The impact of simulation-based trabeculectomy training on resident core surgical skill competency

PURPOSE: To measure the impact of trabeculectomy surgical simulation training on core surgical skill competency in resident ophthalmologists. METHODS: This is a post-hoc analysis of the GLAucoma Simulated Surgery (GLASS) trial, which is a multi-center, multi-national randomized controlled trial. Resident ophthalmologists from six training centers in sub-Saharan Africa (in Kenya, Uganda, Tanzania, Zimbabwe and South Africa) were recruited according to the inclusion criteria of having performed zero surgical trabeculectomies and assisted in less than five. Participants were randomly assigned to intervention and control arms using allocation concealment. The intervention was a one-week intensive trabeculectomy surgical simulation course. Outcome measures were mean surgical competency scores in eight key trabeculectomy surgical skills (scleral incision, scleral flap, releasable suturing, conjunctival suturing, sclerostomy, tissue handling, fluidity and speed), using a validated scoring tool. RESULTS: Forty-nine residents were included in the intention-to-treat analysis. Baseline characteristics were balanced between arms. Median baseline surgical competency scores were 2.88/16 (IQR 1.75-4.17) and 3.25/16 (IQR 1.83-4.75) in the intervention and control arms respectively. At primary intervention, median scores increased to 11.67/16 (IQR 9.58-12.63) and this effect was maintained at three months and one year (p= 0.0001). Maximum competency scores at primary intervention were achieved in the core trabeculectomy skills of releasable suturing (n=17, 74%), scleral flap formation (n=16, 70%) and scleral incision (n=15, 65%) compared to scores at baseline. CONCLUSION: This study demonstrates the positive impact of intensive simulation-based surgical education on core trabeculectomy skill development. The rapid and sustained effect of resident skill acquisition pose strong arguments for its formal integration into ophthalmic surgical education.