Overall five instructors were involved in the delivery of the practical session. All instructors were in their fourth year of ophthalmic residency training or above, and competent in ophthalmic surgical skills. Instructors were also emailed instructions regarding the session and links to pre-recorded surgical skills videos. A pre-session briefing was held with all instructors via Zoom®. As part of the briefing, instructors were shown how to navigate the platform; including use of breakout rooms, as well as how to demonstrate the taught skills in ‘Surgeon’s view’.

‘Surgeon’s view’ is a specific camera angle enabling viewers (in this case students) to see exactly what the surgeon sees. It reduces cognitive overload as the student is able to directly emulate the steps of the skill rather than needing to mentally invert the process for delivery. ‘Surgeon’s view’ was achieved by turning our camera devices 180 degrees and angling the camera angle so that the fruit and our hands were in full view (Fig. 1a and b).

Videos were created in ‘Surgeon’s view’ specifically for the session and could be accessed via YouTube® links. Instructional videos were first made showing how to perform reef and slip knots using a cable so that students could understand how to tie a knot on a macro level. Further instructional videos were created demonstrating suturing and knot tying using sutures and surgical instruments on the prepared fruit. A final video was made showing how to tie a releasable suture as part of trabeculectomy surgery [9].

Surgical skills teaching delivery

The Zoom® platform was chosen over other platforms to deliver the virtual surgical skills session due to its reliability and accessibility in countries outside of the United Kingdom. Synchronous teaching began with a PowerPoint presentation describing suture materials, instrument and suture handling in the main virtual teaching room. For the practical skills element, students began by watching a pre-recorded video on how to tie a reef knot with a cable, after which they were assigned to breakout rooms where they could practice this skill under direct supervision of an instructor (Fig. 1c). This was practiced until students had obtained a level of proficiency. This cycle was repeated for each of the remaining skills starting with basic general surgical skills and progressing to advanced ophthalmic skills: tying a slip knot with a cable, suturing and tying a reef knot, suturing and tying a slip knot, tying a trabeculectomy releasable suture. Instructor to student ratio in the breakout rooms was 1:4. At the end of the session, students were again brought back to the main teaching room for a PowerPoint presentation summarising key points of the day and reflecting on learning outcomes.

Data collection

This is a mixed methods study where both qualitative and quantitative data were collected to assess student perceptions. Semi-structured interviews were used to understand instructor perceptions towards the virtual surgical skills session delivered.

Student perceptions

Students were sent pre-session and post-session questionnaires via Google® Forms. The pre-session questionnaire consisted of seven Likert questions and one open-ended question. Students were asked about their baseline surgical skills, their perceptions regarding a virtual ophthalmic surgical skills course and to rate their confidence in surgical instrument handling, basic suturing capabilities and knot tying. In addition, they were asked whether their view, level of supervision or interaction with tutors would be negatively impacted by holding the session virtually.

The post-session questionnaire consisted of 17 Likert type questions and two open-ended questions about equipment, virtual platform, pre-recorded skill demonstration videos, practical session and supervision (see supplementary material).

To measure internal consistency of pre-session and post-session questionnaires Cronbach alpha (α) was calculated using SPSS 25 software. Internal consistency measuring α ≥ 0.7 was considered acceptable (pre-session questionnaire α = 0.72, seven items and post-session questionnaire α = 0.72, 12 items).

Instructor perceptions

Semi-structured interviews were conducted to evaluate instructor perceptions towards the virtual session and consisted of 12 core questions (see supplementary material). All five instructors were interviewed by an independent interviewer. Interviews were digitally recorded and transcribed verbatim, before undertaking thematic analysis.

Data analysis

Changes in pre-session and post-session responses (six items) were analysed using Wilcoxon signed rank (SPSS 25). The remainder of items were summarised using descriptive and summary statistics. Thematic analysis was used to evaluate the answers to open-ended questions from students and instructors. An inductive analytic approach based on the constant comparative method was used for coding, aggregation, and theme development. The qualitative analysis was done using NVivo 12.0 software.