Commentary: Improving training in retina in Indian residency programmes.

Retinal diseases have become a significant cause of low vision in every part of the world than had previously been thought. Blindness surveys underestimate the prevalence of blindness caused by retinal pathologies due to lack of routine dilated fundus examinations. Most of the irreversible blindness is caused by retinal disorders like age-related macular degeneration (AMD). The incidence of diabetic retinopathy and its devastating complications will increase as the prevalence of diabetes is increasing rapidly. The posterior segment complications of anterior segment surgeries will increase due to high numbers of cataract, glaucoma, and refractive surgeries performed everywhere.[1] Blindness can be avoided as most diseases are preventable or treatable if diagnosed at appropriate time. Thus, we need proper exposure and good training in retina during ophthalmology residency or subspecialty fellowships to prepare them for facing future challenges.

Basic understanding of common retinal diseases like diabetic retinopathy, retinal detachment, AMD, venous occlusions, endophthalmitis, etc. should be inculcated in minds of young ophthalmologists through well-defined curriculum. They should be trained comprehensively to diagnose, investigate, and manage these common retinal disorders. They should also be made aware of recent developments/innovations in retina like advancements in retinal imaging, newer anti-VEGF agents and role of artificial intelligence in retinal disorders. The resident should be able to screen and diagnose common retinal diseases at the end of his/her residency. This will lead to early diagnosis and referral to retina specialists if necessary. Patient counseling, communication, and ethics should be given special emphasis in residency curriculum as it remains an important aspect in managing retinal diseases.[2] Holistic management including optimization of systemic co-morbidities should be taught during residency training.

The resident should be well versed in doing basic clinical procedures like direct ophthalmoscopy, indirect ophthalmoscopy, 90D slit lamp biomicroscopy, and scleral indentation if possible. Recent studies have shown that these skills are inadequate in residents. One of the reason is lack of feedback as the teacher is unaware of what the resident sees, limiting opportunity for refinement. To overcome this difficulty, several alternate methods of demonstration like virtual indirect ophthalmoscope, model eyes, and virtual reality computer simulations such as the EYESi ophthalmoscope, (VRMagic Holding, Mannheim, Germany) have been developed.[3] These help in building confidence and improves examination skills.

The resident should be competent enough to detect potential vision threatening emergencies such as retinal tears and detachments. They should be aware of the basics of retinal imaging like OCT, fluorescein angiography, ultrasonography as well as advances like ultra-widefield imaging. It will be heartening if they learn basic laser procedures such as pan retinal photocoagulation or sectoral lasers. These are compulsory skills which have to be learnt during residency training in western countries.[456] Competency in incisional vitreoretinal surgeries is not expected from residents. With the advent of digitally assisted vitreoretinal surgery like Ngenuity, multiple residents/fellows can learn the basics of surgery by seeing surgery of experts at the same time. New vitreoretinal surgery virtual reality simulators like Eyesi can serve as a platform to learn and improve surgical skills.[7] The resident should be confident to perform intravitreal injections or vitreous tap in various conditions like endophthalmitis.

The present study has highlighted the high variation of exposure in the subspecialty of retina in residency training programs in India.[8] This can be linked to lack of standardized curriculum, limited number of faculties trained in retina subspecialty and lack of equipment (imaging and surgical) due to limited resources especially in government setups. Need of the hour is to implement a basic uniform curriculum like ACGME in USA, which should be feasible and affordable. This should include proficiency in knowledge about common retinal diseases and examination skills which are must to practise retina. Advances can be taught in workshops or conferences which should be given due importance. There should be scope for research, critical analysis, and patient communication.[2]