The Effect of Supervision and Out-of-Hours Surgery on the Outcomes of Primary Macula-On Retinal Detachments Operated by Vitreoretinal Fellows: A Review of 435 Surgeries

Abstract

<b><i>Purpose:</i></b> During bank holidays and weekends (BHWE), many primary macula-on retinal detachments (RD) across the United Kingdom are performed unsupervised out-of-hours by experienced vitreoretinal (VR) fellows. We aimed to determine whether first-year (F1) and second-year (F2) fellows could safely operate out-of-hours independently with remote supervision on primary macula-on RDs. <b><i>Methods:</i></b> This is a retrospective consecutive series of 435 patients attending the Birmingham and Midlands Eye Centre from January 2017 to July 2020. We evaluated (i) 6-month re-detachment rate and (ii) visual outcomes of F1, F2, and consultants during office hours and BHWE as well as the effects of supervision versus non-supervision. <b><i>Results:</i></b> For the re-detachment rate, no difference was found between surgeon grade (<i>p</i> = 0.821), whether supervised (<i>p</i> = 1.000), whether BHWE (<i>p</i> = 1.000), unsupervised BHWE and supervised mid-week (<i>p</i> = 0.757), and unsupervised F1 and F2 (<i>p</i> = 1.000), with non-significance maintained on multivariate regression. No difference was detected in the level of supervision (15.7%) between fellow grades during BHWE (<i>p</i> = 0.761) or mid-week (<i>p</i> = 0.295) or between surgeon grade and logMAR letters gained pre-postoperatively (<i>p</i> = 0.834). <b><i>Conclusion:</i></b> Safe VR services can be provided by experienced VR fellows during office hours, BHWE, supervised, or unsupervised, with similar primary success and visual outcomes to consultants in this patient subgroup. Initial intensive supervision and feedback and a gradual increase in independence is fundamental for VR fellows to gain confidence and become safe independent surgeons.

Virtual supervision in ophthalmology: a scoping review

“…Two studies included supervisees who were physicians, including an ophthalmic surgeon from a foreign country (14%) [ 9 ] and a general practitioner in a rural hospital (14%) [ 8 ]. Five studies included supervisees who were medical trainees, such as ophthalmology residents (43%) [ 7 , 11 , 13 ], vitreoretinal fellows (14%) [ 12 ], and emergency medicine (EM) residents (14%) [ 10 ].…”

“…Study setting varied between the ED [ 5 , 7 , 10 , 11 ], operating room (OR) [ 9 , 12 ], rural hospital [ 8 ], and eye clinic [ 13 ]. Virtual supervision was used for a clinical examination in three studies (43%) [ 7 , 11 , 13 ], surgical procedure in three studies (43%) [ 9 , 10 , 12 ], and in-office procedure in one study (14%) [ 8 ].…”

“…Study setting varied between the ED [ 5 , 7 , 10 , 11 ], operating room (OR) [ 9 , 12 ], rural hospital [ 8 ], and eye clinic [ 13 ]. Virtual supervision was used for a clinical examination in three studies (43%) [ 7 , 11 , 13 ], surgical procedure in three studies (43%) [ 9 , 10 , 12 ], and in-office procedure in one study (14%) [ 8 ]. For studies involving a surgical or in-office procedure, VS was used to teach surgeons endoscopic laser-assisted dacryocystorhinostomy (ELA-DCR) [ 9 ], perform orbital decompression on a patient with extensive facial trauma [ 10 ], remove a corneal foreign body and rust ring in a rural hospital [ 8 ], and supervise retina fellows repairing macula-on rhegmatogenous retinal detachments (RRD) during bank holidays and weekends [ 12 ].…”

“…Four studies reported successful transmission of real-time video of surgical or in-office procedures [ 8 – 10 , 12 , 13 ]. In three studies on VS for clinical examinations, supervisees held synchronous communication with their supervisors to reach an agreement in diagnosis [ 7 , 11 , 13 ].…”

Experience gained during vitreoretinal fellowships in the United Kingdom

“…Our results show that confidence of fellows in performing phacoemulsification cataract surgery was generally high at baseline with a mean, median (IQR) of 5, 5 (4-5), nevertheless, this did rise to 5, 5 (5-5) (p < 0.05). The Royal College of Ophthalmologists mandates a minimum requirement of 350 phacoemulsification cataract surgeries for CCT [1,10]. However, this minimum number does not necessarily to surgeon confidence and competence.…”