Is It Time to Adopt Vision Screening for Ophthalmology Residency Program Applicants

Although standards of vision have been set to drive a car, a minimum standard has not been set to perform intraocular surgery. This dichotomy exists despite a general feeling among many educators of the importance of good vision in predicting the technical ability of the beginning microsurgeon. There have been barriers to implementing vision screening for ophthalmology residency applicants. Title I of the Americans With Disabilities Act of 1990 (ADA) covers employers with 15 or more employees and prohibits discrimination of qualified individuals with disabilities in recruitment, hiring, promotions, training, pay, social activities, and other privileges of employment.1 ADA Title I restricts the questions that can be asked about an applicant’s disability before a job offer is made and requires reasonable accommodation be made, unless it results in undue hardship. Because of fears of running afoul of the ADA, many ophthalmology programs do not perform visual screening of residency applicants. It is time for the profession to set a minimum standard of vision to practice ophthalmology. A 2001 workshop of surgeons from the United States and Europe were queried as to the attributes felt important in the selection of surgery resident candidates.2 In addition to cognitive factors and personality traits, innate dexterity, defined as the “strongest determining factor in the level of technical (operative) skills that the individual attains with training and experience,”was identified as a critical attribute. Felt important to innate dexterity were spatial perception, hand–eye coordination, aiming, multilimb coordination, and hand–arm steadiness. At the Royal College of Surgeons in Ireland, all shortlisted candidates for higher surgical training undergo formal testing of both technical skills and fundamental abilities (including psychomotor skills, visuospatial ability, and depth perception).3 Testing would not be necessary if applicants self-selected themselves for surgical careers on basis of their dexterity. A study using laparoscopic virtual reality simulation found applicants significantly performed lower than their self-assessment of dexterity.4 Self-assessed dexterity tasks like video gaming, sports, artistic activities, and musical instruments were not predictive of performance on the simulator. Internal medicine interns scored higher than applicants to a general surgery program on three of four tasks. If there is no apparent self-selection for a surgical career based on actual surgical skills, one needs a way to assess technical proficiency of applicants. So what visual factors are important in determining the technical ability of amicrosurgeon? Stereopsis would seem to be an obvious place to start.Weknowhigh-grade stereopsis is essential in skilled precision grasping.5 Amblyopes with deficient stereopsis have normal initial reaching and grip shaping, but deficient terminal reach and final grip closure and application.6 With the development of virtual simulators for intraocular surgery, we now have the capability to assess the effects of deficient stereopsis in a safe environment. The Eyesi eye surgery simulator (VRmagic, Mannheim, Germany) provides a virtual reality environment that can teach basic skills, measure tremor, and allow practice of some of the steps of intraocular surgery. Construct validity for the Eyesi antitremor, forceps training, and capsulorhexis modules has been established.7–9 Waqar et al studied 30 junior doctors with no previous ophthalmic surgical experience.10 Subjects undertook four attempts of the level 4 forceps module binocularly and another four monocularly to simulate an acute loss of stereopsis. Significant findings (p < 0.05) included a decrease in average total score and increases in average corneal area injured, average lens area injured, and average time taken when the simulation was performed monocularly compared with binocularly. The authors did note that 3 of the 30 subjects had a statistically significant increase in the total score when performed monocularly. This may be a function of study design, however. The increase in scores when performed monocularly was mainly due to quicker time or decreased odometer scores, perhaps due to themonocular trials being