the data were accumulated during 
 two evaluations performed 8 years apart . while the second 
 evaluation was suggested at the end of the first study , it was not 
 part of the plan when the first assessment took place .
however , 
 the methodology , as well as the data collected during the second 
 study , was based on the first .
eight medical college departments were evaluated during 
 the first visit . during the ensuing years , 3 more departments had 
 developed ; and a total of 11 departments were evaluated during 
 the second phase . a structured questionnaire [ appendix 1 , 2 ] 

was sent out in advance to the respective heads of department 
 to determine details like the number of students , patients 
 seen , operations done and list of the equipment available . 
 following this , the evaluator scheduled a site visit and spent a 
 day in each of the departments .
the preferred characteristics of an ophthalmology training 
 program were specified in advance and were the considered 
 opinion of the first evaluator and agreed to by the second prior 
 to the next evaluation .
the criteria considered 
 indicators of suitable outpatient and ward care in a medical 
 college department are shown in table 3 ; those for the 
 operating room are shown in table 4 .
undergraduate training 
 was assessed using a questionnaire , observation and personal 
 interview only during the first evaluation . at the time of the first visit ,
fourteen trainer of trainers who had been 
 trained by the world bank program were interviewed .
changes in teaching and practice pattern , including surgery , 
 instrumentation and their use , were documented for the eight 
 departments examined on the two occasions .
the number of outpatients seen in the departments varied from 
 95 ( 70 new and 25 old ) to 1,300 ( 800 new , 500 old ) per month . 
 the number of beds varied from 16 to 500 ; and the number of 
 ophthalmologists in each department , from 4 to 46 .
the number 
 of residents ( do and ms ) ranged from 4 to 16 .
three departments with 
 residency programs had no slit lamps ; the maximum number of 
 functioning slit lamps in a department was 10 .
two departments 
 did not have indirect ophthalmoscopes ; five departments had 
 one to two in working order , while one department had six . 

only one department had a functioning a - scan . the number 
 of cataracts done each year varied from 234 to 8,371 ; cataracts 
 with intraocular lenses ( iols ) were 20 to 5,600 .
none of the criteria considered necessary for patient care in 
 a teaching department were routine in any of the departments . 

none of the criteria for resident teaching were met in any of 
 the departments . a brief description follows .
most departments had an adequate outpatient load , but 
 patients were managed ( and teaching undertaken ) between 9 
 a.m. and 2 p.m. none of the departments practiced a routine 
 comprehensive eye examination . this concept was not taught to 
 residents either .
this practice was prevalent even in the only hospital that had all 
 the essential equipment for teaching .
could best 
 be described as what would be considered routine in an eye 
 camp. while there was clinical teaching , the residents did not 
 manage patients independently or even under supervision . 

this pattern was true even in the 
 only department that had most of the modern ophthalmic 
 instrumentation .
there were several reports of essential instrumentation being 
 locked up without access for residents , and , in some instances , 
 even the faculty . in one department
, there was a well - preserved 
 10-year - old indirect ophthalmoscope reported to be in routine 
 use. the original bulb was still functioning .
the operating room ( or ) design was unsuitable in six of 
 the departments .
while most surgeons scrubbed between cases , 
 the gowns were not changed throughout the day ; gloves 
 were not used .
surgeons with the training and skills to perform 
 microsurgery could not do so , due to lack of instrumentation .
if 
 a microscope was available , only some surgeons were allowed 
 to use it .
magnification for cataract surgery was not the norm ; 
 in one department , a 2-year - old child had undergone an iol 
 implantation without any magnification .
undergraduates had regular theory and clinical teaching . in 
 one department , findings were demonstrated on the slit lamp . 

the evaluator was impressed by the intelligence of , and the 
 interest shown by , the residents interviewed  which he put 
 on record .
the 
 number of intra - capsular operations performed during the 
 course ranged from 15 to 150 ; extra - capsulars , from 0 to 300 ; 
 and iols , from 0 to 25 .
only one of the 
 residents interviewed felt confident about going into practice 
 immediately after graduation .
the instrumentation provided included slit lamps with 
 applanation tonometers , teaching microscopes , a - scans and 
 other basic instrumentation .
6 crores for state - of - the - art 
 instrumentation - including high - quality surgical microscopes , 
 slit lamps with applanation tonometers , phacoemulsification 
 machines , additional a - scans , fundus cameras , lasers ( yag and 
 green ) , automated perimeters and audiovisual equipment . 

each department also received state - of - the - art teaching 
 surgical microscopes and slit lamps with beam splitters , 
 stereo observer - scopes and monitors provided specifically for 
 teaching purposes .
in other words , the departments were as 
 well equipped as any medical college department anywhere 
 in the world could be .
the number of doctors , postgraduates , beds and patients seen 
 remained almost at the same level between the two visits .
the head of departments reported that instrumentation 
 provided was used frequently in 4 of the 11 departments .
one 
 head of department stated that patient care and teaching had 
 improved considerably .
however , 
 the criteria of care and teaching considered appropriate for 
 medical colleges [ tables 2 - 4 ] were not achieved .
the timings for 
 patient management and teaching were still 9 a.m. to 2 p.m. a comprehensive eye examination was still not the norm 
 and was not routinely undertaken by the residents or faculty . 

resident interviews revealed that the residents were not 
 allowed to use diagnostic instruments provided for training . 

resident interviews also revealed that while the residents now 
 used microscopes for surgery , the recommended supervision 
 was lacking .
the teaching microscopes with the beam splitters 
 and monitors were not made available to postgraduates ; in 
 some cases , not even to faculty .
the teaching slit lamps were used 
 for demonstrations for undergraduates and residents , but 
 residents did not get to use the newer equipment provided . 

laser 
 machines were unused or sparingly used ( two lasers in a year ) . 

high - end automated perimeters were available ; but as they 
 were sparingly used , fields were not preformed for all glaucoma 
 suspects or cases .
phacoemulsification machines were still in 
 their packing in three departments , and phacoemulsification 
 was not the norm in any of the hospitals .
a - scans were 
 available in all the departments but were not routine for all 
 iol surgery . the surgical pattern had changed in that iol usage was 
 now the norm ( 91 to 99% ) .
other surgical practices , however , 
 remained the same and actual visual outcomes were not known . 

routine postoperative slit lamp examination was still not 
 the norm . at the time of both the visits ,
patients were not informed 
 about the examinations , investigations or procedures they were 
 about to undergo .
an informal discussion of risks and benefits 
 or a formal informed consent was not the norm and was not 
 witnessed during either visit .
the trainer of trainer ( tot ) issue was addressed formally 
 only at the first visit , but , as will be seen , still has relevance .
they had independently 
 performed the minimum number of cases stipulated by the 
 world bank .
only one training institution taught what would 
 be considered the appropriate evaluation ( required of a trainer ) 
 necessary to diagnose and manage potential problems .
training 
 using a microscope with beam splitters was not imparted 
 in most instances . additionally , only one institution taught 
 trainers appropriate management of vitreous loss .
a no touch 
 technique was not taught in any institution to the trainers or 
 students .
all 14 trainers of trainers who had returned to their 
 parent institutions and were interviewed were male .
following their return from the tot program , till the first 
 evaluation took place , none of the trainers had taught a single 
 person .
teachers interviewed during the second visit felt their 
 training was insufficient to enable them to confidently use , 
 and teach the use of , the instrumentation provided .
many were 
 uncomfortable with performing or teaching phacoemulsification 
 as they did not have the wherewithal to manage complications . 

some of 
 them did , however , use the instrumentation ( and perform 
 phacoemulsification ) in private practice .
as far as inappropriate 
 postings were concerned , the second evaluator too reported that 
 many ophthalmologists trained in microsurgery were posted 
 to departments of anatomy , microbiology and radiology even 
 when trainers were not available in the parent department of 
 ophthalmology .
the number of outpatients seen in the departments varied from 
 95 ( 70 new and 25 old ) to 1,300 ( 800 new , 500 old ) per month . 
 the number of beds varied from 16 to 500 ; and the number of 
 ophthalmologists in each department , from 4 to 46 .
the number 
 of residents ( do and ms ) ranged from 4 to 16 .
three departments with 
 residency programs had no slit lamps ; the maximum number of 
 functioning slit lamps in a department was 10 .
two departments 
 did not have indirect ophthalmoscopes ; five departments had 
 one to two in working order , while one department had six . 

only one department had a functioning a - scan . the number 
 of cataracts done each year varied from 234 to 8,371 ; cataracts 
 with intraocular lenses ( iols ) were 20 to 5,600 .
none of the criteria considered necessary for patient care in 
 a teaching department were routine in any of the departments . 

none of the criteria for resident teaching were met in any of 
 the departments . a brief description follows .
most departments had an adequate outpatient load , but 
 patients were managed ( and teaching undertaken ) between 9 
 a.m. and 2 p.m. none of the departments practiced a routine 
 comprehensive eye examination . this concept was not taught to 
 residents either .
this practice was prevalent even in the only hospital that had all 
 the essential equipment for teaching .
could best 
 be described as what would be considered routine in an eye 
 camp. while there was clinical teaching , the residents did not 
 manage patients independently or even under supervision . 

this pattern was true even in the 
 only department that had most of the modern ophthalmic 
 instrumentation .
there were several reports of essential instrumentation being 
 locked up without access for residents , and , in some instances , 
 even the faculty . in one department
, there was a well - preserved 
 10-year - old indirect ophthalmoscope reported to be in routine 
 use. the original bulb was still functioning .
the operating room ( or ) design was unsuitable in six of 
 the departments .
while most surgeons scrubbed between cases , 
 the gowns were not changed throughout the day ; gloves 
 were not used .
surgeons with the training and skills to perform 
 microsurgery could not do so , due to lack of instrumentation .
if 
 a microscope was available , only some surgeons were allowed 
 to use it .
magnification for cataract surgery was not the norm ; 
 in one department , a 2-year - old child had undergone an iol 
 implantation without any magnification .
undergraduates had regular theory and clinical teaching . in 
 one department , findings were demonstrated on the slit lamp . 

the evaluator was impressed by the intelligence of , and the 
 interest shown by , the residents interviewed  which he put 
 on record .
the 
 number of intra - capsular operations performed during the 
 course ranged from 15 to 150 ; extra - capsulars , from 0 to 300 ; 
 and iols , from 0 to 25 .
only one of the 
 residents interviewed felt confident about going into practice 
 immediately after graduation .
the instrumentation provided included slit lamps with 
 applanation tonometers , teaching microscopes , a - scans and 
 other basic instrumentation .
6 crores for state - of - the - art 
 instrumentation - including high - quality surgical microscopes , 
 slit lamps with applanation tonometers , phacoemulsification 
 machines , additional a - scans , fundus cameras , lasers ( yag and 
 green ) , automated perimeters and audiovisual equipment . 

each department also received state - of - the - art teaching 
 surgical microscopes and slit lamps with beam splitters , 
 stereo observer - scopes and monitors provided specifically for 
 teaching purposes .
in other words , the departments were as 
 well equipped as any medical college department anywhere 
 in the world could be .
the number of doctors , postgraduates , beds and patients seen 
 remained almost at the same level between the two visits .
the head of departments reported that instrumentation 
 provided was used frequently in 4 of the 11 departments .
one 
 head of department stated that patient care and teaching had 
 improved considerably .
however , 
 the criteria of care and teaching considered appropriate for 
 medical colleges [ tables 2 - 4 ] were not achieved .
the timings for 
 patient management and teaching were still 9 a.m. to 2 p.m. a comprehensive eye examination was still not the norm 
 and was not routinely undertaken by the residents or faculty . 

resident interviews revealed that the residents were not 
 allowed to use diagnostic instruments provided for training . 

resident interviews also revealed that while the residents now 
 used microscopes for surgery , the recommended supervision 
 was lacking .
the teaching microscopes with the beam splitters 
 and monitors were not made available to postgraduates ; in 
 some cases , not even to faculty .
the teaching slit lamps were used 
 for demonstrations for undergraduates and residents , but 
 residents did not get to use the newer equipment provided . 

laser 
 machines were unused or sparingly used ( two lasers in a year ) . 

high - end automated perimeters were available ; but as they 
 were sparingly used , fields were not preformed for all glaucoma 
 suspects or cases .
phacoemulsification machines were still in 
 their packing in three departments , and phacoemulsification 
 was not the norm in any of the hospitals .
a - scans were 
 available in all the departments but were not routine for all 
 iol surgery . the surgical pattern had changed in that iol usage was 
 now the norm ( 91 to 99% ) .
other surgical practices , however , 
 remained the same and actual visual outcomes were not known . 

routine postoperative slit lamp examination was still not 
 the norm . at the time of both the visits ,
patients were not informed 
 about the examinations , investigations or procedures they were 
 about to undergo .
an informal discussion of risks and benefits 
 or a formal informed consent was not the norm and was not 
 witnessed during either visit .
the trainer of trainer ( tot ) issue was addressed formally 
 only at the first visit , but , as will be seen , still has relevance .
they had independently 
 performed the minimum number of cases stipulated by the 
 world bank .
only one training institution taught what would 
 be considered the appropriate evaluation ( required of a trainer ) 
 necessary to diagnose and manage potential problems .
training 
 using a microscope with beam splitters was not imparted 
 in most instances .
a no touch 
 technique was not taught in any institution to the trainers or 
 students .
all 14 trainers of trainers who had returned to their 
 parent institutions and were interviewed were male .
following their return from the tot program , till the first 
 evaluation took place , none of the trainers had taught a single 
 person .
teachers interviewed during the second visit felt their 
 training was insufficient to enable them to confidently use , 
 and teach the use of , the instrumentation provided .
many were 
 uncomfortable with performing or teaching phacoemulsification 
 as they did not have the wherewithal to manage complications . 

some of 
 them did , however , use the instrumentation ( and perform 
 phacoemulsification ) in private practice .
as far as inappropriate 
 postings were concerned , the second evaluator too reported that 
 many ophthalmologists trained in microsurgery were posted 
 to departments of anatomy , microbiology and radiology even 
 when trainers were not available in the parent department of 
 ophthalmology .
residency training is crucial for the future of indian 
 ophthalmology , as well as for the delivery of quality eye care 
 to the population .
we are aware of the constraints under which 
 the publicly funded medical college departments function ; 
 however , there are public and private departments in the 
 country that can compete with the best in the world . therefore , 
 the objective was to compare the training programs to what is 
 possible in the country . to the best of our knowledge ,
there are 
 no published reports of on - site evaluation of residency training 
 in india .
the 
 teachers felt that with the provision of audiovisual equipment , 
 student presentations had improved dramatically .
also , iol 
 usage in all departments had increased dramatically and had 
 become the norm .
the visual outcomes of this advance and 
 the occurrence of complications were however not available . 

nevertheless , teaching standards and care delivery in all medical 
 college departments failed to meet the specified benchmarks , at 
 both the evaluations , performed after the provision of quality 
 equipment ( and training in their use ) on two separate occasions . 

the provision of instrumentation and training had 
 not effected the desired changes . what should our training philosophy be ? patients treated 
 in training departments participate in the learning process . 

it behooves us then to ensure that the probability of best 
 possible outcomes is maximized .
this can only be achieved if 
 all patients are carefully examined not just from the training 
 point of view , but also from the view of selecting ( at least , at 
 first ) uncomplicated cases for training .
additionally , 
 all surgery in such situations must be taught by experienced 
 surgeons using the recommended instrumentation ; for the 
 initial cases , this requires an experienced surgeon scrubbed 
 up and actively assisting through the observer scope . 

furthermore , all complications in a training situation must be 
 managed in the best possible manner to minimize morbidity 
 and maximize acceptable outcomes .
this too requires 
 an experienced surgeon assisting the student , using accepted 
 modern instrumentation .
management of complications 
 extends well into the postoperative period and mandates 
 routine postoperative slit lamp and fundus examination .
such 
 routine pre- and postoperative examinations , assistance during 
 surgery and management of complications ( and its teaching ) 
 did not exist in any of the departments .
the faculty in some departments indicated that students 
 routinely used slit lamps , applanation tonometers , gonioscopes 
 and indirect ophthalmoscopes . in all departments , however , the 
 residents told a different story .
they were not allowed to use 
 instruments specifically provided for them , and some diagnostic 
 instruments were locked up to prevent access for anyone . 

they were not taught to perform routine comprehensive eye 
 examination and did not manage cases either under supervision 
 or independently . while not a part of the checklists , an important aspect of 
 modern eye care is informed consent and patient participation 
 in the treatment .
this was not practiced in any department ; 
 unless it is part of patient care in teaching departments , students 
 are unlikely to understand its importance and employ it in 
 practice . in a training department , this ethical aspect becomes 
 even more demanding . ideally patients should be informed that 
 they may be operated on by a trainee or at least be informed that 
 they will not have the choice of surgeon .
research methodology 
 is another important component of postgraduate teaching , 
 especially if we want to encourage ophthalmic research in india . 

the paucity of 
 publications from most medical college departments would 
 seem to be a direct consequence.8 the reasons for lack of appropriate teaching and eye care 
 are complex .
the usually large patient loads can not 
 be appropriately managed and teaching undertaken in a 5-hour 
 day . the issues of private practice and nonpracticing allowance 
 responsible for such limited working hours need urgent 
 resolution . on the other hand ,
an increase in working hours 
 may not guarantee that desired benchmarks will be achieved . 

( there are states where the working hours are longer but the 
 patient care and practice is similar . ) another unlikely , purely 
 theoretical possibility is poor leadership , improper attitude 
 and lack of accountability .
measures to identify and address 
 the source of the problem and ensure appropriate teaching and 
 preferred practice are urgently needed .
as far as modern ophthalmology is concerned , the existing 
 archaic guidelines for the recognition and continued accreditation 
 of teaching departments need major restructuring .
programs 
 without the necessary instrumentation , teaching and practice 
 required for modern ophthalmology are recognized for training . 
 on the other hand ,
we are aware of one well - functioning 
 modern teaching department ( fulfilling all the benchmarks ) 
 that was not recognized as it was not split into units and 
 had too many beds. it would seem that the rules require units 
 and beds , not instrumentation , teaching or preferred practice 
 patterns .
interestingly , while modern ophthalmology hardly 
 requires beds , provision of such beds in teaching departments 
 may actually be desirable .
postgraduates could then at least be 
 responsible for the care of patients on their beds ; if undertaken 
 and supervised properly , the work - up , investigations and 
 intervention on their own patients is one way to ensure 
 examination , management and follow - up skills .
to ensure 
 modern requirements , the final postgraduate examination to 
 certify ophthalmologists too needs major change .
the clinical 
 component of the examinations should at least observe and 
 test competence in the components of a comprehensive eye 
 examination and clinical ( including surgical ) ability , not just 
 theoretical knowledge as is currently the case .
the tot became accepted terminology during the world 
 bank-funded program . during the planning of this program , 

indian experts had stressed the need for placement of quality 
 training equipment in the parent department before the tot 
 returned .
they also expressed concern about maintenance of 
 equipment and the potential for transfers of the tot before the 
 objective of the program was achieved .
in reality , the promised 
 equipment for training was not available on return in any of 
 the parent departments .
a tot who was waiting for 6 months 
 for the basic equipment dourly expressed the need for a 
 refresher course .
tot was to be the backbone of the modern 
 training process ; yet their training too was below par .
this technique 
 is desirable in all cataract surgery but becomes especially 
 important in less - than - ideal conditions , especially where gloves 
 are not used : the existing situation in all departments . and 
 once in their parent departments , the tots did not or could 
 not function to the desired potential .
the report generated at the end of the first evaluation 
 recommended the provision of quality teaching instruments in 
 all medical college departments , as well as measures to improve 
 training and care delivery .
to the best of our knowledge , this report was available to 
 all policy makers .
the lessons of the world bank program 
 notwithstanding , the condition remained the same after the next 
 round of funding .
expensive new instrumentation , including 
 field analyzers , lasers , fundus cameras and phacoemulsification 
 machines , lay unused even a year after it had been provided . 

further training may indeed be needed ; however , 
 even those who were trained did not transfer their skills to 
 others in the department or their students .
modern procedures 
 performed in private practice were neither undertaken nor 
 taught in the teaching department .
other reasons 
 cited included fear of spoiling the new instruments , lack of 
 spares and maintenance support .
the practice of trained staff 
 being deputed out to unrelated departments too continued 
 over the years .
the second evaluation 
 was not part of the original plan but serendipitously provided 
 follow - up information . while the same evaluator would have 
 been desirable for both assessments , logistical and other 
 constraints mandated another assessor .
although the format 
 and benchmarks used were the same for visits , the methods did 
 vary and precluded some comparisons .
56 crores allotted to the state 
 by the world bank was used for instrumentation and training . 

we accept 
 that the first estimate may be wrong ( in either direction ) but 
 highlight that an outlay was provided for instrumentation 
 and training on two temporally separated occasions and have 
 reported the impact of that investment on teaching and care .
the study state was chosen for convenience , logistics and 
 because it was a beneficiary of world bank and other funding . 

it is however a representative state of the country , and we 
 feel that the data can be extrapolated to most medical college 
 teaching departments . the standards in the country do vary 
 dramatically , and there are some departments that not only 
 meet but also exceed the benchmarks . some may consider the quality benchmarks as too strict 
 for a developing country .
we feel that this pretext has 
 been used to maintain status quo for too long .
we argue 
 that at least in departments responsible for the training of 
 future ophthalmologists , this overused developing country 
 justification is no longer valid .
the benchmarks used are not 
 unrealistic ; they have been achieved in the country and are 
 eminently desirable . in conclusion , the postgraduate programs do not train 
 residents in modern ophthalmic examination and surgical 
 techniques .
the residents were not taught current cataract 
 surgical techniques and were not confident of independent 
 practice .
the quality of care in the teaching departments did 
 not conform to accepted preferred practice patterns .
finally , 
 two rounds of funding totaling about rs . 34 crores towards 
 modern instrumentation and training did not materially change 
 the standard of training and care .
while there may be denials , accusations , recriminations and 
 inaction , we hope that publication in our journal will help 
 the ophthalmic community to acknowledge the problems , 
 encourage dialog and initiate changes that ophthalmology 
 training in india so obviously and desperately needs .
 aim : to evaluate teaching and practice in medical college ophthalmology departments in a representative 
 indian state and changes following provision of modern instrumentation and training.study type : prospective qualitative study.materials and methods : teaching and practice in all medical colleges in the state assessed on two separate 
 occasions by external evaluators . 
 preferred criteria for training and care were pre - specified . 
 methodology 
 included site visits to document functioning and conduct interviews . 
 assessments included resident teaching , 
 use of instrumentation provided specifically for training and standard of eye care . the first evaluation ( 1998 ) 
 
 was followed by provision of modern instrumentation and training on two separate occasions , estimated at 
 rupees 34 crores . 
 the follow - up evaluation in 2006 used the same methodology as the first.results:eight departments were evaluated on the first occasion ; there were 11 at the second . 
 on the first 
 assessment , none of the programs met the criteria for training or care . following the provision of modern 
 instrumentation and training , 
 intraocular lens usage increased dramatically ; but the overall situation 
 remained essentially unchanged in the 8 departments evaluated 8 years later . 
 routine comprehensive eye 
 examination was neither taught nor practiced . 
 individually supervised surgical training using beam splitters 
 was not practiced in any program ; neither was modern management of complications or its teaching . 
 
 phacoemulsification was not taught , and residents were not confident of setting up practice . 
 instruments 
 provided specifically for training were not used for that purpose . 
 students reported that theoretical teaching 
 was good.conclusions:drastic changes in training , patient care and accountability are needed in most medical college 
 ophthalmology departments . 
Materials and Methods
Results
First evaluation (1998)
Second evaluation (2006)
Discussion