The utility of a smartphone‐enabled ophthalmoscope in pre‐clinical fundoscopy training

Abstract

We would like to report a novel teaching adjunct to pre-clinical direct ophthalmoscopy training. While various techniques have been devised to improve instruction with direct ophthalmoscopy, they can be of poor image quality and costly (Borgersen et al. 2016; Twing et al. 2016; Gupta et al. 2017; Ricci & Ferraz 2017). Moreover, none allow for practice on a live patient. With these disadvantages in mind, the need for an effective and practical method of improving direct ophthalmoscopy instruction is ever-present. The purpose of this study was to determine the utility of a smartphone-enabled ophthalmoscope as a teaching aid in pre-clinical fundoscopy training. This randomized study was conducted at Rosalind Franklin University of Medicine and Science (RFUMS). First- and second-year (pre-clinical) medical students and first-year podiatry students were recruited as volunteer participants. Exclusion criteria included previous fundoscopy training outside of the RFUMS curriculum. Each participant was randomly assigned to either use a conventional ophthalmoscope (CO) or a smartphone-enabled ophthalmoscope (SEO). Students in both study arms were given an identical didactic introduction on fundoscopy and retinal anatomy, followed by a demonstration on the use of their device. Participants were then given time to practice fundoscopy on their colleagues’ undilated eyes using their assigned ophthalmoscope. After each practical session, participants completed a questionnaire, which asked them to rate their ability to visualize their colleagues’ red reflex, optic disc and retinal vascular arcades by circling Yes, No or Unsure; and to rate their confidence in performing direct ophthalmoscopy using their assigned ophthalmoscope on a Likert scale of 1 (not at all confident) to 5 (extremely confident). Additionally, the experimental group was asked to rate the usefulness of a smartphone-enabled ophthalmoscope in teaching fundoscopy on a Likert scale of 1 (not at all useful) to 5 (extremely useful). For visualization of the abovementioned structures, means and standard deviations were statistically compared using chi-squared analysis. For Likert score data, means and standard deviations were compared using the Fisher's exact test. Ninety students volunteered to participate in this study. Of these, 2 were excluded due to previous direct ophthalmoscopy experience outside of the RFUMS core curriculum. After exclusion, 88 students remained for analysis, including 30 first-year podiatry students (n = 15 in each group), 30 first-year medical students (n = 15 in each group) and 28 second-year medical students (n = 14 in each group). Compared to participants using the CO, significantly more students using the SEO identified the optic disc (100% versus 36%, p < 0.001) and retinal vascular arcade (100% versus 64%, p < 0.001). Similar trends were seen when comparing performance across each class subgroup (Table 1). Reported Likert confidence ratings amongst participants using the SEO were significantly higher than those reported by participants using the CO (4.50 ± 0.629 versus 2.61 ± 0.813, p < 0.001). Participants using the SEO reported the D-EYE to be useful as a teaching aid in fundoscopy training (4.77 ± 0.522). Poorly performed fundoscopy secondary to poor pre-clinical training is a pervasive problem amongst non-ophthalmologist providers that can lead to incomplete or inadequate workup of patients with suspected ocular disease (Byrd et al. 2014). One of the primary difficulties in learning and teaching direct ophthalmoscopy using a CO is the device's inherent inability to share the user's view with an instructor. This not only creates difficulty in verifying students’ reported findings, but also limits the instructor's ability to offer constructive feedback (Schulz et al. 2016). The D-EYE effectively addresses this barrier, making it a useful educational tool in fundoscopy training. Additionally, this study population included both medical and podiatry pre-clinical students. This choice was intentional, as podiatrists also care for a large population of diabetic patients who are likely to suffer from both ocular and podiatric complications. By having a basic understanding of direct ophthalmoscopy and a strong level of confidence in performing a basic fundoscopic examination, podiatrists and other non-ophthalmologist providers can help identify early signs of ocular pathology and prevent complications through expeditious ophthalmology referrals.

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