ORIGINAL STUDY
The Ophthalmology Surgical Competency Assessment
Rubric for Trabeculectomy
Catherine M. Green, MBChB, FRANZCO, MMedSc, Grad Cert Surg Ed,*
Sarwat Salim, MD,w Deepak P. Edward, MD, FACS,zy
Raghu C. Mudumbai, MD,8 and Karl Golnik, MD, MEdz
Purpose: To produce an internationally valid tool to assess skill in
performing trabeculectomy surgery.
Methods: A panel of 5 experts developed a tool for assessing tra-
beculectomy surgery by using a modified Dreyfus scale of skill
acquisition and providing descriptors for each level of skill for each
category. The tool was then reviewed by a panel of 10 international
content experts for their constructive comments, which were
incorporated into the final rubric tool.
Results: A final rubric, incorporating the suggestions of the inter-
national panel, published here as the ICO-OSCAR:
Trabeculectomy.
Conclusions: The tool ICO-OSCAR: Trabeculectomy has content
and face validity. It can be used internationally to assess trabecu-
lectomy surgery skill. Predictive and construct validity, and reli-
ability are yet to be determined.
Key Words: trabeculectomy, assessment rubric, evaluation tool,
residency training, glaucoma surgery
(J Glaucoma 2017;00:000–000)
G laucoma remains one of the leading causes of blindness
in the world.1–5 Despite the availability of effective
medical treatment, many patients still require surgery to
control intraocular pressure to prevent progression of the
disease.6 In addition, access to medical treatment in devel-
oping countries can be difficult, with surgery often the most
cost-effective treatment option. Trabeculectomy, first
described in 1968 by Cairns,7 remains the most commonly
performed glaucoma-filtering operation. It is a safe and
effective procedure performed to control intraocular pres-
sure and halt or slow visual loss from glaucoma.8–10 Opti-
mal surgical technique improves success rates.11,12
Received for publication November 6, 2016; accepted June 12, 2017.
From the *Royal Australian and New Zealand College of Oph-
thalmologists, Royal Victorian Eye and Ear Hospital, Melbourne,
Australia; zKing Khaled Eye Specialist Hospital, Riyadh, Saudi
Arabia; wThe Eye Institute, Medical College of Wisconsin, Mil-
waukee, WI; yJohns Hopkins University School of Medicine,
Wilmer Eye Institute, Baltimore, MD; 8UW Medicine Eye Insti-
tute, Seattle, WA; and zUniversity of Cincinnati and the Cincinnati
Eye Institute, Cincinnati, OH.
K.G. is supported in part by Research to Prevent Blindness.
Disclosure: The authors declare no conflict of interest.
Reprints: Catherine M. Green, MBChB, FRANZCO, MMedSc, Grad
Cert Surg Ed, Level 5, 182 Victoria Parade, East Melbourne, Vic.
3002, Australia (e-mail: seagreen@bigpond.com).
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/IJG.0000000000000723
J Glaucoma  Volume 00, Number 00, ’’ 2017
Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
In recent decades, there has been an increased
emphasis on the outcomes of ophthalmic training with a
trend toward assessing competence.13–15
The International Council of Ophthalmology’s Oph-
thalmology Surgical Competency Assessment Rubrics
(ICO-OSCARs)16 are designed to facilitate assessment and
acquisition of surgical skills. Surgical procedures are
described in individual steps; each step is graded on a scale
based on performance, progressing from novice to begin-
ner, advanced beginner, and competent. A description of
the performance necessary to achieve each grade in each
step is given. The assessor circles the observed performance
description for each step of the procedure; alternatively, the
relevant table cell can be highlighted electronically. The
ICO-OSCAR is completed at the end of a case and dis-
cussed with the trainee to provide timely, structured, and
specific feedback. These tools have been developed by
panels of international experts and are valid assessments of
surgical skill. To date, ICO-OSCARs have been produced
for extracapsular cataract extraction,16 small incision cat-
aract surgery,16 phacoemulsification,17 strabismus,18 lateral
tarsal strip,19 and pediatric cataract surgery.20 This paper
describes our methods of designing and validating (for face
and content validity) an assessment tool for trabeculectomy
surgery using a similar rubric.
METHODS
A group of content experts (the authors) from Aus-
tralia, Saudi Arabia, and the United States worked together
to create a rubric with descriptions of the skills and
behaviors expected for each step of a trabeculectomy. The
structure was based on a modified Dreyfus model of skill
acquisition (novice, beginner, advanced beginner, com-
petent, expert).21 As we do not expect residents to become
expert during their training, the expert category was omit-
ted. As for previously published rubrics, rating categories
were assigned a numerical value so that a total score for the
tool could be calculated and monitored for improvement
over time. Behavioral anchors were written for each of 13
surgical steps and 7 global indices.
We sought comment from a second group of 12 con-
tent experts from around the world (Argentina, Australia,
Canada, China, Colombia, Kenya, the Pacific Islands, and
Switzerland), 10 of whom reviewed the draft and provided
constructive feedback. Aiming for global representation,
the reviewers were selected for their expertise and experi-
ence in teaching glaucoma surgery. Their suggestions were
cataloged, reviewed, and incorporated to produce the final
rubric.
1 www.glaucomajournal.com |
 Green et al J Glaucoma  Volume 00, Number 00, ’’ 2017

TABLE 1. ICO-OSCAR: Trabeculectomy

Resident: Assessor: Date

ICO-Ophthalmology Surgical Competency Assessment Rubric: Trabeculectomy

(ICO-OSCAR: Trabeculectomy)

Not applicable.
Novice Beginner Advanced Beginner Competent Done by
Surgical Step preceptor
(score = 2) (score = 3) (score = 4) (score = 5)
(score = 0)

Universal Has not heard of universal Aware of time-out process but not Able to perform team time-out but Independently initiates team time-
precautions precautions. confident to perform. May perform needs prompting to do so. out at beginning of case, identifies
1 with guidance/ prompting, but misses correct patient, procedure and side.
some information. Team members have been
introduced. Alerts / allergies noted.
Draping: Unable to start draping without Drapes with minimal verbal Lashes mostly covered, drape at most Lashes completely covered and clear
help. instruction. Incomplete lash coverage. minimally obstructing view. Attains of incision site, drape not
2 proper head position. obstructing view.

Corneal or Unable to describe purpose and Difficulty loading needle, needs Able to load and handle needle Is able to consistently perform the
superior rectus method of inserting traction instruction for correct needle appropriately. Some difficulty in step with the appropriate length of
3 traction suture suture. placement and completion of suture finding correct depth of suture, needs bite, depth of suture and achieve the
placement. instruction, needle track too deep or desired rotation of the eye for
too shallow or bite not of ideal size. exposure.

Conjunctival Is able to describe but not able to Is able to perform limbal or fornix
incision & perform limbal or fornix conjunctival incision but is inefficient
Tenon’s conjunctival incision for and requires guidance. Has difficulty
dissection trabeculectomy surgery. with judging appropriate length of
incision, dissection down to sclera of
both conjunctiva and Tenon’s and the
necessary force to apply to the tissue
Has difficulty avoiding damage to the.
4
superior rectus muscle with limbal-
based conjunctival flap.
Is able to perform subconjunctival
dissection, but needs occasional
guidance. Able to describe the
complications that can occur during
conjunctival dissection and their
management.
Is able to efficiently perform either
limbal or fornix conjunctival
incision. Judges appropriately the
length of incision, adequately
dissects down to sclera of both
conjunctiva and Tenon’s and
handles the tissue with the
appropriate tension. Takes condition
of the patient’s conjunctiva into
account. Ensures that an adequate
area of conjunctiva has been
dissected, creating a pocket to
facilitate application of anti-
metabolite.

Hemostasis Is unable to describe the need for
hemostasis, type of cautery
required, appropriate technique. Is
5 unable to perform.
Application of Is unable to accurately describe
antimetabolite role of antimetabolites in
trabeculectomy, types of
antimetabolites and the relative
indication for use of each type,
safety considerations and use of
pledget material.
6 fashioning of sponges. Inefficient
Is able to describe the need for
hemostasis, type of cautery required,
appropriate technique. Has difficulty
performing proper technique.
Is able to accurately describe role ,of
antimetabolites in trabeculectomy
types of antimetabolites and the
relative indication for use of each
type, safety considerations and use of
pledget material. Needs guidance for
choice of anti-metabolite and
exposure time. Needs guidance for
placement of sponges. Needs to be
reminded to keep surgical count.
Does not protect conjunctival edge.
Inefficient irrigation and /or removal
of sponges.
Is able to apply cautery but has
difficulty with scleral burns,
shrinkage of tissue, obtaining
hemostasis.
Is able to safely apply antimetabolite
onto eye but may have difficulty
creating pledget material to
appropriate size and thickness.
Appropriately discards materials into
toxic waste and rinses eye of residual
antimetabolite material.
Is able to efficiently and precisely
apply hemostasis without significant
scleral burns, shrinkage of tissues
and obtains hemostasis. Understands
advantages and disadvantages of
different types of cautery tips.
Is able to safely, efficiently and
accurately, apply antimetabolite
onto eye and has no difficulty
creating pledget material to
appropriate size and thickness.
Appropriately discards materials
into toxic waste and thoroughly
rinses eye of residual antimetabolite
material. Keeps surgical count of
pledgets used.

antibiotics, patching at the end of the case, and post-

RESULTS operative management. The authors acknowledge that
The authors named the tool the Ophthalmology Sur- these factors are important, but felt that the current tool
gical Competency Assessment Rubric for Trabeculectomy should primarily focus on the surgical steps of the proce-
(OSCAR: Trabeculectomy) (Table 1). The International dure. In addition, inclusion of these other parameters
Council of Ophthalmology (ICO) has approved this would make the rubric long and unwieldy, which could
assessment tool; the authors have thus termed it the ICO- potentially discourage uptake of the tool.
OSCAR: Trabeculectomy. The comments of the interna- A potential criticism is the length and detail of the
tional panel on the initial tool draft included general and tool, which may be a disincentive for its use: in practice,
specific suggestions, including incorporating emerging completing the assessment takes only a few minutes and can
techniques, for example, the use of subconjunctival injec- be done while providing feedback on the case with the
tion of antimetabolites and the insertion of stents. How- resident. One author suggested including an overall grading
ever, the authors decided to limit the rubric to the most of the trainee’s performance in the operation. The trainee’s
widely used and standardized techniques.22 In addition, level of training is relevant, as a junior trainee being
several authors commented on the importance of patient assessed at a novice level could be acceptable, but the same
selection and consent, anesthetic considerations, use of performance in an advanced trainee would be a cause for

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 J Glaucoma  Volume 00, Number 00, ’’ 2017 Surgical Assessment Rubric: Trabeculectomy

TABLE 1. (Continued)

Creation of scleral Is able to describe dissection Is able to describe dissection Is able to perform basic flap creation Is able to efficiently create flap to
flap technique for flap creation. technique for flap creation but but is inefficient and/or creates flaps the appropriate size, depth and
requires constant guidance to perform that -may be too thin, deep, small, or location without constant guidance.
7 the basic steps. Needs reminding to posterior. Able to describe the complications
grasp sclera outside flap construction and management of faulty scleral
area. flapcreation including buttonholing
and avulsion of the flap.
Paracentesis Puts anterior capsule or iris at risk Needs instruction on how to perform. Incision not in correct position or Incision parallel to iris, self sealing,
8 when entering anterior chamber Leakage and/or iris prolapse with leaks. adequate size, provides good access
Inappropriate incision architecture, local pressure, provides poor surgical for surgical maneuvering.
location, and size. access.
Sclerostomy Has difficulty with entry into Is able to create an entry plane into Is able to create an appropriate entry Is able to create an appropriate entry
(with Kelly anterior chamber, either ineffective anterior chamber but has significant plane into the anterior chamber and is plane into the anterior chamber and
punch) or trauma to ocular tissue. difficulty with using Kelly punch. able to use Kelly punch with is able to use Kelly punch with
9
Uncontrolled entry into AC. Damages scleral flap. Makes dexterity. Makes sclerostomy too dexterity. Sclerostomy appropriate
(a)
Difficulty using Kelly punch. sclerostomy too large / small or too large or too small for appropriate size for filtration.
anterior/ posterior for appropriate filtration.
filtration.
Sclerostomy Needs constant direction. Size of Difficulty outlining and dissecting Able to outline deep scleral flap and Outlines deep scleral flap with ease,
(without Kelly sclerostomy inappropriate or not in deep scleral flap. There may be perform dissection, but has difficulty dissects flap sclera from underlying
punch) correct position damage to surrounding tissues. performing this smoothly, needs tissue without trauma to other
direction. structures, excises deep scleral flap
9
cleanly. Deep scleral flap/
(b)
sclerostomy of appropriate size and
correctly positioned. Avoids damage
to the underlying ciliary body

Peripheral Cannot grasp iris tissue, damages
iridectomy (PI) surrounding structures.
10
Scleral flap Instruction is required and stitches
suturing/ anterior are placed in an awkward, slow
chamber (AC) fashion with multiple passes to
11 reformation sclera or tear of flap, loosens prior
placed scleral flap sutures, bends
needles, incomplete suture rotation.
Anterior chamber Cannot cannulate anterior chamber
reformation via paracentesis. Unable to assess
whether anterior chamber of
12 appropriate depth. Unable to assess
whether IOP is satisfactory to
proceed to next step.
Conjunctival Is unable to close conjunctiva.
closure Unable to differentiate Tenon’s
capsule from conjunctiva. Unable
to differentiate wing sutures from
13 mattress sutures and running
sutures and when appropriate to
place.
Needs direction in grasping iris tissue
and performing iridectomy. Unable to
control size of PI.
Stitches are placed with some
difficulty, resuturing may be needed,
questionable wound closure with
probable loosening of prior placed
scleral flap sutures, instruction may
be needed.
Has difficulty cannulating anterior
chamber via paracentesis to reform
anterior chamber. Needs guidance
Is able to perform basic conjunctival
closure technique but is inefficient
and requires significant guidance.
Additional sutures are required.
Significant bleb leak at the end of
surgery with unstable, shallow
anterior chamber. May have
buttonhole of conjunctiva.
Able to grasp iris tissue without
damage to intraocular structures, but
PI either too large or too small. May
need more than one attempt
Stitches are placed with minimal
difficulty; tight enough to achieve-
wound -closure -and allow for
appropriate filtration, may have slight
loosening of prior placed scleral flap
sutures.
Cannulates anterior chamber with
ease to reform anterior chamber, but
has difficulty assessing ideal AC
depth/ IOP
Is able to safely close conjunctiva
with good tissue approximation but is
inefficient. Requires guidance to
ensure closure is effective without a
leak. Placement of additional sutures
or replacement of loose sutures
required before closure is complete
and Seidel negative.
Able to grasp iris tissue without
damage to surrounding structures, PI
is of correct size.
Stitches are placed with correct
tension to allow for appropriate
filtration. Not too tight as to induce
loosening of prior placed scleral flap
sutures. Proper final IOP.
Cannulates AC with ease and is able
to assess correct AC depth/ IOP for
eye
Is able to safely and efficiently close
conjunctiva with good tissue
approximation and no bleb leak and
stable anterior chamber. Has good
understanding of various suture
types and appropriate needles

concern and could trigger remediation. The training level will be able to use this feature to plot their progression as
has thus been included at the start of the document. their skills evolve. Reflective practice can be enhanced if
procedures are recorded: the trainee is able to self-assess
performance using the rubric when reviewing the recording
DISCUSSION and can compare this with the feedback received.
Although there are well-established global surgical The assessment of competence is complex and should
rating tools23 to our knowledge, there is no accepted take into account not just surgical skills, but other pro-
standard competency assessment tool for trabeculectomy. fessional attributes such as those referred to as “Non-Tech-
There is a growing understanding that judging competence nical Skills for Surgeons” (NOTSS),29 which include situa-
in a discipline, including ophthalmic surgery, is a result of tional awareness, decision-making, communication and
the assessment of cumulative and progressive experiences, teamwork, and leadership. The competent performance of a
in the United States referred to as “Milestones.”24 single procedure does not equate with overall competence to
Although performing ophthalmic surgery is listed as a surgically manage glaucoma patients unsupervised; this
milestone, the metrics to evaluate individual procedures should be included in the debriefing discussion at the con-
have not been fully developed. clusion of the case/operating list. It is recommended that this
Globally, there is great variability in the number of assessment tool be used in conjunction with other forms of
procedures performed by residents and metrics to assess assessment, both formative and summative, integrated into a
competence.25–28 This assessment tool serves two purposes: formal training framework.
first, it will decrease subjectivity of the assessment by clearly The ICO-OSCAR: Trabeculectomy has face and con-
defining for the assessor which skills must be observed for tent validity and can be used internationally to teach and
each level of proficiency; second, the rubric clearly com- assess trabeculectomy surgical skills. However, further
municates to the learner what is expected to attain com- work is necessary to determine its reliability and predictive
petence and thus can be used for both teaching and and construct validity.
assessment. It is suitable for both formative (designed to
improve performance) and summative (final grade) assess-
ment. As it is a structured assessment of competency, it ACKNOWLEDGMENTS
does not take into account the expected performance of an The authors thank the following panel experts for their
individual who is at a specific stage of training. Trainees commentary and feedback on the rubric: Javier Casiraghi

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Copyright r 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Green et al
TABLE 1. (Continued)
Maintaining Is unable to describe types of
hemostasis cautery, settings for cautery and/or
unable to describe electrocautery
1 technique.
Tissue handling Is excessively aggressive or timid
in manipulating tissue. Inadvertent
tissue damage occurs to
2 conjunctiva or sclera. Needs
direction to grasp sclera outside
margins of intended scleral flap.
Knowledge of Can only identify instruments in
instruments simple terms such as “scissors” and
3 “forceps” but no knowledge of
necessary sutures or needle types.
Technique of Frequently loads needle
holding suture incorrectly.
4 needle in needle
holder
Technique of Unable to tie knots.
surgical knot
5 tying
6 Overall speed and Hesitant, frequent starts and stops,
fluidity of not at all fluid.
procedure
7 Communication Does not know role of surgical
with surgical team team members. Lacks confidence
or has too much. Does not establish
good rapport with team. Unable to
request instruments from scrub
nurse using proper instrument and
suture names and/or instructions to
surgical assistant are vague or
nonexistent.
Overall difficulty of case (circle): Standard
Good points:
Suggestions for development:
Agreed action(s):
Signature of assessor:
Signature of trainee:
(Argentina), Karim Damji (Canada), Roger Dethlefs (Pacific
Eye Institute), Ivan Goldberg (Australia), Jonathan Goodfellow
(United Kingdom), Fernando Gómez Goyeneche (Columbia),
Xiulan Hang (China), Lisa Heckler (Canada), Fabián Lerner
(Argentina), Daniel Kiage (Kenya), Sheila Marco (Kenya).
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J Glaucoma  Volume 00, Number 00, ’’ 2017
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