Simulation
Ophthalmoscopy using an
eye simulator model
Paul Larsen, Hugh Stoddard and Michael Griess, University of Nebraska College of
Medicine, Nebraska, USA
SUMMARY
Background: Ophthalmoscopy is
an important skill for the medical
student to master. Students have
difficulty visualising the retina,
and are hesitant to practise with
patients. Our study aim was
to demonstrate that an eye
simulation experience would be
beneficial for developing ophthal-
moscopy skills.
Design: This study was designed
for second-year medical stu-
dents who elected to partici-
pate. Students were observed
and instructed on the correct
use of the ophthalmoscope.
Both normal and pathological
retinas were used. The students
matched what they observed
TCT_12064.indd 99
with printed photographs to
verify what they had actually
seen. A pre- and post-session
questionnaire, with comments,
was completed. The study was
conducted over 4 years. Three of
the years were structured as
outlined above. One year, the
students used the simulator but
without an instructor being
present. Students were surveyed
as senior medical students and
asked to rate the value of the
simulator experience for pre-
paring them for their clinical
years.
Results: A total of 64 per cent
of the students elected to par-
ticipate when a faculty member
was present to instruct them,
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 99–103 99
whereas only 12 per cent of the Ophthalmo-
class elected for the experience scopy is
without instruction. The self-
an important
rating results from the pre-
versus post-session question- skill for the
naire showed statistically medical
significant improvement for all student to
items. Student comments master
reflected that they felt strongly
that the experience was valuable
to them.
Conclusions: This simulation
ophthalmoscopy experience was
valuable for increasing confidence
and skill. This experience is most
valued when an instructor is
present. The simulator experience
was valuable to students as they
applied their ophthalmoscopy
skills clinically.
3/6/2014 2:40:43 PM
 The student is INTRODUCTION course, which is taught during the ophthalmology course, all
second year of medical school. second-year medical students
often hesitant

T
he adequate visualisation of (115–125 students) were invited
to practise this a patient’s retina using an METHODS to sign up for a 30–minute
skill while ophthalmoscope is an session with the ophthalmology
examining a important physical diagnosis skill An Eye Examination Simulator simulator. Students were ob-
for all medical students.1 (made by Kyoto Kagaku) was served and instructed on the
real patient used. This model provides an
Developing this skill is difficult correct use of the ophthalmo-
because it requires practise, and optical system with two sizes of scope (Figure 1). One normal and
the student is often hesitant to pupil, with kodachromes of both four pathological retinas were
practise this skill while examin- normal and pathological retinas. presented to students in the
ing a real patient because of the The institutional review board simulator. The students matched
discomfort for the patient caused judged this study as research what they observed using the
by the bright light and the that is exempt from ethical simulator with printed photo-
awkwardness of taking the extra approval, and student participa- graphs to verify what they had
time required by an inexperienced tion was voluntary. During the seen (Figure 2). The retinal
examiner. A novice faces the
challenge of developing hand–eye
coordination, using the non-
dominant eye and adequately
visualising the important struc-
tures of the retina. In turn, the
clinical mentor has difficulty
assessing whether a student has
actually seen the important
structures of the retina.

As a medical student, the first

author of this study used a
simulation model made from a
shoebox with a small hole in one
end, through which a kodachrome
of the retina was viewed using a
hand-held ophthalmoscope. This
simple model provided an invalu-
able opportunity to develop the
skill of using the dominant and
Figure 1. Students practise their examination technique with both the dominant and non-dominant
non-dominant eye for ophthal- eye. An instructor observes and provides instruction and help, as needed
moscopy. More sophisticated
retinal examination simulation
models have now become avail-
able that allow for the selection
of pupil size and kodachrome
slides of normal and abnormal
retinas. We hypothesised that
the use of an eye simulator would
be a valuable experience for
medical students to develop their
ophthalmoscopy skills in a non-
threatening environment, and in
a setting that would allow for
expert coaching and for the
assessment of their ability to see
important retinal findings.

A study was designed to

provide a simulated ophthalmos-
copy experience and to assess its
value for medical students during
a basic science ophthalmology
Figure 2. After looking at the retina in the simulator, the student then identifies what was seen
with the matching photograph. This allows the instructor to make sure that the student actually
sees the simulator retina. The retinal findings and their clinical implications are then discussed

100 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 99–103

TCT_12064.indd 100 3/6/2014 2:40:50 PM

 findings and their clinical
implications were then discussed.
The students completed a pre-
and post-session questionnaire
in which they self-rated their
hand–eye coordination, non-
dominant eye use, confidence in
identifying important structures
and confidence in identifying four
important retinal pathologies. The
questionnaire presented students
with five options, scaled from 0 to
4. Three questionnaire items asked
students to rate their ability to
use an ophthalmoscope (from 0,
i.e. ‘none’, to 4, i.e. ‘excellent’).
Six items asked students to rate
their confidence in using an
ophthalmoscope and identifying
pathologies. Students were also
asked to comment on their
experience. A paired-samples
Student’s t–test was used to
determine whether student
perceptions of their confidence
and ability changed after
completing the simulation
exercise.
The study was conducted over
four academic years with four
separate cohorts of students. For
cohorts 1, 2, and 4, the experi-
ence was structured as described
above. For the year–3 cohort, the
students were invited to use the
simulator but without an instruc-
tor being present.
As a follow-up, the cohort of
students who participated during
the second year of the study were
asked 2 years later, as final-year
medical students, to rate the value
of the simulator experience in
preparing them to use the
ophthalmoscope with real patients.
RESULTS
The number of students that
elected to participate each year
that the study was conducted
was: 68/115 (59%), 77/119 Student’s t–test
(65%), 12/113 (11%) and
was used to
88/127 (69%), respectively.
Table 1 shows the aggregated re- determine
sults of the pre- and post-session whether student
questionnaire for three cohorts; perceptions of
because of the low participa- their confidence
tion rate during the third year of
and ability
the study, pre- and post-session
questionnaires were not adminis- changed
tered. Useable pre- and post-ses-
sion data were collected from 231
of the 245 participants. The low
p values and large effect sizes
for the pre- and post-session
analyses of all nine items indi-
cate that students perceived that
both their ability and confidence
to use the ophthalmoscope were
substantially improved after the
simulation experience.
Box 1 shows representative
student comments collected after
their experience during the second
year of medical school. Box 2
shows representative comments

Table 1. Results of a survey of second-year medical students regarding the eye

simulator (n-231)
Pre- and post-eye simulator experience questions Mean rating, Mean rating, p Effect size
pre post d

How would you rate your ability to use the ophthalmoscope with 2.535 3.187 0.0001 0.7608
respect to: hand–eye coordination? (0, none; 4, excellent)
How would you rate your ability to use the ophthalmoscope with 1.792 2.857 0.0001 1.0790
respect to: use of non-dominant eye? (0, none; 4, excellent)

How would you rate your ability to use the ophthalmoscope with 1.248 3.226 0.0001 2.0329
respect to: ability to see retinal structures? (0, none; 4,
excellent)
Do you feel confident that you could see the optic nerve, 1.761 3.413 0.0001 1.5156
vessels, background and macula using an ophthalmoscope with
your dominant eye? (0, none; 4, very confident)
Do you feel confident that you could see the optic nerve, 1.105 2.930 0.0001 1.8379
vessels, background and macula using an ophthalmoscope with
your non-dominant eye? (0, none; 4, very confident)
Using an ophthalmoscope, could you identify: papilledema? 0.961 3.251 0.0001 2.0557
(0, unlikely; 4, very confident)
Using an ophthalmoscope, could you identify: hypertensive 0.870 2.792 0.0001 1.8132
retinopathy? (0, unlikely; 4, very confident)
Using an ophthalmoscope, could you identify: diabetic 0.926 2.900 0.0001 1.9165
retinopathy? (0, unlikely; 4, very confident)
Using an ophthalmoscope, could you identify: glaucoma? 0.974 3.208 0.0001 2.1036
(0, unlikely; 4, very confident)

All effect sizes are ‘large’.

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 Increased skill collected in the survey of final- essential skill to be mastered by use of an eye or retina simulator
comes as a year students, 2 years later. The all medical students. In a recent is invaluable in providing this
results of the fourth-year medical survey of Canadian medical directed practise.
result of student survey are shown in students, 47 per cent of junior
‘feedback, Table 2. For this electronic survey, clerks were not confident in Various simulation models
guidance, 59 students (50%) responded. The their ophthalmoscopy skills, and have been proposed and used,
attention, and results presented are descriptive; 87 per cent were interested in including: a styrofoam head with
practice’ no analysis was conducted on gaining more practise and experi- a slide holder tray3,4; a table
these data. ence.2 The authors concluded tennis ball with painted words on
that increased skill comes as a the back of the inner surface5,6;
DISCUSSION result of ‘feedback, guidance, and small plastic canisters with
attention, and practice’.2 This is retinal photographs placed at the
It is recognised that using the often not available to the stu- bottom.7,8 All of these models are
direct ophthalmoscope is an dent in the clinical setting. The designed to use a direct ophthal-
moscope to look through a small
opening that simulates a pupil,
Box 1. Student comments about the eye simulator with the retina slide, photograph
experience or writing viewed on the opposite
• Great way to get practise in a non-pressured environment. side of the device. We chose to
use a commercially available
• It’s incredibly beneficial to be able to practise without invading
model because of its availability
someone’s personal space for an awkwardly long period of time.
and standardisation. Included
• It helped me identify my weakness. with the model are selective
• Instructors’ presence was helpful, especially for strategies for using my slides of normal and pathological
non-dominant eye. retinas that can be inserted into
the model.
• First time I could really see anything. I actually learned how to use the
ophthalmoscope.
Our study allowed us to draw
• It was a great way to get some one-on-one practise in an atmosphere several conclusions. Students, by
where you will feel more comfortable making mistakes and asking self-report, felt that ophthalmos-
questions. copy using the eye examination
• I could never see anything before this – just faked it. simulator was a valuable experi-
ence for increasing their confi-
• It helped to actually see what common diseases look like.
dence and skill. We chose the
• Having it explained and being quizzed on what you see is very helpful. four different pathologies
(papilledema, hypertensive
retinopathy, diabetic retinopathy
Box 2. Senior student comments about the and glaucoma) because we felt it
usefulness of the eye simulator experience was important that students
should be able to recognise the
during their clinical years retinal findings in these diseases.
• It is absolutely effective in allowing us to see what we are expected to
see on real exams with real patients. The importance of having an
• I personally used the information from the simulator experience every instructor present to facilitate
time I did a complete eye exam. directed practise cannot be over-
stated. Both the students’ written
• Great experience, and has been extremely valuable in improving my
comments and their behaviour
ophthalmoscopy skills. I would strongly consider this experience a must
for all medical students. reflected this fact. A key indicator
of the students valuing the
• I feel that having had that practise allowed me to visualise structures presence of an instructor was that
more quickly and cause less discomfort to patients during my clinical in the year that students knew
years.
they would use the simulator on
• This made me much more comfortable when examining a patient and their own, without an instructor
gave me an idea of how to find what I was looking for in a patient’s eye. being present, only 12 per cent of
• I think the skills I learned in the session gave me enough confidence to the class opted to take advantage
attempt an exam but not the competence to observe all the findings. of the experience. In comparison,
when an instructor was present in
• I really liked being able to use the actual ophthalmoscope with the each of the other 3 years of the
mannequin. I knew what to look for when doing the exam on a patient
study, on average 64 per cent of
due to the simulator.
the class elected to participate.

102 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 99–103

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 Table 2. Results of a survey of final-year medical students regarding the eye Without
simulator mentoring
from a faculty
Question 1 Strongly Disagree Agree Strongly
disagree agree member, even a
I feel like the ophthalmoscope eye simulator experience 2% 0 49% 49%
high-quality
was helpful to me when I used the ophthalmoscope to simulation
examine patients as a third- and fourth-year student experience has
Question 2 Below average Average Very good Excellent diminished
How would you rate your ability to see the optic disc and 12% 58% 28% 2% value
vessels using an ophthalmoscope?

With an instructor present, the
students were able to receive
coaching and feedback as they
were observed practising with the
ophthalmoscope. Often a strug-
gling student is hesitant to admit
that they are having difficulty
observing the retina, and the
instructor is unable to tell
whether they really have seen
important findings. Using the
activity of the student matching
the retina with a photograph was
invaluable in helping the
instructor verify that the student
was actually able to view the
retina. On occasion, a student
could not see the retinal struc-
tures on the model, in which case
the instructor spent time diag-
nosing the student’s problem and
helping the student find success.
Using the matching technique
also provided a teaching oppor-
tunity to quiz the student and
enhance the student’s under-
standing of the findings. This
became a discovery moment for
many of the students, as they
were finally able to understand
and connect concepts taught in
lectures. This result may be the
key feature of our study: that
without mentoring from a faculty
member, even a high-quality
simulation experience has
diminished value.
After our second-year medical
students went through this
experience, we wanted to know
whether they felt that this
experience was helpful to them
during their clinical third and
fourth years. The survey of senior
medical students overwhelmingly
indicated that they found the
experience helpful when they
used the ophthalmoscope for real
patient examinations.
Our study conclusions were
based primarily on students’
self-reports of the value of the
experience. A future controlled
study to measure students’
recognition of retinal pathology
with actual patients and their
dexterity with the ophthalmo-
scope would be desirable. The
other limitation of the current
study is that students self-selected
to participate, which could be a
source of bias. Because this
experience has now been incorpo-
rated as a requirement in our
second-year curriculum, and
survey results have not been
different than when it was an
optional experience, there is little
evidence of selection bias. This
style of directed practise for direct
ophthalmoscopy, using a simula-
tion model with guidance from a
faculty member, is an invaluable
experience that we would recom-
mend for all medical schools to
incorporate into their curriculum.
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Corresponding author’s contact details: Dr Paul Larsen, 982163 Nebraska Medical Center, Omaha, Nebraska 68198-2163, USA. E-mail: pdlarsen@
unmc.edu.

Funding: None.
Conflict of interest: None.
Ethical approval: This study was approved by the University of Nebraska College of Medicine Institutional Review Board.
doi: 10.1111/tct.12064

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