Phacoemulsification

Vitreous Surgery

• Intra-vitreal and intra-cameral (anterior chamber) injection techniques and dosages, particularly for endophthalmitis management.

• The student should know the basis of anterior vitrectomy in the management of cataract surgery complications.

iv. The student should have preferably assisted in the following microscopic surgeries:

Keratoplasty

• Therapeutic and optical

Glaucoma surgery

• Trabeculectomy

• Pharmacological modulation of trabeculectomy

v. The student should have assisted in the following laser procedures:

• Yag Capsulotomy

• Laseriridotomy

• Focal and pan-retinal photocoagulation

vi. The student should have assisted/know Kerato-refractive procedures.

c) Ocular Histopathology:

The student shall have basic knowledge of gross and microscopic features of various ocular pathologic conditions, to assist them in confirmation of clinical diagnosis, and help in management.

V. LOG BOOK:

A candidate shall maintain a log book of operations (assisted/performed) during the training period, certified by the concerned postgraduate teacher / Head of the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal at the time of the final examination.

The logbook should show evidence that the before-mentioned subjects were covered (with dates and the name of the teacher(s) The candidate will maintain a record of all academic activities undertaken by him/her in the logbook.

1. Personal profile of the candidate

2. Educational qualification/Professional data

3. Record of case histories

4. Procedures learned

5. Record of case Demonstration/Presentations

6. Every candidate, at the time of the practical examination, will be required to produce a performance record (log book) containing details of the work done by him/her during the entire period of training as per the requirements of the log book. It should be duly certified by the supervisor as work done by the candidate and countersigned by the administrative Head of the Institution. 7. In the absence of the production of a log book, the result will not be declared.

VI. RECOMMENDED TEXTBOOKS AND JOURNALS

1. Clinical Ophthalmology - Kanski JJ

2. Parson's Diseases of the Eye - Sihota and Tandon

3. Anatomy of the eye and orbit: EugeneWolff

4. Clinical anatomy of the eye: Richard Snell

5. Adler's Physiology of the Eye: Francis HAdler

6. Biochemistry of the eye: Elaine R.Berman

7. Ocular Pathology: A Text and Atlas: Yanoff M & FineBS

8. Ophthalmic Pathology: An Atlas and Textbook: Zimmerman

9. Ocular pharmacology: William Heavener

10. Ocular Immunology: GilbertSmolin

11. Duke Elder's Practice of refraction: Sir StewartDuke-Elder

12. Clinical optics: A. R. Elkington, Helena J. Frank, Michael J.Greaney

13. Paediatric Ophthalmology and strabismus: Kenneth Wright

14. Binocular vision and ocular motility: Gunter K vonNoorden

15. Diagnosis and Management of Ocular Motility Disorders: Mein J, Trimble.

16. Shields' textbook of glaucoma: Bruce MShields

17. Becker-Shaffer's Diagnosis and Therapy of the glaucomas

18. Uveitis: a clinical approach to diagnosis and management: Ronald E Smith, Robert Nozick

19. Uveitis: fundamentals and clinical practice: Robert B. Nussenblatt and Alan G. Palestine

20. Vitreous Microsurgery: SteveCharles

21. Ultrasound of the eye and orbit: Sandra F Byrne and Ronald L.Green

22. Clinical neuro-ophthalmology: Walsh &Hoyt

23. Diagnosis and management of intraocular tumors: Jerry A Shields

24. Diseases of the orbit: a multidisciplinary approach: JackRootman

25. Diseases of the orbit: Frederick A. Jakobiec and Ira SJones

26. Diagnosis and management of orbital tumors: Jerry A.Shields

27. Grayson's disease of the cornea

28. Smolin and Thoft's The Cornea: scientific foundations and clinical practice

29. Stallard's eye surgery

30. Ophthalmic Surgery: Principal and Practice. George L.Spaeth

31. Cataract Surgery and its Complications. Normal S.Jaffe

32. Principal and Practice of Ophthalmology. G. A.Peymen

33. Basic and Clinical Science Course. American Academy of Ophthalmology

34. Principles and Practice of Ophthalmology by FAJakobeic.

35. Retina by Stephen J.Ryan

36. Basic & Advanced Biostatistics - ManjuPandey

37. Oxford Handbook of MedicalBiostatistics

JOURNALS

1. Indian Journal of Ophthalmology

2. American Journal of Ophthalmology

3. Ophthalmology

4. Archives of Ophthalmology

5. Survey of ophthalmology

6. International Ophthalmology Clinics

7. British Journal of Ophthalmology

8. Cornea

9. Retina

10. Journal of Cataract and Refractive Surgery

11. Ophthalmic Surgery, Imaging, and Lasers

WEB RESOURCES

1. International Council of Ophthalmology (ICO): www.icoph.org

a. ICO Center for Ophthalmic Educators: educators.icoph.org

b. ICO Examinations: www.icoexams.org/

c. ICO International Fellowships: www.icoph.org /refocusing education/ fellowships.html

d. ICO Foundation: www.icofoundation.org/

2. American Academy of Ophthalmology: http://www.aao.org

3. American Academy of Ophthalmology Education Resource Center: http://www.aao.org/education/index.cfm

4. American Board of Ophthalmology: http://www.abop.org

5. Digital Journal of Ophthalmology: http://www.djo.harvard.edu

6. Eye Search: http://www.eyesearch.com

7. Eye Atlas - Online Atlas of Ophthalmology: http://www.eyeatlas.com

8. Eye Cancer Network: http://eyecancer.com

9. Eye Library.Org: http://www.eyelibrary.org

10. Eye Text.Net: http://www.eyetext.net