Basic Level Goals: Year 1
A.
Cognitive Skills
1. Describe
simple types of refractive errors: **
a. Myopia
b. Hyperopia
c. Astigmatism
d. Presbyopia
2.
Describe basic optic principles, such as line of sight and Purkinje
image.**
3. Explain
theories of accommodation.
4. Describe
the basics of ophthalmic optics, including how the following affect
the optics of the eye: **
a. Low and
high order aberrations
b. Corneal
layers
c. Shape of
cornea
d. Shape of
lens
5. Describe
basic refraction techniques using trial lenses or phoropter for basic
refractive errors, including:
a. Retinoscopy
b. Modification
and refinement of subjective refraction
c. Cycloplegic
retinoscopy and refraction
d. Postcycloplegic
refraction
6. Describe
the optical principles of common refractive surgery diagnostic tools,
including:
a. Ultrasonic
pachymetry
b. Keratometer
c. Lensometer
d. Pupillometry
e. Corneal
topography
f. Scheimpflug
imaging and elevation maps
g. Optical
coherence tomography (OCT)
7. Describe
the following topographic maps using different scales (ie, absolute,
normalized, adjustable):
a. Axial
b. Instantaneous
c. Refractive
8. Describe
normal corneal topographic patterns, as well as topographic signs of
keratoconus and ectasia.
9. Describe
elevation topography maps and their importance in screening
refractive surgery candidates.
10. Describe
indications and limitations of corneal topography in refractive
surgery.
11. List
the mandatory diagnostic tests necessary for refractive surgery.
12. Describe
the basics of laser biophysics and laser tissue interaction.
13. Describe
the complications of high myopia, high hyperopia, and pathologies
related to high astigmatism.**
14. Define
the clinical stages of keratoconus and forme fruste keratoconus using
clinical and topographic tests.**
15. Describe
the milestones in refractive surgery development, including radial
keratotomy, keratomileusis, and phakic
intraocular lenses (IOLs).
16. List
current refractive procedures, their mechanisms of action,
indications, and limitations, including:
a. Types of
excimer laser procedures
b. Phakic
IOLs
d. Implantation
of intracorneal ring segments
e. Corneal
inlays
f. Accommodative
lenses
17. Describe
the main IOL calculation formulas.
18. Describe
the principles and different types (ie, linear, rotational, pendular)
of mechanical microkeratomes, including their characteristics,
indications, risks, and possible complications.
19. Describe
the role of femtosecond technology in refractive surgery, including
advantages and limitations of flap creation with a femtosecond laser.
20. Describe
different techniques of keratoplasty and their relation with
refractive surgery.
B. Technical/Surgical Skills
1. Perform
objective and subjective refraction, including cross cylinder and
Worth 4-dot test.
**
2.
Diagnose refractive defects.**
3. Use
different prescription formulas.**
4. Prescribe
spectacles for at least 20 patients with simple refractive errors
(eg, myopia, hyperopia, regular astigmatism).**
5. Perform
refraction on patients with extreme errors of refraction (eg, 5
patients with hyperopia over 8.0 D, and 5 patients with myopia above
20.0 D).**
6. Use the
lensometer to measure spectacle power.**
7. Use the
keratometer to make corneal measurements.**
8. Use the
ultrasonic pachymeter to measure corneal thickness.
9. Validate
corneal topography maps, including elevation topography. Recognize
signs of ectatic disorders and/or candidates at risk for an
unsatisfactory refractive surgery outcome, and rule out poor-quality
tests (eg, artifacts, alignment, and corneal exposure issues).
10. Interpret
an aberration map and evaluate its significance in the refractive
defect of a patient, as well as the need to treat or not.
11. Validate
a manual refraction as a real refractive defect of a patient,
comparing results with keratometers, aberrometers, and topography.
12. Analyze
tear film and tear deficiency.
13.
Recognize and unmask astigmatism from higher order aberrations, such
as coma.
14.
Demonstrate how informed consent should be explained.
Standard Level Goals: Year 2
A. Cognitive Skills
1. Describe
various types of refractive defects, and define the possible
corrective solutions for each one.**
2.
Describe basic diagnostic tools used in refractive surgery,
including topography, pachymetry, and biometry; and interpret
results.**
3. Describe
more complex types of refractive errors, including postoperative
refractive errors following cataract surgery, keratoplasty,
refractive surgeries, ectatic conditions, and irregular
astigmatism.**
4. Explain
basics of wavefront analysis, including ray tracing and dynamic
skiascopy, and graphical representation of wavefront errors,
including corneal and entire eye high-order aberration maps,
point-spread function, and modulation-transfer function.
5. Describe
the basics of Zernike polynomials and Fourier analysis.
6. Use
different topographic maps and scales for different purposes (eg,
screening, postoperative evaluation, detection of complications).
7. Describe
the basics of measuring contrast sensitivity.
8. Describe
laser-tissue interaction and explain Munnerlyn
formula.
9. Describe
corneal biomechanics, including biomechanical responses to
keratorefractive surgery, corneal healing after excimer laser
procedures, corneal hysteresis, and corneal resistance factor.
10. Define
and diagnose post laser in-situ
keratomileusis (LASIK) ectasia, and
differentiate it from other conditions.
11. Describe
the mechanism of action, indications, advantages, and potential
complications of mitomycin C application in surface ablation.
12. Describe
the affect of corneal crosslinking on the biomechanical properties of
the cornea, including its indications and how it can be combined with
other refractive surgery procedures.
B. Technical/Surgical Skills
1. Perform
refraction techniques using trial lenses or phoropter for basic and
more complex cases, including:
a. Modification
and refinement of subjective manifest refractive error
b. Cycloplegic
retinoscopy and refraction
c. Postcycloplegic
refraction
d. Contact
lens use
e. Irregular
astigmatism
f. Postkeratoplasty
g. Refractive
surgery cases
2. Apply
the basics of optics and optical principles of refraction and
retinoscopy in the clinical setting, including higher order
aberrations.
3. Gather
accurate information essential for preoperative evaluation of
patients seeking refractive surgery, including:
a. Medical
interview
i. Patient
expectation
ii. Social
history
iii. Medical
history
iv. Pertinent
ocular history
b. Physical
examination
i. Uncorrected
visual acuity
ii. manifest
and cycloplegic visual acuity
iii. Intraocular
pressure
iv. Slit-lamp
examination
v. Fundus
examination
4. Diagnose
and manage dry eye prior to surgery.
5. Use the
keratometer to make corneal measurements in more complex patients
(eg, prior corneal surgery or corneal disease), and correlate results
with corneal topography maps, visual acuity, and quality of vision.
6. Use
basic refractive instruments and techniques (eg, auto refractor,
pachymetry, automated corneal topography, aberrometer, pupillometry,
contact lens refraction, OCT, corneal hysteresis, and corneal
resistance factor) in the clinical setting for refractive surgery
patients.
7. Assist
in developing patient care management plans for simple refractive
errors (eg, myopia, hyperopia, regular astigmatism), and define the
risks and benefits for each procedure.
8. Assist
in various types of refractive surgery, including:
a. Twenty
surface ablation procedures
b. Twenty
LASIK procedures
c. Ten
intracorneal ring segment implantation procedures
d. Ten
phakic IOL surgeries
Advanced Level Goals: Year 3
A. Cognitive Skills
1.
Describe and diagnose various types of refractive problems,
including irregular astigmatism, and identify the best solution for
each.**
2. Describe
the most complex types of refractive errors, including postoperative
refractive errors, postkeratoplasty, and refractive surgery.**
3. Describe
the most advanced optics and optical principles of refraction and
retinoscopy, including higher-order aberrations.
4. List the
indications for and interpret preoperative and postoperative
diagnostic testing, including:
a. Corneal
topography
b. Wavefront
analysis
c. Pachymetry
d. Calculation
of stromal-bed thickness before and after LASIK
e. Aspheric
profile of ablation
5. Formulate
informed diagnostic and therapeutic decisions based on patient
information, current scientific evidence, clinical judgment, and
patient expectations.
6. Describe
accommodative and nonaccommodative treatments of presbyopia,
including:
a. Monovision
b. Excimer
laser correction
c. Conductive
keratoplasty
d. Corneal
inlays
e. Accommodating
IOLs
f. Multifocal
IOLs
7. Describe
the advanced formulas for IOL calculation in extreme myopia,
hyperopia, and after corneal refractive surgery.
8. Develop
patient care management plans for more complex cases (eg, mixed and
irregular astigmatism, irregular corneas, combined refractive surgery
procedures).
9. Describe
the basics of modulation transfer function (MTF), point speed
function (PSF), and Strehl ratio as objective ways to measure quality
of vision.
10. Describe
the basics of topography-guided, wavefront-guided, and optimized
ablations as compared to standard ablations.
B. Technical/Surgical Skills
1. Perform
basic refractive surgery procedures, such as low myopia
or low hyperopia with LASIK (microkeratome) and surface ablation
(LASIK or photorefractive keratectomy
[PRK]).
2. Perform
the most advanced objective and subjective refraction techniques
using trial lenses or the phoropter, including:
a. Contact
lens refraction for more complex refractive errors, including
modification and refinement of subjective manifest refractive error
b. Cycloplegic
retinoscopy and refraction
c. Postcycloplegic
refraction
d. Irregular
astigmatism
e. Postkeratoplasty
f. Refractive
surgery cases
3. Utilize
the most advanced optics and optical principles for refraction and
retinoscopy, including higher order aberrations.
4. Utilize
the keratometer for detection of subtle or complex advanced corneal
refractive errors.**
5. Use and
interpret results from more advanced refraction instruments and
techniques (eg, corneal topography, pupillometry, aberrometry,
Scheimpflug imaging, OCT).
6. Fit
contact lenses in patients with irregular corneas, irregular
astigmatism, and following refractive surgery.
7. Assist
in advanced refractive surgeries, including topography-guided
ablation, wavefront-guided ablation, and combined refractive
surgeries.
8. Encourage
patients to actively participate in their own care by providing
disease and treatment information, and counsel patients on how to
prevent postoperative injury.**
9. Correct
refractive error after surgeries, such as penetrating keratoplasty,
deep anterior lamellar keratoplasty, and
radial keratotomy.
Very Advanced Level Goals: Subspecialist
A. Cognitive Skills
1.
Diagnose and treat difficult cases such as irregular astigmatism.**
2.
Identify and utilize the new technological advances in refractive
surgery.**
3. Formulate
informed diagnostic and therapeutic decisions based on patient
information, current scientific evidence, and clinical judgment:
a. Use
effective and appropriate clinical problem-solving skills
b. Understand
the limits of one’s knowledge and expertise
c. Use
consultants and referrals appropriately
4. Collect
data, analyze refractive outcomes, and develop personal nomograms
based on data.
5. Plan for
retreatment of patients who had refractive surgery.
6. Develop
refractive surgery management plans in the context of other
conditions (eg, dry eyes, herpes, keratoconus, postkeratoplasty,
glaucoma, retinal disease, amblyopia).
7. Describing
methods of IOL calculation after refractive surgery.
B. Technical/Surgical Skills
1. Prescribe
and perform procedures essential for the scope of practice.
2. Screen
patients for refractive surgery.
3. Develop
and carry out patient care management plans.
4. Perform
the following, if feasible:
a. Twenty
surface ablation procedures
b. Twenty
LASIK procedures
c. Ten
intracorneal ring segment implantation procedures
d. Ten
phakic IOL surgeries
5. Perform
under supervision 10 advanced refractive surgeries for complicated
cases, including excimer laser enhancement procedures and
topography-guided ablations for highly irregular corneas.
6.
Perform–if feasible–supervised femtosecond refractive surgical
procedures, specifically three femto-Lasik procedures and three
intracorneal ring segment implantation procedures using a femtosecond
laser.
7. Perform–if
feasible–supervised corneal crosslinking on five eyes.
*
* *
Note: Inclusion
of therapies and investigations in the ICO Residency Curriculum does
not imply that listings are all inclusive or that methods are
endorsed by the ICO. Appropriate levels of expertise and knowledge
should be achieved based on the care provided. Practitioners should
know of therapies and investigations not available at their hospital
or clinic, so that they can advise patients who may be able to seek
care elsewhere.
