Efficacy of Simulator-Based Direct Ophthalmoscopy Training using New Refractive Adjustment Fundoscopic Examination Simulator for Medical Students – ICEye Model: A Comparative Randomized Crossover Study

Efficacy of Simulator-Based Direct Ophthalmoscopy Training using New Refractive Adjustment Fundoscopic Examination Simulator for Medical Students – ICEye Model: A Comparative Randomized Crossover 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 Efficacy of Simulator-Based Direct Ophthalmoscopy Training using New Refractive Adjustment Fundoscopic Examination Simulator for Medical Students – ICEye Model: A Comparative Randomized Crossover Study Ratima Chokchaitanasin, Sritatath Vongkulsiri, Raveewan Choontanom This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4510466/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted 24 You are reading this latest preprint version Abstract Background : The use of simulators for ophthalmology training is growing globally. However, all developed simulators have certain limits based on different circumstances. The study aims to assess the efficacy and satisfaction of the new refractive adjustment simulator "ICEyeModel" compared to a traditional simulator for direct ophthalmoscopy training in medical students. Methods : This is a comparative, randomized cross-over study. Our study enrolled fifty participants from a 6-year medical student training program at Phramongkutklao Hospital. They required a refreshment lecture on primary direct ophthalmoscopy usage and a short course on common retinal disease review. They were randomized into two training sequence groups: Training sequence 1 started with a traditional film photograph simulator followed by the ICEyeModel. Training sequence 2 started with the ICEyeModel, followed by a traditional simulator. Both groups were asked to complete a fundoscopic description test and satisfaction questionnaires. Results : Medical students training with the ICEye Model achieved significantly higher fundoscopic examination scores (14.42±2.34) compared to those training with traditional simulators (11.30±6.43), with p <0.001. For the ICEyeModel, 86% of participants can correctly adjust the direct ophthalmoscope power match to the refractive state from the trial lens placed in the simulator. ICEyeModel has a higher satisfaction score regarding picture quality, enhancing motivation and confidence than a traditional simulator. Conclusion : The ICEye Model is the first combination of fundoscopic examination training and refraction practicing simulators that significantly improves fundoscopic examination skills and increases medical students' motivation and confidence in practicing direct ophthalmoscopy. In the future, it can be used to practice with indirect ophthalmoscopes and retinoscopes. direct ophthalmoscope fundoscopic examination simulator medical student Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Fundoscopic examination is essential for accurately diagnosing many visual- and life-threatening conditions. Several studies [ 1 , 2 ] reported that 1.3% of chief complaints in the emergency room are presented with eye manifestation every year. Some of the patients need further fundoscopic examination to confirm the diagnosis. In 1850, Hermann von Helmholtz published a complete account of optical principal involvement and reinvented the ophthalmoscopy instrument [ 3 ]. His instrument was ordered throughout Europe later. It was the starting point of direct ophthalmoscope innovation for assignment to the ophthalmology course syllabus worldwide. Nowadays, fundoscopic examination by direct ophthalmoscope remains an essential skill of physicians for preliminary diagnosis and management before referral to a specialist. Many different simulators have been developed for fundoscopic examination training. A simple image quiz was an original fundoscopic photograph. In 2004, Chung and Watzke developed a closed plastic chamber with 37 mm photographs, which was effective for training [ 4 ]. The others developed many different design simulators for training at a later date [ 5 – 12 ]. A newly published Eyesi model for direct ophthalmoscopy training has been reported as a new virtual reality (VR) simulator [ 13 – 15 ], but they are not available in all medical schools. A traditional simulator with fundus photo film called Eye Retinopathy Trainer (developed by Adam, Rouilly Co., Sittingbourne, UK) [ 12 , 16 ] has been used globally for training and in Phramongkutklao Hospital for over ten years. The extra light source application from the table lamp is required to enhance the visualization of pathology films, which sometimes showed limitations to practice continuously for a long time. A new refractive adjustment simulator, “ICEyeModel”, has been developed to resemble a human optical eye system with other new add-on adjustable refraction features. This study evaluates the efficacy of a newly developed ICEyeModel, a fundoscopic examination simulator for medical student training. Methods Study design: We conducted a comparative, randomised, cross-over trial at the Department of Ophthalmology, Phramongkutklao Hospital, Thailand. Sixth-year medical students were recruited from August 2019 to July 2020. Written informed consent was obtained from all participants. The Institutional Review Board approved the study, Royal Thai Army Medical Department (approve protocol ID R058q/62) and adhered to the principles of the Declaration of Helsinki before participant recruitment and data collection. Inclusion criteria comprised of the following : 1) Be 6-year medical students who completed training in the annual ophthalmology period on the fifth academic year 2) Have best corrected visual acuity (BCVA) at 0 logMar converted from Early Treatment Diabetic Retinopathy Study (ETDRS) chart [ 17 ] 3) Have not been participating in any other ophthalmic simulator study We excluded medical students who had yet to complete a 3-week eye block in the fifth academic year. We calculated the sample size using the pilot study, and the number of participants recruited should be at least 40. Innovation phase : A new simulator was developed to resemble practicing with human eyes, particularly an eyeball designed to imitate the similarity of the human optical system called the ICEyeModel. The simulator specifications include an adult male half-head manikin with a neck, as shown in Fig. 1 . The human head manikin was made from a three-dimensional (3D) printing technology widely used in ophthalmology [ 18 – 22 ] with a hard resin material and behind the head, composed of 4 slots for replacement parts. Replacement parts designed for two optical half-eyeballs and slots for commercial trial lens placement for refractive adjustment. A 5-cm diameter front half-eyeball is attached with a high-plus convexity lens. The front half was covered with a hole cut centre as a “pupil,” which has three sizes of adjustable pupil diameter (3, 6, 9 millimetres), and the back half was constructed with an exchangeable ocular fundus photograph glued to the inner wall. One set of fundus has eight different fundus photographs, including normal fundus, glaucomatous optic neuropathy, diabetic retinopathy, hypertensive retinopathy, central retinal vein occlusion, central retinal artery occlusion, optic disc oedema, and optic disc atrophy. The fundus photographs were obtained in Phramongkutklao Hospital by a Kowa Vx-10 digital fundus photo camera, as shown in the appendix. Intervention phase: As shown in the appendix, questionnaires were developed to evaluate and compare the efficacy and satisfaction between training with traditional simulator and ICEyeModel simulator. The set of questionnaires consisted of two sections: participant information and effectiveness assessments. The participant information includes demographic data (age, sex, refraction status, frequency of using direct ophthalmoscope within three months). The efficacy questionnaire assessment comprised two major segments: fundoscopic description and satisfaction. The fundoscopic description consisted of a checkbox on a three-grading scale (unseen, seen with incorrect answer, seen with correct answer) and one short answer for diagnosis. The scoring system used for all reports was as follows: unseen = 0 points, seen with incorrect answer = 1 point, seen with correct answer = 2 points. All participants were asked to complete all questionnaires and to describe fundoscopic findings. The total score of the fundoscopic description was 18 points. The questionnaire validity was approved by three attending ophthalmologists from Phramongkutklao Hospital with an adequate index of item value (> 0.5) objective congruence. The reliability was tested by trying out with participants from the pilot study using the Cronbach alpha method (alpha range 0.7–0.8) [ 23 ]. Pre-training period : All participants had to complete a refreshment course containing a 10-minute video on principles of direct ophthalmoscopy (Ophthalmoscope controls and proper technique) from the E-learning tool. A small group (2–3 participants) was trained with a 1-hour clinical fundoscopic examination and common retinal diseases lecture. Training period : Welch Allyn 3.5v Coaxial direct Ophthalmoscope with C-Cell Handle in Hard Case was used in the study. All participants were randomized by concealed enveloped into two training sequence groups, as shown in Fig. 2. Training sequence 1 started with direct ophthalmoscopy training on a traditional simulator (fixed-size of pupil at 5 mm) coded Simulator A, followed by the ICEyeModel (adjusted-size of pupil at 6 mm) coded Simulator B, as shown in Fig. 3. The traditional simulator (simulator A), which required a table lamp light source for visualization, is not shown in the figure. Training sequence 2 started with direct ophthalmoscope training in the reciprocal order (ICEyeModel (B) and then the traditional simulator (A)). Both sequences consisted of 2 randomly selected fundus photographs Each direct ophthalmoscopy simulator training session was allowed for thirty minutes. The fundoscopy examination tests assessed various fundus findings, including the red reflex, optic disc, retinal background, vessel configuration, macula, and diagnosis. Additionally, all participants underwent testing for refractive adjustment of the direct ophthalmoscope using the ICEyeModel. Post-training period: A survey was conducted to evaluate participant preference for using traditional or ICEye models for direct ophthalmoscope training. Statistical Analysis: Demographic data was presented using the mean and standard deviation or median, IQR ranges for continuous data, and percentages for categorical data. Paired nominal and independent data were analyzed using the Extended McNemar and McNemar tests. For the primary outcome, the comparison fundoscopic description total score (18 points), pair samples test was used for normal distribution data, and the Wilcoxon matched pair rank test for abnormal distribution data. Refractive collection scores and satisfaction scores were reported using percentages for other outcomes. A 2-tailed p-value of less than 0.05 was considered statistically significant. All statistical analyses were carried out using STATA 14.0 software. Results The study adhered to the guidelines of the International Network for Simulation-based Pediatric Innovation, Research, and Education [ 24 ]. A total of 52 6th-year medical students enrolled in our study; 2 medical students were excluded because of amblyopia and an incomplete refreshment course. Fifty participants completed all the required elements. Twenty-nine (58%) were male. The median (SD) age was 23.14 (0.64) years old. Most participants had myopic refraction. The Majority of participants (68%) found no exposure to direct ophthalmoscope within the past three months, as shown in Table 2. 34 participants strongly agree that general physicians should have skill direct ophthalmoscopy usage and should practice with the simulator before "examination" an actual patient. 64% of the participants also reported strongly agreeing that direct ophthalmoscopy skills should be reviewed with a simulator before examining an actual patient and regular training until confidence and skill are achieved. The pre-training opinion survey reported that 46% and 36% of participants' degree of understanding in direct ophthalmoscopy usage was around the most and average levels, respectively. Half of the participants reported a moderate confidence level in diagnosing retinal pathology using direct ophthalmoscopy. The total fundoscopic description score from each simulator showed no statistical difference in either training sequence 1 or training sequence 2. Simulator B also achieved a higher total description score from both training sequences than simulator A (Table 4). The refractive adjustment feature of simulator B demonstrated that 86% of participants could answer correctly. 88% of participants preferred simulator B as a simulator of choice for training direct ophthalmoscope. 82% and 80% of participants also voted for simulator B, with its human-like appearance and higher-quality fundus photo compared to simulator A respectively. As shown in Fig. 6, training with simulator B showed higher satisfaction in every aspect. Discussion Direct Ophthalmoscopy is a difficult skill for many medical students, and it is one of the skills in which there is a gap in medical education training [ 25 ]. Our study survey demonstrates that 34 participants (68%) were concerned that direct ophthalmoscopy is a vital skill and agreed that practicing ophthalmoscopy with a simulator before examining the patients and regular practice is also essential. Multiple studies [ 26 – 30 ] reported a need for more confidence in medical students and general practitioners. Our survey revealed nearly the same direction: that most medical students (54%) have moderate confidence in using direct ophthalmoscope which may correlate to infrequency use and lack of motivation. Training with simulators helps practitioners achieve proficiency, including providing an environment that enhances skill management and repeatability, is independent of time, and has no harmful effect on actual patients. We identified better performance among participants regarding the ability to describe fundus pathology and diagnosis by training with our innovation. The total fundoscopic description scores were significantly higher for training with our new design simulator (ICEyeModel) than the traditional simulator. This result can reflect increased competency in the fundoscopic examination. For the other pleasurable outcome, we represented the better quality of the simulator, especially the fundus picture quality and realistic appearance. After that, our innovation was registered successfully with a Thai petty patent, patent number 2103002366. Nowadays, the Virtual Reality (VR) simulator is the most advanced technology available worldwide for training in various ophthalmology skills [ 31 – 34 ]. The Perspectives trial conducted at Indiana University School of Medicine 14 reported that VR technology simulators (Eyesi) also support the idea that stimulation enhances the technical skill of direct ophthalmoscopy. It might be appropriate for several countries that have no limited financial support. Because of the comparative study design, we calculated whether the fundoscopic description score correlated to the simulator sequence in training and found no effect of the simulator training sequence on the score. The strengths of our study include the fact that the crossover trials can achieve statistical power with fewer participants by utilizing each subject as his or her control. All interventions minimized the confounding effects based on the same participants. Although the carry-over effect is also a concern in crossover studies, an adequate wash-out period can reduce this consequence. For our study, we can only provide a short wash-out period due to the daily schedule of participants. The score of simulator B (ICEyeModel) between two sequence training demonstrates higher statistical significance than simulator A or the traditional version, which also warrants reducing the concern of the carry-over effect. In the FOTO-ED study [ 35 ], they reported that non-mydriatic fundus photography taken by nurses is the alternative to a direct ophthalmoscope in an emergency room. The fundus photo camera can be performed only with cooperative patients sitting upright and might not be available in every emergency room. It could replace direct ophthalmoscope in some situations. However, a direct ophthalmoscope could be more suitable for patients who are uncooperative or cannot sit upright. For our innovation, the training can be practiced in upright and supine positions with improved competency for examination in various situations, especially in the emergency unit. The high-resolution printing of fundus photographs and the realistic fundus appearance are better than other technologies. The highlight of our innovation is a combination of ophthalmoscopy and retinoscopy, which no other simulator has described before. Traditional methods can facilitate training retinoscopy to assess refractive error, providing the best-corrected visual acuity [ 36 , 37 ], including repeated testing on humans with limitations such as difficult enrollment, fatigue, and potential risk to actual patients. The schematic mechanical eyes may be a reasonable solution. In 2015, a device to aid retinoscopy training in low-resource countries was described [ 38 ]. Donghyun Kim et al. reported a 3D-printed eye model that enhances retinoscopy and demonstrated non-inferior improvements in refractive accuracy compared to students practicing on actual patients [ 39 ]. Our institute also used a simulator called Heine Retinoscope Trainer (model 13301, manufactured in Germany), as reported in the other study [ 40 ], for refractive training for a long time. Several limitations of positional training are different from those of actual patients. The report of clear red reflex of our innovation using a true optical system is 92% of participants. The red-reflex quality in our simulator can be a better candidate and more feasible for training retinoscopy. They need further study to assess the efficacy of the retinoscopy option. Our study has some limitations. This new design simulator cannot provide the real-time assessment of labelling of pathological findings from students like virtual reality. The other skills of training, including time of diagnosis, instrument handling, and examination in a non-mydriatic setting, were not assessed in our study. Conclusion ICEyeModel significantly improves fundoscopic examination and increases satisfaction and self-confidence in medical students' practice of direct ophthalmoscopes. It might be a choice for direct ophthalmoscope, indirect ophthalmoscope, and retinoscope training in the real world. Declarations Ethics approval and consent to participate All study procedures were approved by the Institutional Review Board of The Institutional Review Board approved the study, Royal Thai Army Medical Department (approve protocol ID R058q/62) and adhered to the principles of the Declaration of Helsinki before participant recruitment and data collection. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Phramongkutklao College of Medicine Grants, 2021-2022. Funding was used to obtain the supplies for the study. Authors’ Contributions All authors contributed to the conception of the study. Ratima Chokchaitanasin and Raveewan Choontanom contributed to drafting and revising the manuscript. All authors contributed to the article and approved the submitted version. Author information Authors and Affiliations Department of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, and Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand Ratima Chokchaitanasin MD Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand Sritatath Vongkulsiri MD Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand Raveewan Choontanom MD Corresponding author Correspondence to Raveewan Choontanom MD Acknowledgements Not applicable. References Imsuwan I, Amnuaypattanapon K, Vongkittirux S, Imsuwan Y. The Study of Incidence and Characteristics of Patients with Eye-Related Chief Complaints at the Emergency Department of Thammasat University Hospital. 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Supplementary Files Appendix.docx Questionaire.docx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 28 Jul, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 12 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviews received at journal 09 Aug, 2024 Reviews received at journal 07 Aug, 2024 Reviews received at journal 01 Aug, 2024 Reviewers agreed at journal 31 Jul, 2024 Reviews received at journal 31 Jul, 2024 Reviews received at journal 30 Jul, 2024 Reviewers agreed at journal 30 Jul, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 25 Jul, 2024 Reviewers agreed at journal 24 Jul, 2024 Reviewers agreed at journal 23 Jul, 2024 Reviewers agreed at journal 21 Jul, 2024 Reviewers agreed at journal 21 Jul, 2024 Reviews received at journal 12 Jul, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviewers invited by journal 10 Jul, 2024 Editor invited by journal 10 Jul, 2024 Editor assigned by journal 18 Jun, 2024 Submission checks completed at journal 18 Jun, 2024 First submitted to journal 31 May, 2024 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. 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17:32:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4510466/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4510466/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-07418-x","type":"published","date":"2025-07-28T16:28:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60443960,"identity":"2e304cc5-2046-40d5-9cb5-da1cdfc27ad9","added_by":"auto","created_at":"2024-07-16 20:22:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":573384,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/96ee5654331d00535815f5d8.png"},{"id":60443963,"identity":"98550ffa-dc33-41c8-a4fc-e67ce24d508e","added_by":"auto","created_at":"2024-07-16 20:22:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":247851,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/049e42de1a7a631a6ebeecd6.png"},{"id":60443965,"identity":"711a36f2-17bc-4bf8-a5fb-d19a4a33fb1d","added_by":"auto","created_at":"2024-07-16 20:22:55","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":629316,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/03babfd217d890b0bf2f056e.png"},{"id":60443961,"identity":"b1d469e0-87ba-41ff-bf81-2e2da98328fd","added_by":"auto","created_at":"2024-07-16 20:22:54","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":388130,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/3d2e467a440776da94d52303.png"},{"id":60443966,"identity":"ad6f6fb9-85f4-431d-9eea-d1ac68b12f8c","added_by":"auto","created_at":"2024-07-16 20:22:55","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":183243,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/d8ec752b1bb5ea053434a4eb.png"},{"id":88268472,"identity":"be57c345-6c79-4225-a0fe-dce70ca65826","added_by":"auto","created_at":"2025-08-04 16:51:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3175105,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/c5d97dd1-3c61-4d7b-8369-03a5244f9e24.pdf"},{"id":60444494,"identity":"bbb3053c-e6eb-4f5e-ade2-64a372e3c537","added_by":"auto","created_at":"2024-07-16 20:30:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2263647,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/ea86c51515e5a0547ad003db.docx"},{"id":60443967,"identity":"2d100247-45b9-4886-aea3-108807d532e8","added_by":"auto","created_at":"2024-07-16 20:22:55","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":30190,"visible":true,"origin":"","legend":"","description":"","filename":"Questionaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/d3d5801cc704453a50b0efbf.docx"},{"id":60444493,"identity":"3349e4e7-5347-4d70-9e81-5d57444972bf","added_by":"auto","created_at":"2024-07-16 20:30:54","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":100145,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510466/v1/cb2a72604f40b40dc93d8082.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of Simulator-Based Direct Ophthalmoscopy Training using New Refractive Adjustment Fundoscopic Examination Simulator for Medical Students – ICEye Model: A Comparative Randomized Crossover Study","fulltext":[{"header":"Background","content":"\u003cp\u003eFundoscopic examination is essential for accurately diagnosing many visual- and life-threatening conditions. Several studies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] reported that 1.3% of chief complaints in the emergency room are presented with eye manifestation every year. Some of the patients need further fundoscopic examination to confirm the diagnosis. In 1850, Hermann von Helmholtz published a complete account of optical principal involvement and reinvented the ophthalmoscopy instrument [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. His instrument was ordered throughout Europe later. It was the starting point of direct ophthalmoscope innovation for assignment to the ophthalmology course syllabus worldwide. Nowadays, fundoscopic examination by direct ophthalmoscope remains an essential skill of physicians for preliminary diagnosis and management before referral to a specialist. Many different simulators have been developed for fundoscopic examination training. A simple image quiz was an original fundoscopic photograph. In 2004, Chung and Watzke developed a closed plastic chamber with 37 mm photographs, which was effective for training [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The others developed many different design simulators for training at a later date [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A newly published Eyesi model for direct ophthalmoscopy training has been reported as a new virtual reality (VR) simulator [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], but they are not available in all medical schools. A traditional simulator with fundus photo film called Eye Retinopathy Trainer (developed by Adam, Rouilly Co., Sittingbourne, UK) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] has been used globally for training and in Phramongkutklao Hospital for over ten years. The extra light source application from the table lamp is required to enhance the visualization of pathology films, which sometimes showed limitations to practice continuously for a long time. A new refractive adjustment simulator, \u0026ldquo;ICEyeModel\u0026rdquo;, has been developed to resemble a human optical eye system with other new add-on adjustable refraction features. This study evaluates the efficacy of a newly developed ICEyeModel, a fundoscopic examination simulator for medical student training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design:\u003c/h2\u003e \u003cp\u003eWe conducted a comparative, randomised, cross-over trial at the Department of Ophthalmology, Phramongkutklao Hospital, Thailand. Sixth-year medical students were recruited from August 2019 to July 2020. Written informed consent was obtained from all participants. The Institutional Review Board approved the study, Royal Thai Army Medical Department (approve protocol ID R058q/62) and adhered to the principles of the Declaration of Helsinki before participant recruitment and data collection.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eInclusion criteria comprised of the following\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e1) Be 6-year medical students who completed training in the annual ophthalmology period on the fifth academic year\u003c/p\u003e \u003cp\u003e2) Have best corrected visual acuity (BCVA) at 0 logMar converted from Early Treatment Diabetic Retinopathy Study (ETDRS) chart [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e3) Have not been participating in any other ophthalmic simulator study\u003c/p\u003e \u003cp\u003eWe excluded medical students who had yet to complete a 3-week eye block in the fifth academic year. We calculated the sample size using the pilot study, and the number of participants recruited should be at least 40.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eInnovation phase\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eA new simulator was developed to resemble practicing with human eyes, particularly an eyeball designed to imitate the similarity of the human optical system called the ICEyeModel. The simulator specifications include an adult male half-head manikin with a neck, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The human head manikin was made from a three-dimensional (3D) printing technology widely used in ophthalmology [\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] with a hard resin material and behind the head, composed of 4 slots for replacement parts. Replacement parts designed for two optical half-eyeballs and slots for commercial trial lens placement for refractive adjustment. A 5-cm diameter front half-eyeball is attached with a high-plus convexity lens. The front half was covered with a hole cut centre as a \u0026ldquo;pupil,\u0026rdquo; which has three sizes of adjustable pupil diameter (3, 6, 9 millimetres), and the back half was constructed with an exchangeable ocular fundus photograph glued to the inner wall. One set of fundus has eight different fundus photographs, including normal fundus, glaucomatous optic neuropathy, diabetic retinopathy, hypertensive retinopathy, central retinal vein occlusion, central retinal artery occlusion, optic disc oedema, and optic disc atrophy. The fundus photographs were obtained in Phramongkutklao Hospital by a Kowa Vx-10 digital fundus photo camera, as shown in the appendix.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eIntervention phase:\u003c/h2\u003e \u003cp\u003eAs shown in the appendix, questionnaires were developed to evaluate and compare the efficacy and satisfaction between training with traditional simulator and ICEyeModel simulator. The set of questionnaires consisted of two sections: participant information and effectiveness assessments. The participant information includes demographic data (age, sex, refraction status, frequency of using direct ophthalmoscope within three months). The efficacy questionnaire assessment comprised two major segments: fundoscopic description and satisfaction. The fundoscopic description consisted of a checkbox on a three-grading scale (unseen, seen with incorrect answer, seen with correct answer) and one short answer for diagnosis. The scoring system used for all reports was as follows: unseen\u0026thinsp;=\u0026thinsp;0 points, seen with incorrect answer\u0026thinsp;=\u0026thinsp;1 point, seen with correct answer\u0026thinsp;=\u0026thinsp;2 points. All participants were asked to complete all questionnaires and to describe fundoscopic findings. The total score of the fundoscopic description was 18 points. The questionnaire validity was approved by three attending ophthalmologists from Phramongkutklao Hospital with an adequate index of item value (\u0026gt;\u0026thinsp;0.5) objective congruence. The reliability was tested by trying out with participants from the pilot study using the Cronbach alpha method (alpha range 0.7\u0026ndash;0.8) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003ePre-training period\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eAll participants had to complete a refreshment course containing a 10-minute video on principles of direct ophthalmoscopy (Ophthalmoscope controls and proper technique) from the E-learning tool. A small group (2\u0026ndash;3 participants) was trained with a 1-hour clinical fundoscopic examination and common retinal diseases lecture.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eTraining period\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eWelch Allyn 3.5v Coaxial direct Ophthalmoscope with C-Cell Handle in Hard Case was used in the study. All participants were randomized by concealed enveloped into two training sequence groups, as shown in Fig.\u0026nbsp;2. Training sequence 1 started with direct ophthalmoscopy training on a traditional simulator (fixed-size of pupil at 5 mm) coded Simulator A, followed by the ICEyeModel (adjusted-size of pupil at 6 mm) coded Simulator B, as shown in Fig.\u0026nbsp;3. The traditional simulator (simulator A), which required a table lamp light source for visualization, is not shown in the figure.\u003c/p\u003e \u003cp\u003eTraining sequence 2 started with direct ophthalmoscope training in the reciprocal order (ICEyeModel (B) and then the traditional simulator (A)). Both sequences consisted of 2 randomly selected fundus photographs\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eEach direct ophthalmoscopy simulator training session was allowed for thirty minutes. The fundoscopy examination tests assessed various fundus findings, including the red reflex, optic disc, retinal background, vessel configuration, macula, and diagnosis. Additionally, all participants underwent testing for refractive adjustment of the direct ophthalmoscope using the ICEyeModel.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePost-training period:\u003c/h2\u003e \u003cp\u003eA survey was conducted to evaluate participant preference for using traditional or ICEye models for direct ophthalmoscope training.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis:\u003c/h2\u003e \u003cp\u003eDemographic data was presented using the mean and standard deviation or median, IQR ranges for continuous data, and percentages for categorical data. Paired nominal and independent data were analyzed using the Extended McNemar and McNemar tests. For the primary outcome, the comparison fundoscopic description total score (18 points), pair samples test was used for normal distribution data, and the Wilcoxon matched pair rank test for abnormal distribution data. Refractive collection scores and satisfaction scores were reported using percentages for other outcomes. A 2-tailed p-value of less than 0.05 was considered statistically significant. All statistical analyses were carried out using STATA 14.0 software.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study adhered to the guidelines of the International Network for Simulation-based Pediatric Innovation, Research, and Education [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A total of 52 6th-year medical students enrolled in our study; 2 medical students were excluded because of amblyopia and an incomplete refreshment course. Fifty participants completed all the required elements. Twenty-nine (58%) were male. The median (SD) age was 23.14 (0.64) years old. Most participants had myopic refraction. The Majority of participants (68%) found no exposure to direct ophthalmoscope within the past three months, as shown in Table\u0026nbsp;2. 34 participants strongly agree that general physicians should have skill direct ophthalmoscopy usage and should practice with the simulator before \"examination\" an actual patient. 64% of the participants also reported strongly agreeing that direct ophthalmoscopy skills should be reviewed with a simulator before examining an actual patient and regular training until confidence and skill are achieved.\u003c/p\u003e \u003cp\u003e The pre-training opinion survey reported that 46% and 36% of participants' degree of understanding in direct ophthalmoscopy usage was around the most and average levels, respectively. Half of the participants reported a moderate confidence level in diagnosing retinal pathology using direct ophthalmoscopy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe total fundoscopic description score from each simulator showed no statistical difference in either training sequence 1 or training sequence 2. Simulator B also achieved a higher total description score from both training sequences than simulator A (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe refractive adjustment feature of simulator B demonstrated that 86% of participants could answer correctly. 88% of participants preferred simulator B as a simulator of choice for training direct ophthalmoscope. 82% and 80% of participants also voted for simulator B, with its human-like appearance and higher-quality fundus photo compared to simulator A respectively. As shown in Fig.\u0026nbsp;6, training with simulator B showed higher satisfaction in every aspect.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDirect Ophthalmoscopy is a difficult skill for many medical students, and it is one of the skills in which there is a gap in medical education training [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our study survey demonstrates that 34 participants (68%) were concerned that direct ophthalmoscopy is a vital skill and agreed that practicing ophthalmoscopy with a simulator before examining the patients and regular practice is also essential. Multiple studies [\u003cspan additionalcitationids=\"CR27 CR28 CR29\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] reported a need for more confidence in medical students and general practitioners. Our survey revealed nearly the same direction: that most medical students (54%) have moderate confidence in using direct ophthalmoscope which may correlate to infrequency use and lack of motivation. Training with simulators helps practitioners achieve proficiency, including providing an environment that enhances skill management and repeatability, is independent of time, and has no harmful effect on actual patients. We identified better performance among participants regarding the ability to describe fundus pathology and diagnosis by training with our innovation. The total fundoscopic description scores were significantly higher for training with our new design simulator (ICEyeModel) than the traditional simulator. This result can reflect increased competency in the fundoscopic examination. For the other pleasurable outcome, we represented the better quality of the simulator, especially the fundus picture quality and realistic appearance. After that, our innovation was registered successfully with a Thai petty patent, patent number 2103002366.\u003c/p\u003e \u003cp\u003eNowadays, the Virtual Reality (VR) simulator is the most advanced technology available worldwide for training in various ophthalmology skills [\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The Perspectives trial conducted at Indiana University School of Medicine\u003csup\u003e14\u003c/sup\u003e reported that VR technology simulators (Eyesi) also support the idea that stimulation enhances the technical skill of direct ophthalmoscopy. It might be appropriate for several countries that have no limited financial support.\u003c/p\u003e \u003cp\u003eBecause of the comparative study design, we calculated whether the fundoscopic description score correlated to the simulator sequence in training and found no effect of the simulator training sequence on the score. The strengths of our study include the fact that the crossover trials can achieve statistical power with fewer participants by utilizing each subject as his or her control. All interventions minimized the confounding effects based on the same participants. Although the carry-over effect is also a concern in crossover studies, an adequate wash-out period can reduce this consequence. For our study, we can only provide a short wash-out period due to the daily schedule of participants. The score of simulator B (ICEyeModel) between two sequence training demonstrates higher statistical significance than simulator A or the traditional version, which also warrants reducing the concern of the carry-over effect.\u003c/p\u003e \u003cp\u003eIn the FOTO-ED study [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], they reported that non-mydriatic fundus photography taken by nurses is the alternative to a direct ophthalmoscope in an emergency room. The fundus photo camera can be performed only with cooperative patients sitting upright and might not be available in every emergency room. It could replace direct ophthalmoscope in some situations. However, a direct ophthalmoscope could be more suitable for patients who are uncooperative or cannot sit upright. For our innovation, the training can be practiced in upright and supine positions with improved competency for examination in various situations, especially in the emergency unit. The high-resolution printing of fundus photographs and the realistic fundus appearance are better than other technologies.\u003c/p\u003e \u003cp\u003eThe highlight of our innovation is a combination of ophthalmoscopy and retinoscopy, which no other simulator has described before. Traditional methods can facilitate training retinoscopy to assess refractive error, providing the best-corrected visual acuity [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], including repeated testing on humans with limitations such as difficult enrollment, fatigue, and potential risk to actual patients. The schematic mechanical eyes may be a reasonable solution. In 2015, a device to aid retinoscopy training in low-resource countries was described [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Donghyun Kim et al. reported a 3D-printed eye model that enhances retinoscopy and demonstrated non-inferior improvements in refractive accuracy compared to students practicing on actual patients [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Our institute also used a simulator called Heine Retinoscope Trainer (model 13301, manufactured in Germany), as reported in the other study [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], for refractive training for a long time. Several limitations of positional training are different from those of actual patients. The report of clear red reflex of our innovation using a true optical system is 92% of participants. The red-reflex quality in our simulator can be a better candidate and more feasible for training retinoscopy. They need further study to assess the efficacy of the retinoscopy option. Our study has some limitations. This new design simulator cannot provide the real-time assessment of labelling of pathological findings from students like virtual reality. The other skills of training, including time of diagnosis, instrument handling, and examination in a non-mydriatic setting, were not assessed in our study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eICEyeModel significantly improves fundoscopic examination and increases satisfaction and self-confidence in medical students' practice of direct ophthalmoscopes. It might be a choice for direct ophthalmoscope, indirect ophthalmoscope, and retinoscope training in the real world.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study procedures were approved by the Institutional Review Board of\u0026nbsp;The Institutional Review Board approved the study, Royal Thai Army Medical Department (approve protocol ID R058q/62) and adhered to the principles of the Declaration of Helsinki before participant recruitment and data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cu\u003e\u003cbr\u003e\u0026nbsp;\u003c/u\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003ePhramongkutklao College of Medicine Grants, 2021-2022. Funding was used to obtain the supplies for the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eAll authors contributed to the conception of the study. Ratima Chokchaitanasin and Raveewan Choontanom contributed to drafting and revising the manuscript. All authors contributed to the article and approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors and Affiliations\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, and Department of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand\u003cbr\u003e\u0026nbsp;Ratima Chokchaitanasin MD\u003c/p\u003e\n\u003cp\u003eDepartment of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand\u0026nbsp;\u003cbr\u003e\u0026nbsp;Sritatath Vongkulsiri MD\u003c/p\u003e\n\u003cp\u003eDepartment of Ophthalmology, Phramongkutklao Hospital, Phramongkutklao College of Medicine, Bangkok, Thailand\u0026nbsp;\u003cbr\u003e\u0026nbsp;Raveewan Choontanom MD\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCorresponding author\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to Raveewan Choontanom MD\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eImsuwan I, Amnuaypattanapon K, Vongkittirux S, Imsuwan Y. 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Evaluation of a tool to teach medical students direct ophthalmoscopy. \u003cem\u003eWMJ: official publication of the State Medical Society of Wisconsin\u003c/em\u003e. 2009;108(1):24-26. Accessed February 3, 2024. https://pubmed.ncbi.nlm.nih.gov/19326631/\u003c/li\u003e\n\u003cli\u003eLi D, Zhang W, Li X, Zhen S, Wang Y. Stressful life events and problematic Internet use by adolescent females and males: A mediated moderation model. \u003cem\u003eComputers in Human Behavior\u003c/em\u003e. 2010;26(5):1199-1207. doi:https://doi.org/10.1016/j.chb.2010.03.031\u003c/li\u003e\n\u003cli\u003eMcCarthy DM, Leonard HR, Vozenilek JA. A new tool for testing and training ophthalmoscopic skills. \u003cem\u003eJournal of Graduate Medical Education\u003c/em\u003e. 2012;4(1):92-96. doi:https://doi.org/10.4300/JGME-D-11-00052.1\u003c/li\u003e\n\u003cli\u003eLarsen P, Stoddart H, Griess M. Ophthalmoscopy using an eye simulator model. 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Der Ophthalmologe: Zeitschrift Der Deutschen Ophthalmologischen Gesellschaft [Internet]. 2020 Jan 1 [cited 2024 Feb 24];117(1):44\u0026ndash;9. Available from: https://pubmed.ncbi.nlm.nih.gov/31073679/\u003c/li\u003e\n\u003cli\u003eAndrowiki JE, Scravoni IA, Ricci LH, Fagundes DJ, Ferraz CA, Androwiki JE, et al. Evaluation of a simulation tool in ophthalmology: application in teaching funduscopy. Arquivos Brasileiros de Oftalmologia [Internet]. 2015 Feb 1 [cited 2020 Jul 4];78(1):36\u0026ndash;9. Available from: https://www.scielo.br/scielo.php?script=sci_arttext\u0026amp;pid=S0004-27492015000100010\u003c/li\u003e\n\u003cli\u003eTiraset N, Poonyathalang A, Padungkiatsagul T, Deeyai M, Vichitkunakorn P, Vanikieti K. Comparison of Visual Acuity Measurement Using Three Methods: Standard ETDRS Chart, Near Chart and a Smartphone-Based Eye Chart Application. Clinical Ophthalmology. 2021 Feb;Volume 15:859\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eKim DH, Yang HK, Baek C, Seo J, Hwang JM. Efficacy of 3D-printed eye model to enhance retinoscopy skills. Scientific Reports [Internet]. 2024 Feb 20 [cited 2024 Feb 22];14(1):4207. Available from: https://www.nature.com/articles/s41598-024-53321-8#ref-CR11\u003c/li\u003e\n\u003cli\u003eDonovan L, Brian G, du Toit R. A device to aid the teaching of retinoscopy in low-resource countries. British Journal of Ophthalmology. 2008 Jan 28;92(2):294\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eBaek C, BASc, Seo JM. Development of Schematic Eye for Retinoscopy Training Using 3D Printer. Annals of Optometry and Contact Lens [Internet]. 2016 Dec 25 [cited 2024 Feb 22];15(4):145\u0026ndash;9. Available from: https://www.annocl.org/journal/view.php?number=222\u003c/li\u003e\n\u003cli\u003eKang S, Kwon J, Ahn CJ, Esmaeli B, Kim GB, Kim N, et al. Generation of customized orbital implant templates using 3-dimensional printing for orbital wall reconstruction. Eye. 2018 Aug 28;32(12):1864\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eKim BR, Kim SH, Ko J, Baek SW, Park YK, Kim YJ, et al. A Pilot Clinical Study of Ocular Prosthesis Fabricated by Three-dimensional Printing and Sublimation Technique. Korean Journal of Ophthalmology. 2021 Feb 5;35(1):37\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eTavakol M, Dennick R. Making Sense of Cronbach\u0026rsquo;s Alpha. International Journal of Medical Education [Internet]. 2011 Jun 27;2(2):53\u0026ndash;5. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4205511/\u003c/li\u003e\n\u003cli\u003eCheng A, Kessler D, Mackinnon R, et al. Reporting Guidelines for Health Care Simulation Research. \u003cem\u003eSimulation in Healthcare: The Journal of the Society for Simulation in Healthcare\u003c/em\u003e. 2016;11(4):238-248. doi:https://doi.org/10.1097/SIH.0000000000000150\u003c/li\u003e\n\u003cli\u003eGilmour G, McKivigan J. Evaluating medical students\u0026rsquo; proficiency with a handheld ophthalmoscope: a pilot study. Advances in Medical Education and Practice. 2016 Dec;Volume 8:33\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eMackay DD, Garza PS, Bruce BB, Newman NJ, Biousse V. The demise of direct ophthalmoscopy. Neurology: Clinical Practice [Internet]. 2014 Dec 29;5(2):150\u0026ndash;7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4404284/\u003c/li\u003e\n\u003cli\u003eStern GA. Teaching Ophthalmology to Primary Care Physicians. Archives of Ophthalmology. 1995 Jun 1;113(6):722.\u003c/li\u003e\n\u003cli\u003eKelly LP, Garza PS, Bruce BB, Graubart EB, Newman NJ, Biousse V. Teaching Ophthalmoscopy to Medical Students (the TOTeMS Study). American Journal of Ophthalmology. 2013 Nov;156(5):1056-1061.e10.\u003c/li\u003e\n\u003cli\u003eGupta RR, Lam WC. Medical students\u0026rsquo; self-confidence in performing direct ophthalmoscopy in clinical training. Canadian Journal of Ophthalmology. 2006 Apr;41(2):169\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eShuttleworth GN, Marsh GW. How effective is undergraduate and postgraduate teaching in ophthalmology? Eye. 1997 Sep;11(5):744\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eJacobsen MF, Konge L, Bach-Holm D, la Cour M, Holm L, H\u0026phi;jgaard-Olsen K, et al. Correlation of virtual reality performance with real-life cataract surgery performance. Journal of Cataract \u0026amp; Refractive Surgery. 2019 Sep;45(9):1246\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003eMellum ML, Vestergaard AH, Grauslund J, Vergmann AS. Virtual vitreoretinal surgery: effect of distracting factors on surgical performance in medical students. Acta Ophthalmologica [Internet]. 2020 Jun 1 [cited 2024 Mar 3];98(4):378\u0026ndash;83. Available from: https://pubmed.ncbi.nlm.nih.gov/31580012/\u003c/li\u003e\n\u003cli\u003eRopelato S, Menozzi M, Michel D, Siegrist M. Augmented Reality Microsurgery. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare. 2020 Jan;1.\u003c/li\u003e\n\u003cli\u003eNg D, Sun Z, Young AL, Ko STC, Lok J, Lai T, et al. Impact of virtual reality simulation on learning barriers of phacoemulsification perceived by residents. Clinical Ophthalmology. 2018 May;Volume 12:885\u0026ndash;93.\u003c/li\u003e\n\u003cli\u003eBruce BB, Thulasi P, Fraser CL, Keadey MT, Ward A, Heilpern KL, et al. Diagnostic Accuracy and Use of Nonmydriatic Ocular Fundus Photography by Emergency Physicians: Phase II of the FOTO-ED Study. Annals of Emergency Medicine. 2013 Jul;62(1):28-33.e1.\u003c/li\u003e\n\u003cli\u003eAkil H, Keskin S, \u0026Ccedil;avdarli C. Comparison of the Refractive Measurements with Hand-held Autorefractometer, Table-mounted Autorefractometer and Cycloplegic Retinoscopy in Children. Korean Journal of Ophthalmology. 2015;29(3):178.\u003c/li\u003e\n\u003cli\u003eYoo SG, Cho MJ, Kim US, Baek SH. Cycloplegic Refraction in Hyperopic Children: Effectiveness of a 0.5% Tropicamide and 0.5% Phenylephrine Addition to 1% Cyclopentolate Regimen. Korean Journal of Ophthalmology. 2017;31(3):249.\u003c/li\u003e\n\u003cli\u003eDonovan L, Brian G, du Toit R. A device to aid the teaching of retinoscopy in low-resource countries. British Journal of Ophthalmology. 2008 Jan 28;92(2):294\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eKim DH, Yang HK, Baek C, Seo J, Hwang JM. Efficacy of 3D-printed eye model to enhance retinoscopy skills. Scientific Reports [Internet]. 2024 Feb 20 [cited 2024 Feb 22];14(1):4207. Available from: https://www.nature.com/articles/s41598-024-53321-8#ref-CR11\u003c/li\u003e\n\u003cli\u003eEstay AM, Iv\u0026aacute;n Plaza-Rosales, Torres HR, Cerfogli FI. Training in retinoscopy: learning curves using a standardized method. BMC Medical Education. 2023 Nov 16;23(1).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"direct ophthalmoscope, fundoscopic examination, simulator, medical student","lastPublishedDoi":"10.21203/rs.3.rs-4510466/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4510466/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The use of simulators for ophthalmology training is growing globally. However, all developed simulators have certain limits based on different circumstances. The study aims to assess\u003c/p\u003e\n\u003cp\u003ethe efficacy and satisfaction of the new refractive adjustment simulator \"ICEyeModel\" compared to a traditional simulator for direct ophthalmoscopy training in medical students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: This is a comparative, randomized cross-over study. Our study enrolled fifty participants from a 6-year medical student training program at Phramongkutklao Hospital. They required a refreshment lecture on primary direct ophthalmoscopy usage and a short course on common retinal disease review. They were randomized into two training sequence groups: Training sequence 1 started with a traditional film photograph simulator followed by the ICEyeModel. Training sequence 2 started with the ICEyeModel, followed by a traditional simulator. Both groups were asked to complete a fundoscopic description test and satisfaction questionnaires.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Medical students training with the ICEye Model achieved significantly higher fundoscopic examination scores (14.42±2.34) compared to those training with traditional simulators (11.30±6.43), with \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001. For the ICEyeModel, 86% of participants can correctly adjust the direct ophthalmoscope power match to the refractive state from the trial lens placed in the simulator. ICEyeModel has a higher satisfaction score regarding picture quality, enhancing motivation and confidence than a traditional simulator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The ICEye Model is the first combination of fundoscopic examination training and refraction practicing simulators that significantly improves fundoscopic examination skills and increases medical students' motivation and confidence in practicing direct ophthalmoscopy. In the future, it can be used to practice with indirect ophthalmoscopes and retinoscopes.\u003c/p\u003e","manuscriptTitle":"Efficacy of Simulator-Based Direct Ophthalmoscopy Training using New Refractive Adjustment Fundoscopic Examination Simulator for Medical Students – ICEye Model: A Comparative Randomized Crossover Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 20:22:49","doi":"10.21203/rs.3.rs-4510466/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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