The NYEE-Orbis Oculoplastic Surgery Online Curriculum: A Pilot Study

The NYEE-Orbis Oculoplastic Surgery Online Curriculum: A Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The NYEE-Orbis Oculoplastic Surgery Online Curriculum: A Pilot Study Helen Liu, Jackson Scharf, Jason Jo AB, Jennifer L. Patnaik, David Hunter Cherwek, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7443954/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Ophthalmology residency programs vary greatly in their exposure to oculoplastic conditions based on geographic location, practice setting, presence of fellows, and availability of attending surgeons. Few easily-accessible, structured, interactive curricular resources exist, and the efficacy of these resources is largely unstudied. Methods Thirty ophthalmology residents (PGY2–4) at a single US institution completed a pre-test of oculoplastic clinical knowledge and a survey of self-reported confidence in oculoplastic topics. Following completion of the online curriculum, residents repeated the knowledge test and the confidence survey. Outcomes were compared using Wilcoxon signed-rank tests, analysis of variance, and linear mixed effects modeling. Results The mean clinical knowledge score improved from 15.6 ± 3.0 (pre-course) to 20.3 ± 4.4 (post-course) (p < 0.001), with 84% of residents showing score gains. Although senior residents had higher baseline scores, post-course scores did not differ significantly by training level. Junior trainees (PGY2/PGY3) experienced the greatest benefit, while PGY4 improvements were not statistically significant. Self-reported confidence in the diagnosis, understanding, and management of oculoplastic conditions significantly increased across multiple procedure types (all p < 0.01). The curriculum received high satisfaction ratings, and a majority of participants expressed a preference for online learning post-intervention. Conclusions A structured, interactive, and freely available online curriculum improved oculoplastics-related clinical knowledge and confidence among residents in this cohort, suggesting the effectiveness of this curriculum to supplement oculoplastics training. medical education residency training oculoplastics and orbital surgery educational resource interactive online curriculum Figures Figure 1 Figure 2 INTRODUCTION Oculoplastics encompasses the diagnosis and management of conditions in the periorbital region 1,2 . Exposure to this subspecialty during ophthalmology residency varies widely based on geographic location, practice setting, presence of fellows, and availability of attending surgeons 1,2 . A survey of US ophthalmology residents found that 30% felt underprepared in oculoplastics at graduation 3 . Furthermore, globally, there is a shortage of educators particularly in sub-Saharan Africa. A survey of 155 Nigerian ophthalmologists found only 8 (5.2%) received oculoplastics training 4 . The Accreditation Council for Graduate Medical Education (ACGME) requires a minimum of 86 cataract cases but only 28 oculoplastics procedures, with just three cases each for blepharoplasty/ptosis repair, chalazion excision, and eyelid lacerations/canalicular repair 1,5 . Several studies have shown that ACGME case minimums can influence resident surgical experience by narrowing the range of procedures performed 6,7 . For example, a multi-institutional study found 43% of residents reported no lateral canthotomy experience, a procedure not explicitly stated in the ACGME minimums 8 . Finally, limited rotation length and the practice specifics (e.g. high vs. low-trauma, private practice vs. public health) may limit trainee experience. Standardized ophthalmology texts (e.g. the Basic and Clinical Science Curriculum, or BCSC) include anatomy, pathophysiology, and management, but these resources are not intended for teaching surgical techniques. Anecdotally, we’ve found that residents do not use textbooks for surgical preparation, but rather use the most readily-found online videos. These videos vary in quality and typically omit foundational principles and decision-making frameworks. In-person surgical education occurs via 1-on-1 apprenticeship during live surgery. A few well-resourced programs utilize simulation and animal models that also require in-person instruction 9–17 . For both American and international trainees, curated online content could expand educational access. Despite increased recognition of the value of online learning, no free systematic oculoplastics curricula currently exist to our knowledge 1,6,8–23 . There have also been very few studies on the efficacy of any of these materials in knowledge acquisition. To address these deficiencies, we developed a stepwise interactive online oculoplastics curriculum that pairs clinical evaluation with surgical decision-making and principles. This study evaluates the impact of this curriculum on resident knowledge and confidence. METHODS Resource materials One of the investigators (HSR) created the NYEE-Orbis Oculoplastic Surgery Online curriculum as two courses freely available on the Cybersight online platform (Orbis International): “Basics of Oculoplastics Surgery (BOS)” and “Intermediate Oculoplastics Surgery (IOS)” (see appendix for contents) 24 . Both courses use drag-and-drop features, questions, labeled images, and surgical videos, minimizing passive reading, The curriculum contains over 800 slides and can be completed in 5–7 hours. Study Design This prospective study was approved by the Institutional Review Board at the Icahn School of Medicine (No.23-01344, Mount Sinai Hospital, New York, New York). All procedures adhered to the Declaration of Helsinki. In this prospective study, thirty ophthalmology residents (PGY2–4) at a single US institution (New York Eye and Ear Infirmary) were asked to complete a 30-question knowledge test (Pre-course test) covering practical anatomy, clinical evaluation, and surgical management in oculoplastics as well as a confidence survey (See Supp. 1 for pre-course assessment). Unique identifiers allowed for paired analysis. Residents were given one month to complete the BOS and IOS courses at their own pace (Table S1 ). Subsequently, they took the same 30-question knowledge assessment (Post-course test), confidence survey, and were asked for feedback on the courses (See Supp. 2 for post-course assessment). Statistical Analysis All analyses were performed using R version 4.4.1 (R Core Team 2024) 25–27 . Normality was assessed with Shapiro-Wilk’s test and visual plots. Pre- and post-course test scores were compared using linear mixed effects modeling (accounting for paired data). Subgroup analysis by PGY training level was performed with analysis of variance (ANOVA) modeling. Confidence scores are reported as median ± interquartile ranges (IQR), and compared using Wilcoxon signed-rank tests. Categorical variables were analyzed using Fisher’s exact tests. RESULTS Clinical Knowledge Test Among the 30 participating residents, the mean pre-course test score was 15.6 ± 3.0, which significantly improved in the post-course test score to 20.3 ± 4.4 (p < 0.001). Most residents (84%) improved their scores (Figure 1), with a mean gain of 5.4 ± 5.0 points (18% score improvement). Senior trainees started with higher baseline scores (14.0 for PGY-2s, 13.7 for PGY-3s, 18.6 for PGY-4s) (p < 0.001) but post-course scores did not differ significantly by PGY level (21 for PGY-2s, 20.3 for PGY-3s, 19.2 for PGY-4s) (p = 0.797) (Figure 2). The difference in scores was significantly improved for junior trainees (p < 0.005) and nonsignificant for PGY-4s (p = 0.574). Confidence and Course Feedback Self-reported confidence in oculoplastic anatomy, pathophysiology, and management increased significantly for all surgeries (p < 0.01; Table 1 ). This improvement extended to procedures not emphasized by ACGME minimums, including ectropion, entropion, evisceration, and enucleation. PGY-2 and PGY-3 residents demonstrated a larger increase in self-confidence regarding oculoplastics knowledge compared to PGY-4 residents. Subgroup analysis by training level showed that PGY-2 residents experienced significant gains in confidence in diagnosing oculoplastics conditions, understanding anatomy, and knowledge of surgical principles and techniques (all p < 0.005). PGY-3 residents significantly improved in understanding anatomy and surgical techniques (p 0.05). The curriculum received a median satisfaction rating of 5 (IQR: 5–5), 5 being the highest score. Open-ended feedback highlighted enhanced understanding of anatomy and appreciation for the interactive format. Preference for online learning increased from 72% to 95% (p = 0.111). Table 1 Pre- vs. Post-Curriculum Knowledge/Confidence/Comfort Level with Oculoplastics Questions Pre-course test - Median ± IQR Post-course test - Median ± IQR P Value Rate… 1 – Lowest, 5 - Highest Comfort with Diagnosing Oculoplastics Conditions in Clinic 3.0 ± 2.0 4.0 ± 1.5 < 0.001 Understanding on Eyelid and Soft Tissue Anatomy 3.0 ± 1.0 4.0 ± 2.0 < 0.001 Understanding on the Basic Oculoplastic Surgical Principles and Suturing Techniques 2.0 ± 2.0 4.0 ± 1.0 < 0.001 Understanding on the Oculoplastic Instruments and Suture Types 2.0 ± 2.0 4.0 ± 1.0 < 0.001 How confident are you in understanding the pathophysiology, anatomy, surgical decision making, and surgical steps of the following procedures? (1 - Lowest, 5 - Highest) Chalazion 4.0 ± 2.0 5.0 ± 0.0 0.008 Laceration Repair 3.0 ± 1.5 4.0 ± 1.0 < 0.001 Blepharoplasty 3.0 ± 1.5 5.0 ± 2.0 < 0.001 Ectropion 2.0 ± 2.0 3.0 ± 1.0 < 0.001 Entropion 2.0 ± 2.0 3.0 ± 1.0 < 0.001 Internal Ptosis Repair 2.0 ± 2.0 4.0 ± 1.5 < 0.001 External Ptosis Repair 2.0 ± 2.0 3.0 ± 1.0 < 0.001 Evisceration 2.0 ± 2.0 3.0 ± 1.5 < 0.001 Enucleation 2.0 ± 2.0 3.0 ± 1.0 0.005 Total Clinical Assessment Scores* 15.6 ± 3.0 20.3 ± 4.4 < 0.001 IQR = interquartile range, * = Mean ± Standard Deviation DISCUSSION Given variable oculoplastics learning experiences across ophthalmology residencies, additional educational resources are needed. Online surgical materials have shown advantages over traditional text-based resources, yet existing content is limited 1,22,23,28–30 . We evaluated an image + video-based online curriculum that pairs relevant anatomy, clinical decision-making, and operative steps in an active learning format. Residents begin with fundamental content and procedures, progressing to complex procedures. Residents demonstrated significant improvement in clinical knowledge scores after completing the course (15.6 vs 20.3). While baseline scores were higher among senior residents, the lack of post-course test differences between PGY levels suggest that all residents are capable of learning this content in a relatively short period (on average 5.7 + 1.3 hours). Notably, junior trainees (PGY2 and PGY3) exhibited the most pronounced gains (p < 0.005), while PGY4 residents showed improvement that did not reach statistical significance (p = 0.574). Likewise, junior trainees also exhibited the most pronounced gains in self-reported confidence levels in knowledge of pathophysiology, diagnosis and management of oculoplastics conditions (p 0.05). These findings suggest that introducing this educational content earlier in training may be particularly advantageous. Once residents have completed the course, they have access to revisit the content as needed, e.g. to review the surgical video prior to live surgery. On any given rotation, a resident may not perform all the surgeries in this curriculum, so the online coursework can fill in knowledge gaps, fulfilling the residency program’s goal of a uniform oculoplastic surgical foundation for all trainees. Finally, there was universal appreciation for this format of self-guided interactive learning with residents writing, “Innovative, creative, and interactive course that allowed for better learning and engagement”, “Really enjoyed the course and helped the anatomy (tougher to learn through a textbook) stick better as well”, “Intermediate course is great to review for R3s prior to plastics OR”. This was a single-institution study, and the results may not be universally relevant. However, even in our program where residents were taught by many oculoplastic surgery attendings on a formal rotation, received didactic instruction, and wetlab curriculum (i.e. a well-resourced ‘traditional curriculum), they still demonstrated significant knowledge gains and reported increased confidence. In programs with low oculoplastics exposure, trainees could potentially have an even greater increase in post-course test scores. Another limitation of this pilot study was that long-term knowledge retention was not assessed. As this curriculum is intended to be of practical value to surgeons, future research could directly evaluate resident surgical performance. We believe our online resource can create a baseline for learners and be readily integrated with didactics, wet-labs and live surgery to optimize the teacher’s time. Such a curriculum may be particularly useful in busy under-resourced settings with a shortage of oculoplastics faculty. CONCLUSION Practical surgical training in oculoplastics is variable and often limited. This study demonstrates that an interactive online curriculum can improve clinical knowledge and trainee confidence in oculoplastic surgeries. Declarations Funding: This manuscript was funded by a grant from Research to Prevent Blindness given to the New York Eye and Ear Infirmary of Mount Sinai Department of Ophthalmology. Ethics approval , Consent to Participate : Approval was obtained from the Institutional Review Boards of the Icahn School of Medicine (No.23-01344, Mount Sinai Hospital, New York, New York). Informed consent was obtained from all individual participants included in the study. All participants consented to participating in this study. Consent to Publish : The authors affirm that all participants provided informed consent for publication of their data. No identifying images or other personal or clinical details of participants that compromise anonymity are presented. Consent for publication was obtained for all patient figures. Clinical Trial Number Not applicable. Author Contribution Helen Liu: Writing – original draft, Methodology, Formal analysis, Data curation. Jackson Scharf: Writing – original draft, Methodology, Data curation. Jason Jo: Writing – review & editing. Jennifer Patnaik: Conceptualization, Writing – review & editing. David H. Cherwek: conceptualization, writing – review & editing. Daniel Neely: Conceptualization, Writing – review & editing. Shailesh Gaurav: Conceptualization, Writing – review & editing. Harsha S Reddy: Writing – review & editing, Supervision, Methodology, Data curation, Conceptualization. Data Availability The data that support the findings of this study are not openly available due to participant privacy or ethical restrictions. The data are available upon reasonable request from the corresponding author. Additional Declarations No competing interests reported. Supplementary Files PreCourseSurvey.pdf PostCourseSurvey.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 29 Oct, 2025 Reviewers invited by journal 27 Oct, 2025 Editor assigned by journal 24 Oct, 2025 Editor invited by journal 17 Sep, 2025 Submission checks completed at journal 17 Sep, 2025 First submitted to journal 17 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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periorbital region\u003csup\u003e1,2\u003c/sup\u003e. Exposure to this subspecialty during ophthalmology residency varies widely based on geographic location, practice setting, presence of fellows, and availability of attending surgeons\u003csup\u003e1,2\u003c/sup\u003e. A survey of US ophthalmology residents found that 30% felt underprepared in oculoplastics at graduation\u003csup\u003e3\u003c/sup\u003e. Furthermore, globally, there is a shortage of educators particularly in sub-Saharan Africa. A survey of 155 Nigerian ophthalmologists found only 8 (5.2%) received oculoplastics training\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe Accreditation Council for Graduate Medical Education (ACGME) requires a minimum of 86 cataract cases but only 28 oculoplastics procedures, with just three cases each for blepharoplasty/ptosis repair, chalazion excision, and eyelid lacerations/canalicular repair\u003csup\u003e1,5\u003c/sup\u003e. Several studies have shown that ACGME case minimums can influence resident surgical experience by narrowing the range of procedures performed\u003csup\u003e6,7\u003c/sup\u003e. For example, a multi-institutional study found 43% of residents reported no lateral canthotomy experience, a procedure not explicitly stated in the ACGME minimums\u003csup\u003e8\u003c/sup\u003e. Finally, limited rotation length and the practice specifics (e.g. high vs. low-trauma, private practice vs. public health) may limit trainee experience.\u003c/p\u003e\u003cp\u003eStandardized ophthalmology texts (e.g. the Basic and Clinical Science Curriculum, or BCSC) include anatomy, pathophysiology, and management, but these resources are not intended for teaching surgical techniques. Anecdotally, we\u0026rsquo;ve found that residents do not use textbooks for surgical preparation, but rather use the most readily-found online videos. These videos vary in quality and typically omit foundational principles and decision-making frameworks. In-person surgical education occurs via 1-on-1 apprenticeship during live surgery. A few well-resourced programs utilize simulation and animal models that also require in-person instruction\u003csup\u003e9\u0026ndash;17\u003c/sup\u003e. For both American and international trainees, curated online content could expand educational access.\u003c/p\u003e\u003cp\u003eDespite increased recognition of the value of online learning, no free systematic oculoplastics curricula currently exist to our knowledge\u003csup\u003e1,6,8\u0026ndash;23\u003c/sup\u003e. There have also been very few studies on the efficacy of any of these materials in knowledge acquisition. To address these deficiencies, we developed a stepwise interactive online oculoplastics curriculum that pairs clinical evaluation with surgical decision-making and principles. This study evaluates the impact of this curriculum on resident knowledge and confidence.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eResource materials\u003c/h2\u003e\u003cp\u003eOne of the investigators (HSR) created the NYEE-Orbis Oculoplastic Surgery Online curriculum as two courses freely available on the Cybersight online platform (Orbis International): \u0026ldquo;Basics of Oculoplastics Surgery (BOS)\u0026rdquo; and \u0026ldquo;Intermediate Oculoplastics Surgery (IOS)\u0026rdquo; (see appendix for contents)\u003csup\u003e24\u003c/sup\u003e. Both courses use drag-and-drop features, questions, labeled images, and surgical videos, minimizing passive reading, The curriculum contains over 800 slides and can be completed in 5\u0026ndash;7 hours.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Design\u003c/h3\u003e\n\u003cp\u003e This prospective study was approved by the Institutional Review Board at the Icahn School of Medicine (No.23-01344, Mount Sinai Hospital, New York, New York). All procedures adhered to the Declaration of Helsinki. In this prospective study, thirty ophthalmology residents (PGY2\u0026ndash;4) at a single US institution (New York Eye and Ear Infirmary) were asked to complete a 30-question knowledge test (Pre-course test) covering practical anatomy, clinical evaluation, and surgical management in oculoplastics as well as a confidence survey (See Supp.\u0026nbsp;1 for pre-course assessment). Unique identifiers allowed for paired analysis. Residents were given one month to complete the BOS and IOS courses at their own pace (Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Subsequently, they took the same 30-question knowledge assessment (Post-course test), confidence survey, and were asked for feedback on the courses (See Supp.\u0026nbsp;2 for post-course assessment).\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll analyses were performed using R version 4.4.1 (R Core Team 2024)\u003csup\u003e25\u0026ndash;27\u003c/sup\u003e. Normality was assessed with Shapiro-Wilk\u0026rsquo;s test and visual plots. Pre- and post-course test scores were compared using linear mixed effects modeling (accounting for paired data). Subgroup analysis by PGY training level was performed with analysis of variance (ANOVA) modeling. Confidence scores are reported as median\u0026thinsp;\u0026plusmn;\u0026thinsp;interquartile ranges (IQR), and compared using Wilcoxon signed-rank tests. Categorical variables were analyzed using Fisher\u0026rsquo;s exact tests.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical Knowledge Test\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr /\u003e Among the 30 participating residents, the mean pre-course test score was 15.6 \u0026plusmn; 3.0, which significantly improved in the post-course test score to 20.3 \u0026plusmn; 4.4 (p \u0026lt; 0.001). Most residents (84%) improved their scores (Figure 1), with a mean gain of 5.4 \u0026plusmn; 5.0 points (18% score improvement). Senior trainees started with higher baseline scores (14.0 for PGY-2s, 13.7 for PGY-3s, 18.6 for PGY-4s) (p \u0026lt; 0.001) but post-course scores did not differ significantly by PGY level (21 for PGY-2s, 20.3 for PGY-3s, 19.2 for PGY-4s) (p = 0.797) (Figure 2). The difference in scores was significantly improved for junior trainees (p \u0026lt; 0.005) and nonsignificant for PGY-4s (p = 0.574).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConfidence and Course Feedback\u003c/h3\u003e\n\u003cp\u003eSelf-reported confidence in oculoplastic anatomy, pathophysiology, and management increased significantly for all surgeries (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). This improvement extended to procedures not emphasized by ACGME minimums, including ectropion, entropion, evisceration, and enucleation. PGY-2 and PGY-3 residents demonstrated a larger increase in self-confidence regarding oculoplastics knowledge compared to PGY-4 residents. Subgroup analysis by training level showed that PGY-2 residents experienced significant gains in confidence in diagnosing oculoplastics conditions, understanding anatomy, and knowledge of surgical principles and techniques (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.005). PGY-3 residents significantly improved in understanding anatomy and surgical techniques (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while PGY-4 residents did not demonstrate significant improvement in these areas (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The curriculum received a median satisfaction rating of 5 (IQR: 5\u0026ndash;5), 5 being the highest score. Open-ended feedback highlighted enhanced understanding of anatomy and appreciation for the interactive format. Preference for online learning increased from 72% to 95% (p\u0026thinsp;=\u0026thinsp;0.111).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePre- vs. Post-Curriculum Knowledge/Confidence/Comfort Level with Oculoplastics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eQuestions\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePre-course test - Median\u0026thinsp;\u0026plusmn;\u0026thinsp;IQR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePost-course test - Median\u0026thinsp;\u0026plusmn;\u0026thinsp;IQR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP Value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRate\u0026hellip; 1 \u0026ndash; Lowest, 5 - Highest\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComfort with Diagnosing Oculoplastics Conditions in Clinic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnderstanding on Eyelid and Soft Tissue Anatomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnderstanding on the Basic Oculoplastic Surgical Principles and Suturing Techniques\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnderstanding on the Oculoplastic Instruments and Suture Types\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHow confident are you in understanding the pathophysiology, anatomy, surgical decision making, and surgical steps of the following procedures?\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(1 - Lowest, 5 - Highest)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChalazion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.008\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLaceration Repair\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlepharoplasty\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEctropion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEntropion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInternal Ptosis Repair\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e4.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExternal Ptosis Repair\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEvisceration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnucleation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.005\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal Clinical Assessment Scores*\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIQR\u0026thinsp;=\u0026thinsp;interquartile range, * = Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eGiven variable oculoplastics learning experiences across ophthalmology residencies, additional educational resources are needed. Online surgical materials have shown advantages over traditional text-based resources, yet existing content is limited\u003csup\u003e1,22,23,28\u0026ndash;30\u003c/sup\u003e. We evaluated an image\u0026thinsp;+\u0026thinsp;video-based online curriculum that pairs relevant anatomy, clinical decision-making, and operative steps in an active learning format. Residents begin with fundamental content and procedures, progressing to complex procedures.\u003c/p\u003e\u003cp\u003eResidents demonstrated significant improvement in clinical knowledge scores after completing the course (15.6 vs 20.3). While baseline scores were higher among senior residents, the lack of post-course test differences between PGY levels suggest that all residents are capable of learning this content in a relatively short period (on average 5.7\u0026thinsp;+\u0026thinsp;1.3 hours). Notably, junior trainees (PGY2 and PGY3) exhibited the most pronounced gains (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005), while PGY4 residents showed improvement that did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.574). Likewise, junior trainees also exhibited the most pronounced gains in self-reported confidence levels in knowledge of pathophysiology, diagnosis and management of oculoplastics conditions (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 vs. p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). These findings suggest that introducing this educational content earlier in training may be particularly advantageous. Once residents have completed the course, they have access to revisit the content as needed, e.g. to review the surgical video prior to live surgery. On any given rotation, a resident may not perform all the surgeries in this curriculum, so the online coursework can fill in knowledge gaps, fulfilling the residency program\u0026rsquo;s goal of a uniform oculoplastic surgical foundation for all trainees. Finally, there was universal appreciation for this format of self-guided interactive learning with residents writing, \u0026ldquo;Innovative, creative, and interactive course that allowed for better learning and engagement\u0026rdquo;, \u0026ldquo;Really enjoyed the course and helped the anatomy (tougher to learn through a textbook) stick better as well\u0026rdquo;, \u0026ldquo;Intermediate course is great to review for R3s prior to plastics OR\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThis was a single-institution study, and the results may not be universally relevant. However, even in our program where residents were taught by many oculoplastic surgery attendings on a formal rotation, received didactic instruction, and wetlab curriculum (i.e. a well-resourced \u0026lsquo;traditional curriculum), they still demonstrated significant knowledge gains and reported increased confidence. In programs with low oculoplastics exposure, trainees could potentially have an even greater increase in post-course test scores. Another limitation of this pilot study was that long-term knowledge retention was not assessed.\u003c/p\u003e\u003cp\u003eAs this curriculum is intended to be of practical value to surgeons, future research could directly evaluate resident surgical performance. We believe our online resource can create a baseline for learners and be readily integrated with didactics, wet-labs and live surgery to optimize the teacher\u0026rsquo;s time. Such a curriculum may be particularly useful in busy under-resourced settings with a shortage of oculoplastics faculty.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003ePractical surgical training in oculoplastics is variable and often limited. This study demonstrates that an interactive online curriculum can improve clinical knowledge and trainee confidence in oculoplastic surgeries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis manuscript was funded by a grant from Research to Prevent Blindness given to the New York Eye and Ear Infirmary of Mount Sinai Department of Ophthalmology.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003cp\u003e, \u003cb\u003eConsent to Participate\u003c/b\u003e: Approval was obtained from the Institutional Review Boards of the Icahn School of Medicine (No.23-01344, Mount Sinai Hospital, New York, New York). Informed consent was obtained from all individual participants included in the study. All participants consented to participating in this study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cb\u003eConsent to Publish\u003c/b\u003e:\u003c/strong\u003e\u003cp\u003e The authors affirm that all participants provided informed consent for publication of their data. No identifying images or other personal or clinical details of participants that compromise anonymity are presented. Consent for publication was obtained for all patient figures.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eHelen Liu: Writing \u0026ndash; original draft, Methodology, Formal analysis, Data curation. Jackson Scharf: Writing \u0026ndash; original draft, Methodology, Data curation. Jason Jo: Writing \u0026ndash; review \u0026amp; editing. Jennifer Patnaik: Conceptualization, Writing \u0026ndash; review \u0026amp; editing. David H. Cherwek: conceptualization, writing \u0026ndash; review \u0026amp; editing. Daniel Neely: Conceptualization, Writing \u0026ndash; review \u0026amp; editing. Shailesh Gaurav: Conceptualization, Writing \u0026ndash; review \u0026amp; editing. Harsha S Reddy: Writing \u0026ndash; review \u0026amp; editing, Supervision, Methodology, Data curation, Conceptualization.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are not openly available due to participant privacy or ethical restrictions. The data are available upon reasonable request from the corresponding author.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medical education, residency training, oculoplastics and orbital surgery, educational resource, interactive, online, curriculum","lastPublishedDoi":"10.21203/rs.3.rs-7443954/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7443954/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eOphthalmology residency programs vary greatly in their exposure to oculoplastic conditions based on geographic location, practice setting, presence of fellows, and availability of attending surgeons. Few easily-accessible, structured, interactive curricular resources exist, and the efficacy of these resources is largely unstudied.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThirty ophthalmology residents (PGY2\u0026ndash;4) at a single US institution completed a pre-test of oculoplastic clinical knowledge and a survey of self-reported confidence in oculoplastic topics. Following completion of the online curriculum, residents repeated the knowledge test and the confidence survey. Outcomes were compared using Wilcoxon signed-rank tests, analysis of variance, and linear mixed effects modeling.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean clinical knowledge score improved from 15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 (pre-course) to 20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4 (post-course) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with 84% of residents showing score gains. Although senior residents had higher baseline scores, post-course scores did not differ significantly by training level. Junior trainees (PGY2/PGY3) experienced the greatest benefit, while PGY4 improvements were not statistically significant. Self-reported confidence in the diagnosis, understanding, and management of oculoplastic conditions significantly increased across multiple procedure types (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The curriculum received high satisfaction ratings, and a majority of participants expressed a preference for online learning post-intervention.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eA structured, interactive, and freely available online curriculum improved oculoplastics-related clinical knowledge and confidence among residents in this cohort, suggesting the effectiveness of this curriculum to supplement oculoplastics training.\u003c/p\u003e","manuscriptTitle":"The NYEE-Orbis Oculoplastic Surgery Online Curriculum: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 12:49:31","doi":"10.21203/rs.3.rs-7443954/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"16801134941623809920855636053927484628","date":"2025-10-29T13:08:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-27T04:26:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-24T14:52:57+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-17T07:26:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-17T05:19:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-09-17T05:17:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"45722bdc-c4e5-45ed-b65c-decb8ae8bf52","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T12:49:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-05 12:49:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7443954","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7443954","identity":"rs-7443954","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}