closer you are to the patient’s pupil, the better view you will get. In this instruction, we tell student exactly what we felt and saw during the process of getting closer to the patient to locate the retinal blood vessel. We applied our strategy in 394 junior medical students with informed consent. About 30 students in each small class had 2 hours to practice direct ophthalmoscopy. At first, the students were instructed in the traditional way. In the middle of the class, the number of the students who saw the retinal blood vessel was recorded. Then the students were instructed to follow our precise description steps. At the end of the class, the total number of the students who saw the retinal blood vessel was recorded. Of the 394 students, only 32 (8.1%) students could see the retinal blood vessel in the middle of the class after following the traditional instruction, whereas 350 (88.9%) students could see the retinal blood vessel at the end of the class after following our precise description steps. Once the students could see the retinal blood vessel, they were willing to spend more time to locate the optic disc and macula. Our precise description strategy tremendously improved the students’ confidence and interest in the practice of direct ophthalmoscopy.
BEAU B. BRUCE NANCY J. NEWMAN VALE´RIE BIOUSSE
Atlanta, Georgia CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article3 for any disclosures of the authors.
1. Mottow-Lippa L, Boker JR, Stephens F. A prospective study of the longitudinal effects of an embedded specialty curriculum on physical examination skills using an ophthalmology model. Acad Med 2009;84(11):1622–1630. 2. Mackay DD, Garza PS, Bruce BB, Bidot S, Graubart EB, Newman NJ, Biousse V, Kelly LP. Teaching Ophthalmoscopy to Medical Students (TOTeMS) II: A one-year retention study. Am J Ophthalmol 2014;157(3):747–748. 3. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS study). Am J Ophthalmol 2013;156(5):1056–1061. e10. 4. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic ocular fundus photography in the emergency department. N Engl J Med 2011;364(4):387–389.
KAIJUN LI JIAN-FENG HE
First Affiliated Hospital of Guangxi Medical University Nanning, China CONFLICT OF INTEREST DISCLOSURES: ALL AUTHORS have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
1. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS study). Am J Ophthalmol 2013;156(5):1056–1061.
REPLY WE HAVE USED STRATEGIES SIMILAR TO THOSE DESCRIBED BY
Li and He to educate medical students in the use of direct ophthalmoscopy. However, even intense longitudinal training programs in direct ophthalmoscopy have not been shown to result in sustained skill retention.1,2 Furthermore, our studies show improved accuracy with fundus photography vs direct ophthalmoscopy immediately after training and 1 year later.2,3 We believe that ocular fundus photograph interpretation is an important component of any ophthalmology curriculum because fundus cameras, especially non-mydriatic ones, are becoming increasingly common, especially outside the ophthalmology clinic.4 VOL. 157, NO. 6
Teaching Ophthalmoscopy to Medical Students (the TOTeMS Study) EDITOR: WE WOULD LIKE TO CONGRATULATE THE TEAM OF KELLY
and associates on a brilliant study,1 and we agree with the idea that efforts need to be focused on teaching direct ophthalmoscopy. This valuable procedure could save lives (in the case of papilledema) and/or the patient’s vision (in the case of diabetic retinopathy or glaucoma).2,3 We also noticed that most physicians do not have the appropriate training during medical school and/or do not retain that knowledge.4 Models that simulate real situations are of value in teaching, as well as in diagnostic and even therapeutic maneuvers. The efficacy of these models depends on the skill transfer from the bench to real life and on retention over months and years. A low-cost model that can stimulate students to learn the physical principles of the direct ophthalmoscope while they participate in its construction was developed by the Medhacker team of the Ocular Bioengineering Laboratory (Ophthalmology Department, Paulista School of Medicine– UNIFESP [Sao Paulo, Brazil]). The model consists of a cardboard box that creates a dark space and allows for different pupil sizes, which creates
different difficulty levels. This simple feature, which is not presented in the published paper, proved to be related to the speed of feature recognition by doctors and students. We also included a glass sphere that simulates the enlargement of the image produced by the human eye, allowing the use of high-definition (900 dpi) photographs with actual-size optic discs. Knowing this, the students can easily understand the optical principles when they see a word written inside of the box and realize that the word is not inverted and bigger, for example. Any retinal image could be used in the model to illustrate different diseases and their stages. The design of the model gives the students a chance to move their heads to observe the entire retinal image, making the scenario more realistic. It is also possible to associate a contact lens with the glass sphere to create different types of ametropia. In our study, we increased the level of difficulty to make the students more interested in the examination technique and in the learning process itself. The students also felt safer when performing the actual examination with real patients after utilizing the model with different retinal images.
ophthalmoscopy on patients. However, as emphasized in our study, we do not believe that efforts should be directed at building better eye models. Instead, we would like to underscore that our study suggests that educators should instead provide greater emphasis on interpreting fundus photographs, because students are more accurate with and prefer using fundus photography both immediately after training and at 1 year.1,2 The importance of the fundus examination in patient care3 should not be hidebound by an attachment to direct ophthalmoscopy, which has resisted sustained skill improvements even with extremely ardent education efforts by our group and others.4 BEAU B. BRUCE NANCY J. NEWMAN VALE´RIE BIOUSSE
Atlanta, Georgia CONFLICT OF INTEREST DISCLOSURES: SEE THE ORIGINAL article1 for any disclosures of the authors.
THIAGO GONC ¸ ALVES DOS SANTOS MARTINS PAULO SCHOR
Sa˜o Paulo, Brazil ANA LUIZA FONTES DE AZEVEDO COSTA
Rio de Janeiro, Brazil ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. The authors indicate no funding support.
1. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS Study). Am J Ophthalmol 2013;156(5):1056–1061. 2. Morad Y, Barkana Y, Avni I, Kozer E. Fundus anomalies: what the pediatrician’s eye can’t see. Int J Qual Health Care 2004; 16(5):363–365. 3. Hitchings RA. Visual disability and the elderly: time for general practitioners to begin preventive screening. BMJ 1989; 298(6681):1126–1127. 4. Stern GA. Teaching ophthalmology to primary care physicians. Arch Ophthalmol 1995;113(6):722–724.
REPLY WE USED SIMILAR CUSTOM-MADE OPTICALLY CORRECT EYE
models in our study; this was shown in the figures.1 We varied pupil sizes by changing the size of the hole in the canister lid (see the second figure of the referenced article), and the 16 diopter convex lens requires students to maneuver their heads in a similar fashion to performing direct 1330
1. Kelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching ophthalmoscopy to medical students (the TOTeMS study). Am J Ophthalmol 2013;156(5): 1056–1061.e10. 2. Mackay DD, Garza PS, Bruce BB, et al. Teaching ophthalmoscopy to medical students (TOTeMS) II: A one-year retention study. Am J Ophthalmol 2014;157(3):747–748. 3. Bruce BB, Lamirel C, Wright DW, et al. Nonmydriatic ocular fundus photography in the emergency department. N Engl J Med 2011;364(4):387–389. 4. Mottow-Lippa L, Boker JR, Stephens F. A prospective study of the longitudinal effects of an embedded specialty curriculum on physical examination skills using an ophthalmology model. Acad Med 2009;84(11):1622–1630.
Outcomes of Repeat Descemetopexy in Post-Cataract Surgery Descemet Membrane Detachment EDITOR: WITH GREAT INTEREST I READ THE ARTICLE BY JAIN AND
associates on the outcomes of repeated descemetopexy in post-cataract surgery Descemet membrane detachment.1 Persistent Descemet membrane detachment after intraocular surgery leads to corneal edema, which compromises vision if the visual axis is involved.2,3 This study reported a promising effect of repeated descemetopexy at 1 month in 12 of 13 patients. The only one who failed had taut Descemet membrane detachment. It indeed was interesting that the methods of the first and repeated descemetopexy were the same. The mean interval
AMERICAN JOURNAL OF OPHTHALMOLOGY