Graefe's Archive for Clinical and Experimental Ophthalmology (2022) 260:2361–2368

https://doi.org/10.1007/s00417-021-05538-w

MISCELLANEOUS

Application of a 3D-printed eye model for teaching direct

ophthalmoscopy to undergraduates
Chan Wu1,2 · Mingyue Luo1,2 · Yutong Liu1,2 · Rongping Dai1,2 · Meifen Zhang1,2 · Yong Zhong1,2 · Youxin Chen1,2 

Received: 31 August 2021 / Revised: 17 December 2021 / Accepted: 22 December 2021 / Published online: 17 January 2022
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2022

Abstract
Purpose  This study aims to design an eye model that can simulate the fundus for teaching direct ophthalmoscopy and to
evaluate its effectiveness.
Methods  We first used 3D printing materials to make an eye model and then randomly assigned 92 undergraduates into
group A (model-assisted training group) and group B (traditional training group) to test our model. After the same training
time, real patients were used to test the students, with 120 s as the examination time limit. We recorded the students’ ability
to clearly see the optic disk, the time to determine the cup-to-disk ratio, and whether they were correct.
Results  Forty-three students in group A (93.48%) successfully saw the fundus, while 21 in group B (45.65%) succeeded.
The difference between the two groups was 47.83% (95% confidence interval, 29.59–66.07%, P < 0.0001). The median time
to see the fundus was 29s (95% confidence interval 23–45 s) in group A, while an estimated minimum time in group B was
80 s, indicating that group A was significantly faster than group B (P < 0.0001).
Conclusions  This 3D-printed eye model significantly improved the students’ study interest, study efficiency, and study results
and is worthy of being promoted.

Key messages

Direct ophthalmoscopy is challenging for medical undergraduates, because of a tight curriculum, limited
opportunities and anxiety to face real patients.

The 3D-printed eye model significantly improved the students' study interest, study efficiency and study results
for direct ophthalmoscopy.

Keywords  Direct ophthalmoscopy · Teaching · Eye model · 3D printing

Introduction

In the current teaching system of clinical medicine in China,

Chan Wu and Mingyue Luo contributed equally to this work.
* Youxin Chen
chenyx@pumch.cn
1 slit lamps, direct ophthalmoscopes, and indirect ophthalmo-
Department of Ophthalmology, Peking Union Medical
College Hospital, Peking Union Medical College, Chinese
Academy of Medical Sciences, Beijing, China
2
Key Lab of Ocular Fundus Diseases, Chinese Academy
of Medical Sciences, Beijing, China
time for studying ophthalmology is short. Shortage in class
hours dedicated to ophthalmology within the standard medi-
cal school curriculum is also a common phenomenon seen
globally [1, 2]. Ophthalmology is a subject highly dependent
on various examination instruments, including tonometers,
scopes. When studying ophthalmology, many students have
difficulties in operating various instruments and in mastering
the key operation points in a short period of time, espe-
cially instruments for examining the fundus [3–5]. However,

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direct ophthalmoscopic examination is a basic but very
important requirement for ophthalmology, a practical tool
for the preliminary understanding of fundus conditions and
a vital medical skill. Direct ophthalmoscopy is significant
for many clinical conditions and can help ophthalmologists,
neurologists, emergency physicians, and obstetricians and
gynecologists make immediate judgments and actively man-
age situations that endanger patients’ vision or even life [6].
Timely and accurate fundus examination can be life-saving
in some situations, for example, in recognizing papilledema
[7]. Internationally, many emergency specialists and neu-
rologists have mastered basic direct ophthalmoscopic fun-
dus examination techniques, which is related to the good
foundation laid in medical school [8, 9]. It is in urgent need
for undergraduate ophthalmology programs in China to
improve students’ ability to examine the fundus by direct
ophthalmoscopy.
In teaching ophthalmology, we have noted many prob-
lems related to direct ophthalmoscopy training. First, oph-
thalmoscopic exercises are based on examining partners’
fundus, supplemented by examining a patient’s fundus,
which is inherently less reproducible and not conducive to
achieving proficiency in a short period of time. Many stu-
dents reported that examining each other’s fundus made their
eyes tired, especially when they were unskilled; additionally,
the time required for examining the fundus was long, which
could cause light damage to the fundus of the person being
examined. When patients were used for practice, many stu-
dents were nervous and afraid of subjecting the patient to an
extended examination, worrying that the patient may com-
plain. Thus, it is necessary to explore new teaching methods
to lay a good foundation for medical students studying oph-
thalmology and be consistent with ophthalmology education
at other medical colleges and universities around the world.
Enhancing repeated training and raising students’ interest
are crucial, but both time and resource for practicing are
limited. Therefore, we developed a human eye model for
teaching direct ophthalmoscopy, hoping to fundamentally
solve the abovementioned problems and improve learning
efficiency. Since three-dimensional (3D) printing is a cost-
effective and convenient tool, we constructed our eye model
with 3D printing technology, which was first described by
Charles Hull in 1986 and rapidly growing in medicine [10].
Due to its accuracy, convenience, and flexibility, 3D printing
technology has been reported to be applied in many fields in
medicine, ranging from basic anatomy to surgical training
and advanced research application and also in the area of
medical education. There are many reports about teaching
models using 3D printing technology, such as skull [11],
bone [12], teeth [13], kidney [14], liver [15], and heart [16].
However, there are few reports about this technology in eye
model construction. In this paper, we performed a com-
parative study and analysis on teaching method, including
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3D-printed eye model-assisted training and traditional
teaching means, and explored the feasibility of introducing
a human eye model into clinical ophthalmology teaching
programs for direct ophthalmoscopy training.
Methods
Design of the human eye model
We first made an eye model with processable material to
test and adjust our design. Since the internal portion of the
human eyeball is dark, we chose 2-mm-thick basswood lami-
nate to form all the structures, which were cut using a laser
cutting machine and bonded. The surface on one side was
designed to simulate the pupil, and there was a compartment
that housed a simulated eyeball. The central axis of the pupil
was collinear with the central axis of the eyeball. Because
patients encountered in clinical work have different pupil
sizes, we designed round holes with three different aper-
ture sizes to simulate the aperture of the pupil: large, 8 mm;
medium, 5 mm; and small, 3 mm. To facilitate changing the
size of the pupil for teaching, the pupils were adjustable so
that the model was more realistic (Fig. 1A–C).
If the human eye is simplified as a single spherical refrac-
tion system and the eye is considered to consist of only one
medium, its refractive index is 1.33. The refractive index
of polypropylene (resin) is 1.49, and the refractive index of
glass is 1.5, both of which can be used to make a simulated
eyeball. We chose glass as the material for the simulated eye-
ball in this study. Because the diameter of a normal human
eye is approximately 22–24 mm, we selected a glass ball
with a diameter of 22 mm as the simulated eyeball, placed
it inside the housing of the wooden model, and affixed
printed figures, words, patterns, or true fundus images to
its posterior surface to simulate the fundus. In this way, the
students could view the simulated fundus inside the model
eye through the pupil-sized hole and practice the technique
repeatedly.
To create a realistic fundus image, we reduced the size of
the normal fundus images and, with repeated testing, deter-
mined that when the fundus image was reduced to a size of 1
cm × 1 cm and the diameter of the optic disk was maintained
at 1–2 mm, we could simulate a normal fundus. Therefore,
we reduced the size of different fundus images to 1 cm ×
1 cm and affixed the images to the posterior surface of the
simulated eyeballs. The back of model was designed to be
openable (Fig. 1D–E) so that the pictures could be easily
replaced to expand the scope of teaching and facilitate stu-
dent exposure to more diseases of the fundus.
After we have refined our design, we began to use 3D
printing materials to simulate the eyeball (Fig. 2).
Graefe's Archive for Clinical and Experimental Ophthalmology (2022) 260:2361–2368 2363

Fig. 1  The simulated eyeball

made with basswood lami-
nate. (A–C) The front side of
the simulated eyeball with an
adjustable pupil size. (D–E)
Detailed view of the simulated
eyeball with the back open.

Participants Ethical approval

Ninety-two undergraduate medical students (year of matric-
ulation, 2012) from 8-year program in Peking Union Medi-
cal College participated in this study. All of them were
sixth-year medical students and were studying ophthalmol-
ogy. They were randomly assigned into two groups: group
A (model-assisted training group) and group B (traditional
training group). None of the students in the two groups had
an experience in direct ophthalmoscopy.
No personal information was collected. All participants
completed written informed consent. Study methods were
performed in accordance with approved guidelines.
Study design
First, the same lectures were provided to both groups of
students, explaining the usage of direct ophthalmoscopy and

Fig. 2  Detailed view of the front (A) and back (B) as well as the inside (C, D) of the 3D-printed simulated eyeball. Image (E) shows the fundus
photograph of the posterior pole of pathological myopia seen through the simulated pupil of the 3D-printed eye model.

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2364 Graefe's Archive for Clinical and Experimental Ophthalmology (2022) 260:2361–2368
how to assess basic features of the optic nerve, blood vessels,
and retina. Then, the students in group A (model-assisted
training group) practiced viewing fundus with the human
eye model. They started from a pupil diameter of 8 mm to
familiarize themselves with the ophthalmoscope. After they
had become familiar with how the scope operates, the pupil
diameter could be adjusted to 5 mm by the student, with a
subsequent final adjustment to 3 mm. The pictures affixed
to the posterior surface of the simulated eyeball started with
simple figures and words and were gradually replaced with
real fundus images. After practicing for 1 h, the students
continued practicing by examining each other’s fundus for
another 1 h. The students in group B (traditional training
group) only practiced by examining each other’s fundus for
2 h (each had 1 dilated pupil to allow students to practice
ophthalmoscopy with and without pupillary dilation). When
using the model training, the teacher was able to visualize
whether the correct structure was being visualized. When
the students practiced examining each other’s fundus, the
teacher visualized the fundus in advance to ensure that the
students saw the correct fundus structure. After the two
groups of students had been trained for the same time, we
selected real patients with undilated pupils to test the stu-
dents, with 2 min (120 s) as the examination time limit.
These patients had clear refractive media and basically nor-
mal fundus. We recorded whether the students could clearly
see the optic disk, the reaction time to determine cup-to-disk
ratio, and whether the students were correct. Finally, the data
were summarized for statistical analysis (Fig. 3).
Statistical analysis
Statistical analysis was performed using R 3.5.0 software.
The rates of successfully viewing the optic disk and deter-
mining the cup-to-disk ratio were compared between the two
groups using X2 test. The results were expressed as differ-
ence and 95% confidence interval (CI). The time required to
clearly see the fundus was estimated using the Kaplan–Meier
estimator and log-rank test. If a student could not see the
fundus within 2 min (120 s), the result was recorded as right
censored. The results were expressed as median recognition
time and 95% CI.
Results
A total of 92 medical students, including 36 male students
and 56 female students with an age range of 23 to 26 years,
participated in direct ophthalmoscopy skills training. Group
A (model-assisted training group) and group B (traditional
training group) each included 46 students. There were no
significant differences between the two groups of students in
terms of age, gender, and test results for theoretical lecture.
13
After group A completed the model-assisted training, 43
students (93.48%) successfully saw the fundus and deter-
mine cup-to-disk ratio correctly. After group B completed
the traditional training, 21 students (45.65%) saw the fun-
dus and determine cup-to-disk ratio correctly. The difference
between the two groups was 47.83%, and the 95% CI was
29.59–66.07%, P < 0.0001 (Table 1), indicating that the
difference between the two groups was significantly differ-
ent and that group A was significantly better trained than
group B.
After group A completed the model-assisted training, the
median time to clearly see the fundus and determine cup-
to-disk ratio was 29 s; the 95% CI was 23–45 s (Table 1).
Because the identification rate in the control group was
limited, the median time could not be estimated (Table 1);
however, based on the lower limit of the 95% CI, it was
estimated that a minimum of more than 80 s was required.
The P value of the log-rank test was < 0.0001, indicating
that there was a significant difference in recognition time
between groups and that group A was significantly faster
than group B. The Kaplan–Meier plot provides the estimates
of cumulative hazard function over time. The X-axis presents
the time of recognition in seconds, while the Y-axis is the
cumulative hazard which is a probability density-based esti-
mation without practical unit. To be more reader-friendly,
the cumulative event function is provided, where the Y-axis
is the probability of recognition at given time. For exam-
ple, at 40s, more than 60% of participants in model-assisted
training group successfully achieved target, compared with
about 30% in traditional training group (Fig. 4).
Discussion
In recent years, with the development of 3D printing tech-
nology, its application in medical education has become
more widespread [17–20]. In this study, we described the
construction of a 3D-printed eye model that can improve
the learning ability of students regarding direct ophthalmos-
copy, evaluated its effectiveness in teaching undergraduates
in clinical medicine, and explored a new method for teaching
direct ophthalmoscopy.
Compared with other human eye models on the market
currently [21–24], our human eye model using 3D printing
has several major advantages. First, the 3D-printed model
has low production cost, fewer components, and simple
assembly. The prototype could be printed for testing and
improvement at any time, and a large number of standard-
ized models could be obtained in a short time. Second, our
3D-printed model simulates the three-dimensional structure
of the human eye darkroom, and the internal structure could
be disassembled, which is more conducive to help students
understand the structure and imaging principle of eyeball.
Graefe's Archive for Clinical and Experimental Ophthalmology (2022) 260:2361–2368
Fig. 3  Flowchart of study
design.
Third, in our 3D-printed model, we paste pictures on the
back surface of the glass ball to facilitate students to observe
the fundus along the curved surface, which is more like a
real fundus examination. Fourth, our 3D-printed model
gradually increases the learning difficulty through adjusta-
ble pupil and fundus pictures with different difficulty, which
is more helpful for students to master the ophthalmoscopy
skill.
2365
Learning is inseparable from memory, and according to
Ebbinghaus’ forgetting curve, memory needs constant rep-
etitions to achieve better results, which demonstrates the
importance of “repetition” in teaching for active memory
[25]. Repetition is definitely different from simple repeat.
Simple repeat is a less efficient way of teaching that can
easily make students lose their interest in learning. Repeti-
tion in teaching should be a stepwise advancement, which
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2366 Graefe's Archive for Clinical and Experimental Ophthalmology (2022) 260:2361–2368
Table 1  Comparison of success
rate and median time required
for successful recognition
between the two training
methods. Total number of students
Number of students who saw the fundus (percent)
Difference between groups (95% CI)
Median time for successful recognition (seconds)
Statistically significant values are shown in bold.
CI, confidence interval; NA, not achieved
Fig. 4  Kaplan–Meier analysis of the recognition rate in the two
groups.
means students are asked to repeat learning the same
knowledge at different levels and, in this study, means re-
recognition of fundus presentations with different levels of
difficulty. With such repetition, with the increase in learn-
ing interest and intensity, more actions will be stored in
long-term memory, forming permanent skills. In our tra-
ditional ophthalmology courses, ophthalmoscopic training
is based on students’ checking each other’s fundus, sup-
plemented by checking a patient’s fundus. This teaching
method is inefficient with low repeatability, and there is
no stepwise advancement [26]. Therefore, it is difficult to
increase the students’ self-confidence and interest in learn-
ing and to form an effective active memory.
Through an adjustable pupil of a human eye model and
exchangeable fundus images with different levels of diffi-
culty, we started from the least challenging learning stage. At
the beginning of training, a large pupil was used to identify
13
Group A (model- Group B (tradi- P value
assisted training group) tional training
group)
46 46 -
43 (93.48%) 21 (45.65%) < 0.0001
47.83% (29.59–66.07%)
29 (23–45) NA (80–NA) < 0.0001
numbers and text on the fundus. In this process, students
could repeatedly adjust the light spot and the diopter of the
direct ophthalmoscope and familiarize themselves with the
function and application of various parts. Furthermore, stu-
dents could repeatedly practice the appropriate distance for
holding the ophthalmoscope in relation to the eye. Once the
students saw the correct number and text, they received posi-
tive feedback, which could enhance their confidence [27].
Then, we gradually increased the difficulty by adjusting the
pupil size to medium and small and gradually replaced pic-
tures on the fundus with real fundus images. Therefore, the
students gradually improved their learning ability, constantly
increased their interest in learning, and gradually established
confidence in the application of direct ophthalmoscopy. In
addition, the ability of students to accurately report the cor-
responding number and text sequence allowed the instruc-
tor to immediately assess whether the student had mastered
examining the fundus at a given difficulty level and whether
the difficulty should be increased. In this process, students
could instantly provide feedback regarding difficulties in
learning, and teachers could guide the students and make
point-to-point corrections. Because this teaching method
has high repeatability and the repetition represents stepwise
ascension, it is easier for students to form long-term memory
and better master direct ophthalmoscopy.
Increasing difficulty can also motivate students to
work harder and overcome obstacles that may arise in the
learning process. After the model-assisted training, the
students were more confident in examining other students
and patients. During the tests with patients, the model-
trained group also generally reported reduced degrees of
tension and anxiety when examining patients. Therefore,
this 3D-printed fundus model can be used as a supplement
to existing direct ophthalmoscopy teaching methods. It
can significantly improve students’ learning interest, effi-
ciency, and results and allow students to master direct oph-
thalmoscopy skills in a short period of time. Not only this
model-assisted training method can be applied to teaching
ophthalmology to medical students, but also extended to
teaching ophthalmology graduate students and residents
and for short-term training of doctors in the emergency
Graefe's Archive for Clinical and Experimental Ophthalmology (2022) 260:2361–2368
department, neurology department, and other depart-
ments so that more sight-threatening and life-threatening
diseases can be diagnosed and treated timely, which could
benefit the general public and bring new vitality into oph-
thalmology education.
In terms of our 3D-printed eye model, it has several
advantages. First, our 3D-printed model was based on a
refined wooden model. The design was imported as elec-
tronic data, which could be shared between educational
institutions, duplicated as much as we need, and modified
much easier than a traditional model. Second, the change-
able images inside the box further lower down the cost-
effective ratio.
Our study has several limitations. First, this study was
carried out only among students in one grade in PUMC.
The small sample size and a lack population diversity might
weaken the ability to evaluate the effect and applicability of
this human eye model. Second, due to the intrinsic nature of
the teaching, this study was not a single- or double-blinded
trial. Awareness of the grouping and interventions may affect
students’ performance partially. Finally, the printing accu-
racy is enough for both numbers and text, but not enough for
fundus pictures. It is necessary to explore more fine printing
technology and improve the eye model in the future.
Conclusions
Our study suggests that this 3D-printed eye model can
significantly improve funduscopic skills and confidence
in medical students. This model-assisted training method
can also be extended to teaching ophthalmology graduate
students and residents and for short-term training of doc-
tors in the emergency department, neurology department,
etc. Future studies should be conducted to evaluate whether
skills gained using this model can sustain for a long time and
whether improvements in identifying fundus pathologies in
patients are improved.
Acknowledgements  The authors appreciate the support from Profes-
sor Chunhua Hu and Mr. Xuzhen Du in the Department of Aerospace
Engineering of Tsinghua University for providing 3D materials and
guiding the establishment of the eye model.
Funding  1. Young Medical Education Scholar Program of Peking
Union Medical College (2017zlgc0704)
2. Undergraduate Education Reform Program of Peking Union
Medical College (2017zlgc0123)
3. The Non-profit Central Research Institute Fund of Chinese Acad-
emy of Medical Sciences (2018PT32029)
Availability of data and material  All data are available upon request
from the corresponding author
2367
Code availability  Not applicable
Declarations 
Ethics approval and consent to participate  Waived by the Peking
Union Medical College Hospital Review Board because of the non-
clinical nature of the study. Informed consent was obtained from all
individual participants included in the study.
Conflict of interest  The authors declare no competing interests.
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