NMC Guidelines For Competency-Based Training Programme For MS Ophthalmology

Written by MD Bureau Published On 2022-09-10T14:00:52+05:30 | Updated On 28 March 2024 11:36 AM IST

NMC Guidelines For Competency-Based Training Programme For MS Ophthalmology

The National Medical Commission (NMC) has released the Guidelines For Competency-Based Postgraduate Training Programme For MS In Ophthalmology

The purpose of PG education is to create specialists who would provide high quality health care and advance the cause of science through research & training.

The purpose of this programme is to standardize Ophthalmology teaching at post graduate level throughout the country so that it will benefit in achieving uniformity in post graduate and undergraduate teaching as well as result in creating competent ophthalmic surgeons with appropriate expertise.

The purpose of this document is to provide teachers and learners illustrative guidelines to achieve defined outcomes through learning and assessment. This document was prepared by various subject-content specialists. The Reconciliation Board of the Academic Committee has attempted to render uniformity without compromise to purpose and content of the document. Compromise in purity of syntax has been made in order to preserve the purpose and content. This has necessitated retention of "domains of learning" under the heading "competencies".

SUBJECT SPECIFIC LEARNING OBJECTIVES

Programme Objectives

The clinical post graduate training programmes are intended at developing in a student a blend of qualities that of a clinical specialist, a teacher and a researcher. These programmes are organized such that a post graduate student should possess the following qualities, knowledge and skills:

a. The student should possess basic knowledge of the structure, function and development of the human body as related to ophthalmology, of the factors which may disturb these mechanisms and the disorders of structure and function which may result thereafter.

b. The student should be able to practice and handle most day-to-day problems independently in ophthalmology. The student should recognize the limitations of his/her own clinical knowledge and know when to seek further help.

c. The student should understand the effects of environment on health and be familiar with the epidemiology of at least the more common diseases in the field of ophthalmology.

d. The student should be able to integrate the preventive methods with the curative and rehabilitative measures in the comprehensive management of the disease.

e. The student should be familiar with common eye problems occurring in rural areas and be able to deal with them effectively.

f. The student should also be made aware of Mobile Ophthalmic Unit and its working and components.

g. The student should be familiar with the current developments in Ophthalmic Sciences.

h. The student should be able to plan educational programmes in Ophthalmology in association with senior colleagues and be familiar with the modern methods of teaching and evaluation.

i. The student should be able to identify a problem for research, plan a rational approach to its solution, execute it and critically evaluate his/her data in the light of existing knowledge.

j. The student should reach the conclusions by logical deduction and should be able to assess evidence both as to its reliability and its relevance.

k. The student should have basic knowledge of medico-legal aspects of medicine.

l. The student should be familiar with patient counseling and proper consent taking.

SUBJECT SPECIFIC COMPETENCIES

A post graduate student upon successfully qualifying in the M.S. (Ophthalmology) examination should be able to:

a) 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 situations encountered at the level of health services.

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

c) Be aware of her/his own limitations to the application of the specialty in situations, which warrant referral to more qualified centers or individuals.

d) Apply research and epidemiological methods during his/her practice. The post graduate student should be able to present or publish work done by him/her.

e) Contribute as an individual/group towards the fulfillment of national objectives with regard to prevention of blindness.

f) Effectively communicate with patients or relatives so as to educate them sufficiently and give them the full benefit of informed consent to treatment and ensure compliance.

At the end of the course, the student should have acquired knowledge in the following:

A. Cognitive domain

Basic Medical Sciences:

- Attain understanding of the structure and function of the eye and its parts in health and disease.

- Attain understanding and application of knowledge of the structure and function of the parts of Central Nervous System and other parts of the body with influence or control on 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.

1. Clinical Ophthalmology:

Given adequate opportunity to work on the basis of graded responsibilities in outpatients, inpatient and operation theatres on a rational basis in the clinical sections from the day of entry to the completion of the training programme, the students should be able to:

- Acquire scientific and rational approach to the diagnosis of ophthalmic cases presented.

- Acquire understanding of and develop inquisitiveness to investigate to establish cause and effect of the disease.

- To manage and treat all types of ophthalmic cases.

- To competently handle and execute safely all routine surgical procedures on lens, glaucoma, lid, sac, adnexa, retina and muscle anomalies.

- To competently handle all ophthalmic medical and surgical emergencies.

- To be familiar with micro-surgery and special surgical techniques.

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

2. Refraction:

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

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

3. Ophthalmic super-specialties:

Given an opportunity to work on a rotational basis in various special clinics of sub-specialties of ophthalmology, if possible, the student should be able to:

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

- Examine, diagnose and demonstrate understanding of management of (medical and surgical) complicated problems in the field of (a) lens, (b) glaucoma, c) cornea, (d) retina, (e) pediatric ophthalmology, (f) oculoplasty, (g) uvea, and (I) genetic problems in ophthalmology.

- To demonstrate understanding of the manufacture, and competence in prescription and dispensing of contact lenses and ocular prosthesis.

5. Ophthalmic pathological/microbiological/biochemical sciences

- Be able to interpret the diagnosis in correlation with the clinical data and routine materials received in such cases.

6. Community Ophthalmology

Eye camps may be conducted where the PG students are posted for imparting training to according to a set methodology. The community and school surveys may also be conducted by the post graduate students.

The post graduate students are given an opportunity to participate in surveys, eye camps. They should be able to guide rehabilitation workers in the organisation and training of the blinds in art of daily living and in the vocational training of the blind leading to gainful employment.

7. Research :

- Recognise 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 and objectively record on systematic lines results and observation made.

- Analyze the data with the aid of an appropriate statistical analysis.

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

- Write a thesis in accordance with the prescribed instructions.

- Write at least one scientific paper as expected of International Standards from the material of this thesis.

B. Affective Domain:

1. Should be able to function as a part of a team, develop an attitude of cooperation with colleagues, and interact with the patient and the clinician or other colleagues to provide the best possible diagnosis or opinion.

2. Always adopt ethical principles and maintain proper etiquette in dealings with patients, relatives and other health personnel and to respect the rights of the patient including the right to information and second opinion.

3. Develop communication skills to word reports and professional opinion as well as to interact with patients, relatives, peers and paramedical staff, and for effective teaching.

C. Psychomotor domain

At the end of the course, the student should acquire following clinical skills: Essential diagnostic skills:

I. Examination techniques along with interpretation

1. Slit lamp Examination

i. Diffuse examination

ii. Focal examination

iii. Retroillumination – direct and indirect

iv. Sclerotic scatter

v. Specular reflection

vi. Staining modalities and interpretation

2. Fundus evaluation

• Direct/Indirect ophthamoscopy

• Fundus drawing

• 3-mirror examination of the fundus

• 78-D/90-D/60-D examination

• Amsler's charting

II. Basic investigations along with their interpretation

1. Tonometry

Tonometry - Applanation/Identation/Non-contact

2. Gonioscopy

Gonioscopy grading of the anterior chamber angle

3. Tear/ Lacrimal function tests

i. Staining- fluorescein and Rose Bengal

ii. Schirmer test/tear film break up time

iii. Syringing

iv. Dacrocystography

4. Corneal

• Corneal scraping and cauterization

• Smear preparation and interpretation (Gram's stain /KOH )

• Media inoculation

• Keratometry - performance and interpretation

• Pachymetry

• Corneal topography - if available

5. Colour Vision evaluation

• Ishihara pseudoisochromatic plates

• Farnsworth Munsell, if available

6. Refraction

i. Retinoscopy- Streak/ Priestley Smith

ii. Use of Jackson's cross-cylinder

iii. Subjective and objective refraction

iv. Prescription of glasses

7. Diagnosis and assessment of Squint

i. Ocular position and motility examination

ii. Synoptophore usage

iii. Lees screen usage

iv. Diplopia charting

v. Assessment of strabismus - cover tests/prisms bars

vi. Amblyopia diagnosis and treatment

vii. Assessment of convergence, accommodation, stereopsis, suppression

8. Exophthalmometry

Usage of Hertel's exophthalmometer - proptosis measurement

9. Contact lenses

• Fitting and assessment of RGP and soft lenses

• Subjective verification of over refraction

• Complications arising of contact lens use

• Educating the patient regarding CL usage and imparting relevant knowledge of the complications arising thereon

10. Low Vision Aids

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

• The basics of fitting with knowledge of availability & cost

III. The post graduate must be well versed with the following investigative modalities although the student may or may not perform it individually. But, she/he should be able to interpret results of the following tests:

1. Fundus photography

2. Fluorescein angiography

3. Ophthalmic ultrasound A-scan/B scan

4. Automated perimetry for glaucoma and neurological lesions

5. Radiological tests - X rays - Antero posterior/ Lateral view PNS (Water's view) / Optic canal views

Localisation of intra-ocular and intra-orbital FBs

Interpretations of -USG/ CT/ MRI Scans

6. OCT and UBM

7. ERG, EOG, and VEP

IV. Minor surgical procedures – Must know and perform independently

• Conjunctival and corneal foreign body removal on the slit lamp

• Chalazion incision and curettage

• Pterygium excision

• Biopsy of small lid tumours

• Suture removal- skin/conjunctival/corneal/ corneoscleral

• Tarsorrhaphy

• Subconjunctival injection

• Retrobulbar, parabulbar anaesthesia

• Posterior Sub-Tenon's injections

• Artificial eye fitting

V. Surgical procedures

1. Must know and can perform independently

a. Ocular anaesthesia:

• Retrobulbar anaesthesia

• Peribulbar anaesthesia

• Facial blocks- O'Brein / Atkinson/Van lint and modifications

• Frontal blocks

• Infra orbital blocks

• Blocks for sac surgery

2. Must be able to independently perform and deal with complications arising from the following surgeries :

• Lid Surgery - Tarsorrhaphy

Ectropion and entropion Lid repair following trauma Epilation

• Destructive procedures

Evisceration with or without implant Enucleation with or without implant

• Sac surgery

i. Dacryocystectomy

ii. Dacryocystorhinostomy

iii. Probing for congenital obstruction of nasolacrimal duct

• Strabismus surgery

Recession and resection procedures on the horizontal recti.

• Orbit surgery

Incision and drainage via anterior orbitotomy for abscess

• Cyclocryotherapy/Cyclophotocoagulation

3. PG Students should be well conversant with use of operating microscope and must be able to perform the surgeries listed below competently under the same:

• Cataract surgery

i. Standard ECCE (extracapsular cataract extraction; first year) with or without IOL implantation

ii. Small incision ECCE with or without IOL implantation and/or Phacoemulsification with PC IOL implantation

iii. Intracapsular cataract extraction (second year)

iv. Cataract with Phacoemusification (third year)

v. Secondary AC or PC IOL implantation

• Vitrectomy/Scleral buckling

• Intra-vitreal and intra-cameral (anterior chamber) injection techniques and doses of drugs for the same

• Needs to know the basis of open sky vitrectomy (anterior segment) as well as management of cataract surgery complications.

• Assisting vitrectomy and scleral buckling procedures

• Ocular surface procedures

Pterygium excision with modifications Conjunctival cyst excision/foreign body removal Corneal foreign body removal Conjunctival flap/ peritomy

• Glaucoma

Trabeculectomy

• Corneal

Repair of corneo - scleral perforations Corneal suture removal

Application of glue and bandage contact lens

4. Should have performed/assisted the following microscopic surgeries

i. Keratoplasty Therapeutic and optical

ii Glaucoma surgery

Pharmacological modulation of trabeculectomy Trabeculotomy

Goniotomy

Glaucoma valve implant surgery

5. Desirable to be able to perform following laser procedures

• Yag Capsulotomy

• Laser iridotomy

• Focal and panretinal photocoagulation

6. Should have assisted/knowledge of Keratorefractive procedures

Operations:

The PG is provided with an opportunity to perform operations both extra-ocular and intra-ocular with the assistance of the senior post graduate students and/or under the direct supervision of a faculty member. The student is provided with an opportunity

to learn special and complex operations by assisting the senior post graduate student or the faculty in operations of cases of the specialty and be responsible for the post- operative care of these cases.

In first phase, the post graduate student is given training in preparations of cases for operation, pre-medication and regional anaesthetic blocks. In the next phase, the post graduate student assists the operating surgeon during the operations. In the third phase, the post graduate student operates independently assisted by senior post graduate student or a faculty member. She/he is required to be proficient in some operations and show familiarity with others.

Syllabus

Course contents:

These are only broad guidelines and are illustrative, there may be overlap between sections.

I. Basic Sciences:

1. Orbital and ocular anatomy

i. Gross anatomy

ii. Histology

iii. Embryology

2. Ocular Physiology

3. Ocular Pathology

4. Ocular Biochemistry

General biochemistry, biochemistry applicable to ocular function

5. Ocular Microbiology

General Microbiology, specific microbiology applicable to the eye

6. Immunology with particular reference to ocular immunology

7. Genetics in ophthalmology

8. Community Eye Health

II. Optics

a. Basic physics of optics

b. Applied ophthalmic optics

c. Applied optics including optical devices

d. Disorders of Refraction

III. Clinical Ophthalmology

i. Disorders of the lids

ii. Disorders of the lacrimal system

iii. Disorders of the Conjunctiva

iv. Disorders of the Sclera

v. Disorders of the Cornea

vi. Disorders of the Uveal Tract

vii. Disorders of the Lens

viii. Disorders of the Retina

ix. Disorders of the Optic Nerve and Visual Pathway

x. Disorders of the Orbit

xi. Glaucoma

xii. Neuro-ophthalmology

xiii. Paediatric ophthalmology

xiv. Ocular involvement in systemic disease

xv. Immune ocular disorders

xvi. Strabismus and Amblyopia

xvii. Ocular oncology

TEACHING AND LEARNING METHODS

Teaching Methodology:

The theoretical knowledge is imparted to the post graduate student through distinct courses of lecture demonstrations, seminars, symposia and inter- and intra- departmental meetings. The students are exposed to recent advances through discussions in journal clubs and participation in CMEs, and symposia.

The post graduate students are imparted clinical training in several ways:

1. Group Discussion

The junior post graduate students may present the symposium to their senior postgraduates where it is fully discussed before finally being discussed in front of the faculty or senior eye specialists. A free and fair discussion is encouraged. These discussions enable the post graduate students to prepare for a general discussion in the class.

2. Clinical Case discussion

a. Bedside discussion on the rounds and outpatient teaching take their toll with patient management. Therefore in addition to these, clinical case discussions should form part of a department's schedule at a fixed time every week. This could range from 1-2 hours and could be held at least once a week. The choice and manner of presentation and discussion varies widely and is left to the discretion of the department. Every effort should be made to include as wide a variety of cases as possible over three years with multiple repetitions. Problem oriented approach is better as it aids in decision making skills.

b. In addition to bedside teaching rounds, at least 5-hr of formal teaching per week are necessary.

c. Consultant case presentation is another approach which should be encouraged as it aids in solving complex problems and also is forum for discussion of interesting cases.

d. Case discussions on the patient's records written by the student is to be encouraged as it helps exercise the student's diagnostic and decision making skills. It also helps the consultant in critical evaluation of the student's progress academically.

e. Case presentation at other in-hospital multidisciplinary forums.

f. The postgraduate students shall be required to participate in the teaching and training programme of undergraduate students and interns.

g. Department should encourage e-learning activities.

3. Seminars

Seminars should be conducted at least once weekly. The duration should be at least one hour. The topics selected should be repeated once in 3 years so as to cover as wide a range of topics as possible. Seminars could be individual presentations or a continuum (large topic) with many post graduate students participating.

4. Journal clubs

Journals are reviewed in particular covering all articles in that subject over a 6 months period and are discussed by the post graduate student under the following headings.

1) Aim

2) Methods

3) Observations

4) Discussions and

5) Conclusions

The post graduate student to whom the journal is allotted presents the journal summaries to the senior postgraduates. They are expected to show their understanding of the aspects covered in the article and clarify any of the points raised in the article, offer criticisms and evaluate the article in the light of known literature.

5. A postgraduate student of a postgraduate degree course in broad specialities/super specialities would be required to present one poster presentation, to read one paper at a national/state conference and to present one research paper which should be published/accepted for publication/sent for publication during the period of his postgraduate studies so as to make him eligible to appear at the postgraduate degree examination.

6. Out-Patients: For the first six months of the training programme, post graduate 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 post graduate student may also be oriented to the common ophthalmic problems. After 6 months, the clinical post graduate student may work independently, where he receives new and old cases including refractions and prescribes for them. The post graduate students are attached to a senior post graduate student and faculty member whom they can consult in case of difficulty.

7. Wards: Each post graduate student may be allotted beds in the in-patient section depending upon the total bed capacity and the number of the post graduates. The whole concept is to provide the post graduate student increasing opportunity to work with increasing responsibility according to seniority. A detailed history and case record is to be maintained by the post graduate student.

Relevance of beds and admissions in Ophthalmology has really gone down at present, as most of the surgical and special investigative procedures are being performed on out-patient basis. Most of the teaching has to be imparted in out-patients department and special Clinics.

8. Rotations: Specialty clinics

The student may rotate in the following subspecialty clinics:

• Anterior segment and cataract

• Glaucoma

• Oculoplastics

• Paediatric ophthalmology and strabismus

• Retina and Uvea

• Cornea, Contact lens and low vision

• Neuroophthalmology

• Refractive Clinic

9. Practicals in Ocular Histopathology

The post graduate students may be provided with fully stained slides of the ocular tissues along with relevant clinical data and discuss the diagnosis and differential diagnosis on the basis of the information provided

10. Attend accredited scientific meetings (CME, Symposia, and Conferences).

11. Additional sessions on basic sciences, biostatistics, research methodology, teaching methodology, hospital waste management, health economics, medical ethics and legal issues related to ophthalmology practice are suggested.

13. Maintenance of log book: Log books shall be checked and assessed periodically by the faculty members imparting the training.

During the training programme, patient safety is of paramount importance; therefore, skills are to be learnt initially on the models, later to be performed under supervision followed by performing independently; for this purpose, provision of surgical skills laboratories in medical colleges is mandatory.

ASSESSMENT

FORMATIVE ASSESSMENT, ie, during the training

Formative assessment should be continual and should assess medical knowledge, patient care, procedural & academic skills, interpersonal skills, professionalism, self directed learning and ability to practice in the system.

FORMATIVE ASSESSMENT, ie., during the training General Principles

Internal Assessment should be frequent, cover all domains of learning and used to provide feedback to improve learning; it should also cover professionalism and communication skills. The Internal Assessment should be conducted in theory and clinical examination.

Quarterly assessment during the MS training should be based on following educational activities:

1. Journal based / recent advances learning

2. Patient based /Laboratory or Skill based learning

3. Self directed learning and teaching

4. Departmental and interdepartmental learning activity

5. External and Outreach Activities / CMEs

The student to be assessed periodically as per categories listed in postgraduate student appraisal form (Annexure I)

SUMMATIVE ASSESSMENT, ie., assessment at the end of training

The summative examination would be carried out as per the Rules given in

POSTGRADUATE MEDICAL EDUCATION REGULATIONS, 2000.

The Post Graduate examination shall be in three parts:

1. Thesis:

Every post graduate student shall carry out work on an assigned research project under the guidance of a recognised Post Graduate Teacher, the result of which shall

be written up and submitted in the form of a Thesis. Work for writing the Thesis is aimed at contributing to the development of a spirit of enquiry, besides exposing the post graduate student to the techniques of research, critical analysis, acquaintance with the latest advances in medical science and the manner of identifying and consulting available literature.

Thesis shall be submitted at least six months before the Theory and Clinical / Practical examination. The thesis shall be examined by a minimum of three examiners; one internal and two external examiners, who shall not be the examiners for Theory and Clinical examination. A post graduate student shall be allowed to appear for the Theory and Practical/Clinical examination only after the acceptance of the Thesis by the examiners. From regulations)

2. Theory Examination:

The examinations shall be organised on the basis of 'Grading'or 'Marking system' to evaluate and to certify post graduate student's level of knowledge, skill and competence at the end of the training. Obtaining a minimum of 50% marks in 'Theory' as well as 'Practical' separately shall be mandatory for passing examination as a whole. The examination for M.D./ MS shall be held at the end of 3rd academic year. An academic term shall mean six month's training period.

There shall be four theory papers.

Paper I: Basic Sciences related to Ophthalmology, Refraction & Optics

Paper II: Clinical Ophthalmology

Paper III: Systemic Diseases in Relation to Ophthalmology

Paper IV: Recent Advances in Ophthalmology and Community Ophthalmology

3. Clinical/Practical and oral/viva voce examination Clinical

1 long case

2 short cases with different problems 2 fundus Cases

1 refraction case

. Oral/Viva voce Examination shall be comprehensive enough to test the

post graduate student's overall knowledge of the subject and shall include:

i. Instruments

ii. Pathology specimens

iii. Drugs, X-rays, USG/OCT/CT/MRI Scans, etc.

iv. Visual fields and other ophthalmic diagnostic charts