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ABSTRACT The objective of this article was to review the disorganization of inner retinal layers as a biomarker in diabetic macular edema. A systematic search was conducted in PubMed®/MEDLINE®, Cochrane and Embase until August 2021. The keywords used were: “disorganization of inner retinal layers (DRIL)”, “diabetic macular edema (DME)” and “biomarkers”. No restrictions were imposed on the types of study to be included. The studies selected for eligibility were those that included the diagnosis of diabetic macular edema (center involved, resolved), that were well documented with spectral domain optical coherence tomography, that included disorganization of inner retinal layers as one of the reported alterations, with a follow-up of at least 3 months, and those in which the best corrected visual acuity was evaluated pre and post. There were no limitations regarding the type of treatment established. References of identified studies were searched for additional relevant articles. Articles not published in peer review journals were excluded. All studies were evaluated by two investigators independently. When one of them was in doubt, it was assessed by a third evaluator. A total of seven studies were included. Four were retrospective, longitudinal cohort study and three cross-sectional observational. Regarding the population studied, 61.5% were men and 38.4% were women, most of them had diabetes mellitus type 2 (85.8%). Regarding the stage of diabetes, the percentage of patients with mild nonproliferative diabetic retinopathy was 28.2%, with moderate nonproliferative diabetic retinopathy was 28.5%, with severe nonproliferative diabetic retinopathy was 15.9% and with nonproliferative diabetic retinopathy was 27.4%. In 100% of the studies, the diagnosis of diabetic macular edema in the center involved was included by spectral domain optical coherence tomography (Heidelberg). In all the studies, the presence of disorganization of inner retinal layers was recorded and its association with best corrected visual acuity was evaluated. The measurement was carried out using the LogMAR scale. In all the studies, the presence or absence of disorganization of inner retinal layers was associated with the best corrected worse/better final visual acuity using p

Recommendations could be useful to guide institutions planning to incorporate simulation-based education (SBE) into their training programs or institutions that have an established program but want to benchmark it against best practices. An effective, inclusive, and enjoyable simulation learning environment must be created to optimize learning and skills development. Areas to consider when proposing recommendations for creating an effective SBE environment include the following: the environment, group learning, facilitators, and educational requirements. The common pitfalls in simulation design when simulations are not effective include inadequate prebriefing, cognitive overload, poor alignment with the real-world context or task, inadequate debriefing, and insufficient time for debriefing. The ethical imperatives of SBE must inform the training programs. The role players in the shared ethical values when using SBE include the patients, students, simulationists, and the simulators and simulated patients. SBE programs must be embedded into a curriculum and should not be an optional add-on. To ensure high standards of training in simulation centers, these centers must adhere to specific accreditation standards. SBE aims to create a better training environment, improve patient safety, and address the challenges regarding the training platform and the burden of disease in eye care globally. Surgical simulation in ophthalmology provides an opportunity for partnership between institutions nationally and across borders because simulation centers cannot function in isolation. Recommendations for creating collaborations and partnerships for surgical simulation training will enhance the impact of any eye care program.

Understanding how learning occurs is useful to inform instructional design and create more engaging and enjoyable learning environments. In this first article of a quartet thematic series on good practices in simulation-based training, we reviewed several learning theories that can illuminate learning by simulation. We describe how to develop and improve a simulation center considering a holistic approach. Finally, we conclude by supporting the concept of developing mastery in high-quality education by simulation as a natural ally for accreditation acknowledgment and demonstrable impact on educational and clinical outcomes with patient safety and better care.

Surgical training using the apprenticeship model of “see one, do one, teach one” originated with Halsted in the 19th century and has continued forward. However, it may not be the most optimal and effective way to train clinicians. Simulation-based training emerged in recent decades and follows a stepwise approach starting with basic skills training, moving on to procedural training culminating in team training in an authentic environment. Simulation is used for specific and specialized skills training, deliberate practice, mastery of learning, and rapid knowledge acquisition, creating a structured teaching and learning framework. Simulation-based education programs must be embedded into a curriculum and should not be an optional add-on. Several curriculum design models exist. In this review, the five-phase ADDIE approach was used to inform a prototype curriculum. ADDIE is the acronym for analyze, design, develop, implement, and evaluate. It is used for systematic instructional design where knowledge and performance gaps have been identified and where every step in the design is dictated by the learning outcomes. The ADDIE model is an iterative instructional design where the results of the formative evaluation of each phase may lead to any of the previous phases. The process validates the procedures and products related to the development of learner-centered learning encounters and adds credibility by analyzing and evaluating procedures and interrelatedness. Sufficient evidence that simulation training improves individual and team performance is available. It has a positive effect on self-confidence, knowledge, and operational performance. Further evidence proves that deliberate practice, procedural simulation, and debriefing can be transferred to operational performance in clinical settings and could result in safer and more efficient care for patients, health-care providers, and health systems.

Faculty development should be a priority to sustain and support simulation-based training programs. Clinical educators in ophthalmology should be provided with development opportunities and training in simulation-based education opportunities to become better facilitators and keep up with this fast-growing educational field. Faculty development results in better-skilled faculty and optimized application of this specialized learning strategy. Faculty include experts in simulation-based education, simulation expert technicians as a specialized category, and faculty in the field of ophthalmology, who should embark on a continuing education pathway that keeps them up to date with the latest developments in simulation-based education. Learning experiences on training by simulation can be multimodal with several delivery formats, such as formal courses and training programs, informal apprenticeship, conference attendance, web-based learning, and participation in online discussion forums. Faculty development on simulation-based education programs should be designed in accordance with the level of the facilitator within a progressive skill acquisition model. In this review, we chose to use Kern's six-step model for designing faculty development programs on education by simulation in ophthalmology. Kern's model represents curriculum design that is cyclical, spiral, and multidirectional, and includes problem identification and general needs assessment, targeted needs assessment, goals and objectives for faculty development, educational strategies, implementation, and evaluation and feedback. Faculty development programs must be designed to train facilitators who are competent in simulation-based education which aligns with social needs and the institution's mission and philosophy.