The Use of Peer Optic Nerve Photographsfor Teaching Direct Ophthalmoscopy

Behrad Y. Milani, MD,1 Mercede Majdi, MD,1 Wesley Green, MS,1 Amir Mehralian, MD,1

Majid Moarefi, MD,1 Freddie S. Oh, MD,1 Janet M. Riddle, MD,2 Ali R. Djalilian, MD1

Objective: To use a novel teaching exercise to encourage students to practice ophthalmoscopy and tomeasure the learning effect both subjectively and objectively.

Design: Comparative case series.Participants: One hundred thirty-one fourth-year medical students on their 1-week ophthalmology rotations

with 89 in the experimental group and 42 in the control group.Methods: Those in the experimental group had 1 eye dilated and their optic nerve photographed on the first

day. The next day, these students received an unlabeled optic nerve photograph belonging to 1 of their peers(typically 8–10 per group) and were given 3 days to identify the student matching the photograph. The studentsin the control group were simply encouraged to practice ophthalmoscopy on each other without the use ofphotographs.

Main Outcome Measures: Both objective and subjective changes from the beginning to the end of therotation were measured and compared between the 2 groups.

Results: In the 89 students who used peer optic nerve photographs, 75 (84.3%) showed improvement indirect ophthalmoscopy skills over the course of the week. In contrast, only 12 (28.6%) of the 42 control studentsdemonstrated an objective improvement (P�0.001). The subjective confidence levels likewise were moreimproved in the students who took part in the optic nerve photograph exercise.

Conclusions: These results suggest that the task of matching an unknown optic nerve photograph to thecorrect eye of a peer leads to increased self-confidence and more proficient use of the direct ophthalmoscope.

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed

in this article. Ophthalmology 2013;120:761–765 © 2013 by the American Academy of Ophthalmology.

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Direct ophthalmoscopy is one of the critical physical exami-nation techniques required of all medical school graduates.1 Itis an invaluable tool that enables physicians to recognizecommon ocular abnormalities, ocular manifestations of sys-temic disease, as well as sight- and life-threatening conditions.Despite the importance of developing sufficient skill in per-forming ophthalmoscopy, both students and physicians havedisplayed a lack of confidence in proper performance andidentification of structures within the eye. In one study,2 208medical students were surveyed regarding their confidencewith direct ophthalmoscopy. Eighty-two percent of first- andsecond-year medical students (i.e., junior students), stated theywere “not at all” or only “a little” confident in performingdirect ophthalmoscopy in an undilated eye. When questioningthird- and fourth-year medical students (i.e., senior students)who had obtained additional clinical experience, the confi-dence level was improved, but still discouraging. Many seniormedical students reported they were “not at all” or only “alittle” confident in performing direct ophthalmoscopy on anundilated eye (47%), focusing on the optic nerve head (33%),focusing on the fovea (64%), following vessels (36%), anddifferentiating a healthy from a pathologic retina (48%).2

The lack of proficiency in performing ophthalmoscopy like-wise is reflected by the fact that it is frequently left out from ageneral physical examination. One study3 reviewed 364 notes

that routinely were turned in by third-year medical students as a

© 2013 by the American Academy of OphthalmologyPublished by Elsevier Inc.

art of their curriculum. Only 11% of the notes documentedny attempt at ophthalmoscopy, with less than 2% suggestingctual visualization. Another study4 reviewed 100 case notesrom general internists and geriatricians and found only 3 notesocumenting ophthalmoscopic examination. Of the 72 physi-ians surveyed at the facility, 41 agreed to a questionnaire, ofhich only 18 (44%) were confident in performing ophthal-oscopy properly.A number of innovative approaches for enhancing the in-

truction and practice of ophthalmoscopy have been repor-ed.3,5–10 Most have used nonhuman devices such as cylindri-al plastic canisters,5–7 modified table-tennis balls,8,9 or aimulation mannequin3 to help students master the ophthalmo-copic examination. These devices typically use a photo-raphic representation of a normal or pathologic fundus, whichust be viewed by ophthalmoscopy through an adjustable

upil.7–9 Although these techniques are highly beneficial foreaching the basic skills of direct ophthalmoscopy and assess-ng them objectively, they cannot completely reproduce thexperience of examining a live subject, who poses additionalhallenges such as eye movement and blinking. A previousilot study11 reported the use of a novel approach for assessingphthalmoscopy skills in medical students using optic nervehotographs and volunteer subjects. Ophthalmoscopy skillsere assessed by asking students to examine volunteer subjects

nd to identify the optic nerve photograph corresponding to

761ISSN 0161-6420/13/$–see front matterhttp://dx.doi.org/10.1016/j.ophtha.2012.09.020

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each subject among 3 other decoy pictures (Fig 1). Asman andLinden12 similarly described a computer-based assessmentmethod using optic nerve photography. These methods allowfor the use of human subjects while providing a means forobjective assessment. In the present study, a novel teachingexercise was introduced using peer optic nerve photographs toencourage practice of ophthalmoscopy among medical stu-dents on an ophthalmology rotation. This particular exercisecan enhance ophthalmoscopy skills significantly in medicalstudents both objectively and subjectively.

Materials and Methods

The study was conducted at the University of Illinois at ChicagoMedical School involving fourth-year medical students rotatingthrough their required 1-week ophthalmology clerkship. Beforethis rotation, all students had received formal instruction on directophthalmoscopy during their second year of medical school, in-cluding a hands-on demonstration of the use of the direct ophthal-moscope with supervised practice on fellow students. Addition-ally, most students had experienced a variable amount ofnonstructured exposure to direct ophthalmoscopy during theirthird-year core clerkships. On the first day of their ophthalmologyrotation, all students received an additional 1-hour tutorial withinstructions on the use of a coaxial direct ophthalmoscope. Fur-

Figure 1. Sample array of optic nerve photographs from which objective athe one correct image (A, B, C, or D) after examining a volunteer subje

thermore, it was determined by convenience sample whether each s

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lerkship week would be in the study group or control group.rimarily, when fundus photography was not available on the firstay of the rotation (e.g., camera not working or photographyervice too busy), then those students would be assigned to theontrol group, whereas the remaining weeks would be included inhe study group using the novel teaching exercise. The study waspproved by the Institutional Review Board at the University ofllinois at Chicago and was compliant with the Health Insuranceortability and Accountability Act.

The novel teaching exercise involved photographing the stu-ents’ optic nerves and then providing each student with an anon-mous picture of one of their peers, which they had to identifyorrectly during the rotation. This exercise was implemented in 10otation weeks (89 students). After obtaining verbal informedonsent from the students on the first day of the rotation, alltudents had 1 eye dilated and their optic nerve was photographedsing a Zeiss FF3 camera (Carl Zeiss Meditec, Inc, Dublin, CA).ny student who declined dilation was excluded from the study.he next day, each student received an unlabeled optic nervehotograph belonging to 1 of their 8 to 10 peers and was given 3ays to identify the student who matched their picture. Thenstructor was present intermittently to provide feedback and tonsure participation of all students. In contrast, the students inhe control group were encouraged simply to practice ophthal-oscopy on each other throughout the week with the instructor

vailable for guidance and questions as deemed necessary byhe students. A total of 5 rotation weeks (42 students) were

ent of ophthalmoscopy skills was carried out. The student had to identifyndilated eye.

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tudied as part of the control group. In total, 131 students were

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included in the study from an approximately 180 potential fourth-year students. The students who were not included in this studyeither had declined to be dilated (5–10 students total) or hadrotated during particular weeks when the study could not beimplemented (e.g., because of the lack of volunteer subjects for theobjective testing). All students involved in the study were encour-aged to use a coaxial ophthalmoscope (i.e., not panoptic) in partbecause the objective test at the end of the rotation was based onthis type of ophthalmoscope. It was hypothesized that this novelteaching activity would encourage more practice among thosestudents and would result in a more pronounced enhancement intheir ophthalmoscopy skills.

A previously described assessment method11 was used to as-sess ophthalmoscopy skills objectively at the beginning (i.e., be-fore exposure to the novel teaching strategy) and end of therotation for both the experimental and the control group. Thisrequired each student to examine the undilated eye of 2 separateand never-before-seen volunteer subjects (1 left and 1 right eye).For each volunteer subject, the student attempted to identify the 1correct optic nerve photograph—from an array of 4 totalpictures—that matched the examined eye (Fig 1). The studentsreceived a score of 2 (both eyes correctly identified), 1 (1 eyeidentified correctly), or 0 (both eyes identified incorrectly). A1-point increase in this score from the beginning to the end ofrotation was considered an improvement. Along with this objectiveassessment, the students were asked to grade subjectively theirown confidence level in performing direct ophthalmoscopy using a5-point scale: not confident, a little confident, somewhat confident,quite confident, and very confident. These objective and subjectiveevaluations were completed by all students both at the beginningand at the end of the rotation.

Statistical analysis was carried out using the SPSS software(SPSS, Inc, Chicago, IL). The data between the 2 groups werecompared using either the chi-square test (categorical data), the ttest (data with normal distribution), or the Wilcoxon rank-sum test(for data not normally distributed).

Results

A total of 131 fourth-year medical students completed the study,including 89 students in the peer optic nerve photograph group and42 students in the control group. The students’ performance on theobjective tests at baseline and after the rotation was analyzed andcompared. As shown in Table 1 and Figure 2, both groups dem-onstrated improvement in their performance from the beginning tothe end of the rotation. However, the peer optic nerve photographgroup showed a more marked improvement, with 84.3% of stu-dents performing better than their baseline results compared with28.6% of students in the control group (P�0.001). The distributionof the outcomes for the results at baseline and after the rotationshowed a similar trend (Fig 2). Although the baseline ophthalmos-

Table 1. Changes in Performance from the Beginning to theEnd of the Rotation Using an Objective Assessment of

Ophthalmoscopy Skills

Before Rotationversus After

Rotation WorseNo

Difference Better P Value

Control 3 (7.1%) 27 (64.3%) 12 (28.6%) �0.001Peer Optic Nerve

Photograph3 (3.4%) 11 (12.4%) 75 (84.3%)

aExercise

opy skills were similar between the 2 groups (P � 0.57), objec-ive testing at the end of the rotation revealed the peer optic nervehotograph group to be significantly more competent, with approx-mately 60% of the students correctly identifying both optic nervesersus only 12% in the control group (P�0.001; Fig 2). Likewise,7% of the control group was unable to identify correctly eitherye at the end of the rotation, whereas only approximately 7% ofhe peer optic nerve group failed to identify correctly at least 1 eyeFig 2).

All 131 medical students also subjectively graded their confi-ence level in performing direct ophthalmoscopy at the beginningnd at the end of the 1-week ophthalmology clerkship. The con-dence levels at baseline were not statistically different between

he 2 groups, with the most common response in each group beinga little confident” and no students reporting feeling “very confi-ent” with direct ophthalmoscopy (data not shown). At the end ofhe rotation, both groups subjectively reported increased confi-

igure 3. Bar graph showing the distribution of subjective confidence levelsith ophthalmoscopy in the control and peer optic nerve photograph groups

igure 2. Bar graph showing the distribution of objective direct ophthalmoscopyerformance outcomes at the beginning (Pre-test) and end (Post-test) of theotation in both the control and peer optic nerve photograph groups. 2 points2/2 eyes correctly identified; 1 point (1/2 eyes correctly identified).

t the end of the rotation. control;▓ peer optic nerve photo.

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dence compared with baseline results; however, the peer opticnerve photograph group was distinctly more confident than thecontrol group (P�0.003). The vast majority of responses in thepeer optic nerve photograph group were “somewhat confident” or“quite confident,” with approximately 10% of students feeling“very confident” with their direct ophthalmoscopy skills. In con-trast, the control group improved less dramatically, with moststudents feeling “somewhat confident” or “a little confident” andwith no “very confident” responses (Fig 3).

Discussion

Medical students and physicians repeatedly have demon-strated having low self-confidence and poor performance intheir use of the direct ophthalmoscope.2–4 There are manyreasons why students do not acquire this skill as part of theirtraining. At a fundamental level, this could be attributed tothe fact that ophthalmology is often underemphasized in thecurriculum and, for instance, it is no longer a requiredclerkship in most United States medical schools.3 However,even when sufficient time is dedicated to ophthalmology,most medical schools do not have a structured teachingmethod to help students master the use of an ophthalmo-scope. Thus, there is a need to promote the use of directophthalmoscopy by further enhancing the learning processand increasing the confidence level in this examinationtechnique. As mentioned earlier, a variety of innovativeapproaches have been reported for teaching ophthalmos-copy to medical students and physicians.3,5–10

This study examined an interactive and engaging learn-ing exercise that requires the students to perform ophthal-moscopy repeatedly to match an unlabeled optic nervephotograph to the correct peer. The results demonstrate thatthis novel teaching strategy improves both objective profi-ciency and subjective self-confidence in the performance ofdirect ophthalmoscopy.

There are a few features of this novel teaching exercisethat are worth noting. Although a number of methods forteaching physical examination skills have been described,one of the keys to mastering any examination techniquesuccessfully is practice and repetition.13 However, it is oftendifficult to keep students actively engaged and motivated ina repetitive learning process, particularly when there is noobvious purpose or end point. One of the advantages of thepeer optic nerve photograph exercise is that it requires thestudents to perform ophthalmoscopy repeatedly on a num-ber of their peers while having a well-defined purpose andobjective. The optic nerve photograph not only provides thestudents with an observable guide to define the level ofdetail that they should be able to visualize during examina-tion, but it also promotes a more active learning process,which is essential for a competency-based education.14 Al-though having an instructor to guide the students intermit-tently enhances this exercise, this learning strategy alsotakes advantage of peer-to-peer teaching, which previouslyhas been shown to be effective in medical education.15 Inaddition to sharing examination tips, the subjects can giveimmediate feedback to the examiner on whether the light

beam is directed in the right location. Finally, the group

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ature of the activity also increases the “fun” factor basedn student reviews of the rotation (data not reported).

The described teaching method does have several limi-ations. One limitation is the fact that ophthalmoscopy waserformed on young and healthy subjects without ocularathologic features who also typically are more cooperativend have larger pupils compared with many older patients.owever, the increased confidence and skill level estab-

ished through this exercise potentially may increase theikelihood of future use of ophthalmoscopy on real patients.nother limitation is that the exercise is focused on visual-

zation of the optic nerve head and surrounding vessels.lthough this does not include all of the skills required forirect ophthalmoscopy, it does represent a difficult andmportant portion of the technique. To be more encompass-ng, this method of encouragement should be combinedith further methods of teaching to emphasize additional

spects of the examination, recognition of pathologic fea-ures, and clinical decision making.3 One such method wasescribed by Lippa,16 who introduced a novel disc mantraCCCMV: cup, color, contour, margins, vessels) to rein-orce key aspects of the fundoscopic examination. Theirrading algorithm for fundoscopy involves a 25-point scalehat examines the students’ ability to assess correctly theCCMV, to identify any retinal pathologic features, and to

each a final diagnosis with a list of differential diagnoses.ther additional measures that may be added to make theeer optic nerve exercise more robust include asking thetudents also to draw the optic nerves of their peers, docu-enting the number of times each student performs oph-

halmoscopy, and finally a longitudinal follow-up study toetermine whether this teaching exercise leads to continuedse of direct ophthalmoscopy in residency and ultimately inlinical practice. Also, although this current study used onlyoaxial direct ophthalmoscopy, it could be expanded tonclude panoptic ophthalmoscopy as well.

In summary, this article reports a novel teaching activitysing peer optic nerve photographs that can be implementedasily in programs that have access to fundus photography.his teaching exercise was found to increase ophthalmos-opy skills and confidence levels among students, which inurn may increase the likelihood of performing ophthalmos-opy in future patient encounters.

eferences

1. Mottow-Lippa L. Ophthalmology in the medical schoolcurriculum: reestablishing our value and effecting change.Ophthalmology 2009;116:1235–6.

2. Gupta RR, Lam WC. Medical students’ self-confidence inperforming direct ophthalmoscopy in clinical training. Can JOphthalmol 2006;41:169–74.

3. Lippa LM, Boker J, Duke A, Amin A. A novel 3-year longi-tudinal pilot study of medical students’ acquisition and reten-tion of screening eye examination skills. Ophthalmology2006;113:133–9.

4. Roberts E, Morgan R, King D, Clerkin L. Funduscopy: a

forgotten art? Postgrad Med J 1999;75:282–4.

1

1

1

1

1

1

Milani et al � Peer Optic Nerve Photographs to Teach Direct Ophthalmoscopy

5. Chung KD, Watzke RC. A simple device for teaching directophthalmoscopy to primary care practitioners. Am J Ophthal-mol 2004;138:501–2.

6. Hoeg TB, Sheth BP, Bragg DS, Kivlin JD. Evaluation of a toolto teach medical students direct ophthalmoscopy. WMJ 2009;108:24–6.

7. Swanson S, Ku T, Chou C. Assessment of direct ophthalmos-copy teaching using plastic canisters. Med Educ 2011;45:520–1.

8. Levy A, Churchill AF. Training and testing competence indirect ophthalmoscopy. Med Educ 2003;37:483–4.

9. Bradley P. A simple eye model to objectively assess ophthal-moscopic skills of medical students. Med Educ 1999;33:592–5.

10. Cordeiro MF, Jolly BC, Dacre JE. The effect of formal in-struction in ophthalmoscopy on medical student performance.

Med Teach 1993;15:321–5.

Footnotes and Financial Disclosures

discussed in this article.

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CVS

1. Afshar AR, Oh FS, Birnbaum AD, et al. Assessing ophthal-moscopy skills [letter]. Ophthalmology 2010;117:1863.

2. Asman P, Linden C. Internet-based assessment of medical students’ophthalmoscopy skills. Acta Ophthalmol 2010;88:854–7.

3. Conn JJ, Lake FR, McColl GJ, et al. Clinical teaching andlearning: from theory and research to application. Med J Aust2012;196:527.

4. Sanson-Fisher RW, Rolfe IE, Williams N. Competency basedteaching: the need for a new approach to teaching clinicalskills in the undergraduate medical education course. MedTeach 2005;27:29–36.

5. Weyrich P, Celebi N, Schrauth M, et al. Peer-assisted versusfaculty staff-led skills laboratory training: a randomised con-trolled trial. Med Educ 2009;43:113–20.

6. Lippa L. The Disc Mantra: An Algorithm for Fundus Descrip-tion. MedEdPORTAL; 2008. Available at: www.mededportal.

org/publication/1086. Accessed September 2, 2012.

Originally received: June 21, 2012.Final revision: August 17, 2012.Accepted: September 11, 2012.Available online: December 12, 2012. Manuscript no. 2012-904.1 Department of Ophthalmology and Visual Sciences, Illinois Eye and EarInfirmary, University of Illinois at Chicago, Chicago, Illinois.2 Department of Medical Education, University of Illinois at Chicago,Chicago, Illinois.

Financial Disclosure(s):The author(s) have no proprietary or commercial interest in any materials

upported by an unrestricted grant from Research to Prevent Blindness,nc, New York, New York; and a Curriculum and Instruction Grant fromhe University of Illinois at Chicago, Chicago, Illinois. Dr. Djalilian is alsohe recipient of a Career Development Grant K08EY017561-A1 from theational Eye Institute, National Institutes of Health, Bethesda, Maryland,

s well as a Career Development Grant from Research to Prevent Blind-ess, Inc.

orrespondence: Ali R. Djalilian, MD, Department of Ophthalmology andisual Sciences, University of Illinois at Chicago, 1855 West Taylor

treet, M/C 648, Chicago, IL 60612. E-mail: adjalili@uic.edu.

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