Implementation of teaching strategies and innovation to comply with the training competencies in an ophthalmology residency program during the coronavirus disease-19 pandemic

Angel Eduardo Gonzalez-Garcia; Yolanda Macias-Rodriguez; Raul E Ruiz-Lozano; Alejandro Rodriguez-Garcia

doi:10.4103/pajo.pajo_124_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 4 | Issue : 1 | Page : 19

Implementation of teaching strategies and innovation to comply with the training competencies in an ophthalmology residency program during the coronavirus disease-19 pandemic

Angel Eduardo Gonzalez-Garcia, Yolanda Macias-Rodriguez, Raul E Ruiz-Lozano, Alejandro Rodriguez-Garcia
Tecnologico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences, Monterrey, Mexico

Date of Submission	07-Dec-2021
Date of Acceptance	10-Jan-2022
Date of Web Publication	20-Apr-2022

Correspondence Address:
Dr. Alejandro Rodriguez-Garcia
Instituto De Oftalmologia Y Ciencias Visuales Centro Medico Zambrano Hellion, Av. Batallon De San Patricio No. 112. Col. Real De San Agustin, N.l. Cp. 66278
Mexico

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_124_21

Abstract

Purpose: The coronavirus disease (COVID)-19 pandemic put medical residency programs in a predicament, impacting clinical attention and surgical practice. This study aims to describe the adjustments applied in an ophthalmology residency program to overcome the COVID-19 pandemic restrictions.
Materials and Methods: An observational, comparative, and descriptive study was performed in an ophthalmology residency program to analyze the adaptations and innovations implemented to overcome the medical attention and training restrictions enforced by the sanitary authorities due to the COVID-19 pandemic in the year 2020. The residents' record folders were analyzed yearly for academic, research, clinical, and surgical activities from 2018 to 2020. An online survey was applied to residents for congress attendance, research publications, time spent on classes, lectures, clinical cases, journal club, and surgical videos sessions during the pandemic.
Results: Compared to years 2018 and 2019, during 2020, there was a significant increase in the hours destined per week to academic activities (6.04 vs. 16.42 h, P < 0.001); the monthly hours of journal club sessions (0.5 vs. 3.41 h, P < 0.001); and the number of published articles involving residents (0.4 vs. 2.52, P < 0.001). On the contrary, the hours of outpatient consultation (8 h/day vs. 4 h/day) and the number of cataract surgeries performed per resident decreased (48 vs. 15, P < 0.001) from 2019 to 2020.
Conclusions: Prompt reaction and innovation were required to overcome the educational and training barriers imposed by the COVID-19 pandemic. While remote academic activities increased significantly, online patient consultation and surgical simulation were necessary to avoid hindering patient's attention and surgical training.

Keywords: Coronavirus disease-19 pandemic, innovative education, medical education, ophthalmology residency, surgical training

How to cite this article:
Gonzalez-Garcia AE, Macias-Rodriguez Y, Ruiz-Lozano RE, Rodriguez-Garcia A. Implementation of teaching strategies and innovation to comply with the training competencies in an ophthalmology residency program during the coronavirus disease-19 pandemic. Pan Am J Ophthalmol 2022;4:19

How to cite this URL:
Gonzalez-Garcia AE, Macias-Rodriguez Y, Ruiz-Lozano RE, Rodriguez-Garcia A. Implementation of teaching strategies and innovation to comply with the training competencies in an ophthalmology residency program during the coronavirus disease-19 pandemic. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 May 29];4:19. Available from: https://www.thepajo.org/text.asp?2022/4/1/19/343600

Introduction

Coronavirus disease (COVID-19) continues to affect significantly daily activities worldwide. In Mexico, the first COVID-19 case arrived in February 2020 and, by March, a Phase-2 sanitary contingency was decreed, including social distancing, lockdown, and labor restriction.^[1] Since then, the pandemic continued expanding for the following months. As in other countries, due to the high risk of contagion with the possibility of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by airborne spread and secretions contact, including tears,^[2],[3] medical and clinical education activities were reduced. This shutdown has hindered adequate medical education. Many clinics and hospitals reduced their outpatient consult and elective surgical procedures to diminish crowding and avoid contagions.^[2] Dedeilia et al. divided the educational affection into medical and surgical. The medical education affection included restrictions on presential lectures, patient bedside training, reduction of medical teams, and the need to transfer trainees to COVID services in hospitals.^[4] The surgical training affection included postponed elective surgeries, rationing medical equipment limiting trainees to observe, perform or assist surgery, and simple cases entrusted to senior residents now performed by attendings to minimize surgical time and reduce contagion possibility.^[1] In addition, other activities such as presential lectures, case discussions, and congresses were canceled, limiting continuous medical education.^[1],[5] Changes in residency program models varied depending on their type. For example, an orthopedic residency program divided residents into two groups. One group stayed at the clinic, doing urgent care activities, and the other was quarantined at home, receiving remote education. The groups switched every determined period to ensure the urgent care required for this medical specialty.^[6]

At Tecnologico de Monterrey, Mexico, the ophthalmology residency program experienced similar challenges during the lockdown. Since official restrictions were decreed in Mexico, the institution's epidemiologic surveillance unit closed the ophthalmology facility for 5 months (March 27 to August 17, 2020), and during the second pandemic wave in Mexico (December 18, 2020, to February 7, 2021). As a result, all clinical and surgical attention and training capabilities were suspended, affecting medical students, ophthalmology residents, and subspecialty fellows. However, academic activities such as lectures, clinical case discussions, journal clubs, workshops, and others were actively performed online. Technology and the Internet represented a valuable tool to go through it. Chick et al. proposed innovative solutions for residency programs such as virtual classroom models, online practice questions, online academic conferences, telehealth clinics, and surgical videos facilitation.^[7]

This study describes the implementation of innovative educational and training strategies for complying with the academic curriculum in our ophthalmology residency program during the COVID-19 pandemic lockdown. It also analyzes the pandemic's impact on medical education, the resident's educational curriculum, the operation, the clinical and surgical services, and the research activities to plan the future back period to the new reality.

Materials and Methods

An observational, comparative, and descriptive analysis was performed following the tenets of the Declaration of Helsinki. We analyzed the academic and training activity registries recorded during the 1^st year of the pandemic in Mexico (March 2020 to February 2021) in documentation folders shared via Google^® Drive (Mountain View, CA) belonging to all ophthalmology residents at Tecnologico de Monterrey, Mexico. The curriculum registry folders were divided as follows:

Academic folder (journal clubs, lectures, workshops, grand rounds, participation in national and international congresses or academic forums, and other online continuing education courses)
Clinical and surgical attention (outpatient presential consultation, telemedicine, clinical case sessions, surgical simulation program, surgical videos review and discussion, and support on COVID-19 areas)
Research (advances and thesis conclusion, COVID-related research, and scientific publications).

All folders analyzed were compared with the same scholar periods from 2018 and 2019. In addition, an online survey was applied via Google^® Forms (Mountain View, CA) to all residents of our program during April 2021. The survey's items included recording the attendance to national and international congresses, writing research papers, hours spent on classes, journal clubs, clinical case discussion, number of hours supporting COVID teams, type, and number of courses nonrelated to ophthalmology (extracurricular) attended from March 2020 to February 2021.

The data obtained were entered into an Excel spreadsheet (Microsoft^® Corporation, Redmond, WA) and analyzed using IBM^® SPSS v. 24 (Armonk, NY, USA). Categorical variables were presented as frequencies and percentages. Normality was evaluated with the Shapiro–Wilk test. Normally distributed data were described with means and standard deviations, while skewed data were described with medians and interquartile ranges. As appropriate, group comparison analysis was performed using the t-test or U-Mann–Whitney tests. P < 0.05 was considered statistically significant.

Results

A total of 19 ophthalmology resident activities from the COVID-19 pandemic lockdown period were compared with 19 and 20 resident registries from the 2018 and 2019 academic years, respectively. After analyzing the activities during the COVID-19 lockdown, we found that academic, research, and clinical activities significantly changed during the pandemic.

Academic activities

Teaching was strengthened by diverse learning activities, including increased participation in national and international congresses, symposia, and continuing medical education courses as an assistant or presenting free papers. Such academic activities were facilitated by online attending and presenting via videoconference applications, mostly Zoom^® (v. 5, 2020, San Jose, CA, USA). [Table 1] shows a comparison between 2018 and 2019 presential and online (year 2020) residents' assistance and participation.

Table 1: Average attendance to online and presential congresses by the ophthalmology residents before (2018-2019) and during the COVID-19 pandemic (2020)

Click here to view

Furthermore, there was a radical change in the basic science and subspecialty lectures format, migrating from presential daily workshops to a remote format via Zoom^®. In the prepandemic era, residents spent an average of 6.04 h of academic activities per week, distributed among lectures, clinic case discussions, and journal clubs, increasing significantly from March 2020 to February 2021 to an average of 16.42 h/week (P < 0.001). Before the COVID-19 pandemic, there were no regular journal club sessions for other ophthalmology specialties except for cornea and ocular surface; thus, journal club sessions were implemented every 8 weeks via Zoom^® for all subspecialties, increasing the total number of hours from 0.5 h to 3.41 h/month per semester (P < 0.001). Furthermore, we incorporated the attendance of other national attendees (mostly ex-residents and residents from two other regional residency programs) and international ophthalmologists from other academic centers, such as the Texas Children's Hospital at Houston.

Another extracurricular activity reported by 12 (57.1%) residents during the COVID-19 pandemic was attending online courses from the Tecnologico de Monterrey and other universities via Facebook^®, YouTube^®, Coursera^®, and Zoom^®. According to the survey results, a total of 26 courses were taken with an average of 1.23 courses per resident; most of them included cataract and refractive surgery courses from the American Society of Cataract and Refractive Surgery, among others. [Table 2] compares the academic activities during the prepandemic and pandemic period.

Table 2: Academic activities performed by residents before and during the COVID-19 pandemic

Click here to view

Clinical and surgical activities

After the lockdown, thanks to telemedicine implementation, teaching activities were sustained by surgical videos, clinical case presentations, and case problem simulation with the support of teachers, developing new competencies not considered a priority in our program before. It also included the care provided to COVID-19 patients via telemedicine.

Before the COVID-19 pandemic, the residents attended outpatient clinics 8 h a day. In contrast, after the clinics closed, ophthalmic consultation was given via phone calls, videoconferences, or messages mainly via the WhatsApp^® (Facebook, Inc. Menlo Park, CA, USA) application to maintain the patient's follow-up. During that period, residents were randomly selected into groups of five, rotating every 2 weeks for 5 h/day to evaluate patients with sight-threatening diseases in a presential manner. Meanwhile, 80% of residents attended patients via remote communication at home. Support attendings also accepted residents into their private practice through scheduled rotations. At least 15 residents (71%) reported assisting their teachers' private practice for at least 10 weeks.

Clinical case sessions continued to be scheduled every 6 weeks and involved an online (VCA) discussion between professors, residents, subspecialty fellows of our program, and two other regional residency programs. The easy remote access of participants allowed the attendance of foreign, both national and international, professors of ophthalmology.

The surgical practice was significantly affected by the clinic closure. Operating rooms decreased to zero during the closure, cataract surgery was dramatically affected during the COVID-19 lockdown, phacoemulsification decreased from an average of 49 in 2019–15 surgeries per resident during 2020, and extracapsular cataract extraction decreased from an average of 5 surgeries per resident in 2019–0.83 during 2020. The former was reduced by 68.75% and the latter by 83.4%, respective to the previous year (2019). Also, pterygium surgeries declined from 6/resident in 2019–1.5 surgeries in 2020.

A remote-directed simulation program was started at home to improve the residents' surgical skills. The program included practicing surgical knots with and without a microscope. Consequently, the resident was requested to send video evidence to their academic coordinator for evaluation. Also, during the lockdown, a Center for Simulated Ocular Microsurgery was created and conditioned in a clinic's former dry eye laboratory room. For this purpose, an ophthalmic surgical microscope with video recording capacity was installed, along with an operating table. Different ocular microsurgery simulation materials including preserved pig and cow eyes, grapes, cherry tomatoes, hydrogel marbles, plastic labels Bioniko® models, and Styrofoam heads (as an approach to the face anatomy) were used for gaining surgical skills (cutting, suturing, extracting, irrigation-aspiration, implanting, maneuvering, sealing, among others) in a step-by-step basis, from easiest to most complex maneuvers. By the time the clinic reopened, every resident was scheduled for regular participation in wet laboratoriess in the surgical simulator. On average, each resident spent 3 h/week on surgical simulation. [Table 3] describes activities performed and materials used at the Center for Simulated Ocular Microsurgery since March 2020.

Table 3: Surgical simulation activities performed by residents since the opening of the Center for Simulated Ocular Microsurgery

Click here to view

As in other residency programs worldwide, residents from different specialties supported hospitalized and intensive care COVID-19 areas. In our program, a total of seven residents of 21 (33.3%) were included in medical teams led by an internal medicine doctor or intensivist. The mean time residents were enrolled in COVID-19 clinical activities was 160 h, during 4-week periods per resident. [Table 2] shows a comparison of prepandemic and during pandemic clinical and surgical activities.

Clinical and translational research activities

There was a notable increase in the number of papers published involving our residents, with a total of 53 published papers by the 21 (mean 2.52/resident) enrolled residents during 2020, compared to only 8 published papers by the 20 (mean 0.40/resident) enrolled residents during the previous year (P < 0.001). A total of 9 published papers from 2020 were related to COVID-19 issues, most of them to changes in ophthalmologic practice patterns.^{[8],[9],[10],[11],[12],[13],[14],[15],[16]}

Mentorship and tuition activities

At the beginning of the residency, each resident is assigned a mentor; and each trainee should receive at least one mentorship session every 3 months where some specific topics are discussed, such as academic progress, resident psychological status and well-being, and personal development. This activity is supervised by the Wellness Department of Tecnologico de Monterrey. Before the COVID-19 pandemic, residents' mentorship was performed face-to-face with their assigned mentors. However, during the pandemic, the activity was performed more frequently (every 6 weeks) via Zoom^®, Facetime^® (Apple, Inc. Cupertino, CA, USA), or WhatsApp^® video calls to reinforce trainees support on mental wellness and diminish possible mental health consequences on well-being due to the lockdown. Furthermore, residents were encouraged to make an appointment with our institutions' psychology department when necessary. Mentorship resulted in an excellent way to keep track of residents' academic progress and mental health during the COVID-19 pandemic lockdown.

Discussion

The rise of the COVID-19 pandemic challenged postgraduate medical education and training as we had never experienced before. During the pandemic lockdown, many different difficulties presented in most residency programs, limiting activities in all learning processes, including residents × clinical and surgical training.^[17] Under this adverse scenario, rapid response to the challenge and innovation is crucial to avoid delays and limitations, particularly in clinical and surgical training.^[18] The need for change and response to the defy requires a structured organizational model applied by the program's academic direction through the medical staff, requiring reinforcement to residents.^[19] In adverse situations, close communication between the institution's staff, teachers, and residents is crucial to establish innovative ideas and initiatives to avoid hindering education.^[20]

To meet these challenges, we increased the academic activities, including lectures, clinical case discussion, journal club, and online assistance to national and international congresses compared to prepandemic time. In our university, online courses and tutorials were immediately established to train all teachers to use different electronic platforms and tools available on the World Wide Web for communication and teaching purposes. The Zoom^® software platform was preferentially designated for academic activities and the Microsoft Teams^® for staff boards and meetings. Interestingly, a worldwide survey study found these two platforms the most popular ones used for ophthalmology distance education.^[21] Online activities allow on-time attendance without physical displacement, avoiding traveling and housing for abroad scientific meetings, hence lowering expenses. In the future, we plan to keep the academic activities in a hybrid format to maintain higher assistance and easier access to daily lectures, clinical case discussions, and journal clubs every 6 weeks, encouraging residents to assist to presential and online national and international symposia and congresses.

The lockdown also affected patient consultation in the general and subspecialty eye clinics. Therefore, face-to-face clinical attention was exclusively deemed to emergencies and follow-up of sight-threatening conditions with a remote attention model via messages and videoconferences for the rest of the consultations.^[22] Another adaptation to increase the residents' exposure to patients was creating clinical rotations in attendings' private practice outpatient clinics. However, the pandemic also restricted this clinical activity to primarily therapeutic monitoring of chronic degenerative and infectious inflammatory sight-threatening disorders or emergencies. Nevertheless, this clinical adequacy permitted residents to keep busy in outpatient consultation.

As in most ophthalmology residency programs, our program's surgical practice was the most affected activity during the pandemic lockdown.^[21] Most programmed surgeries were postponed. The rate of cataract phacoemulsification procedures performed by residents dropped by 68.75%, and comparable reductions were applied to other surgical procedures. Similar ophthalmic microsurgery reduction rates under the COVID-19 pandemic have been reported in the literature.^[17] Therefore, an alternative for acquiring surgical skills was developing and implementing wet labs and surgical simulation.^[17],[23] At the beginning of the COVID-19 pandemic, a new remote in-home surgical simulation program was carried out by residents using a shareable and adapted portable microscope for practicing surgical maneuvers at home. Once the Center for Simulated Ocular Microsurgery started operations at the clinic, residents were scheduled to practice surgical simulation under the instructor's supervision with animal eyes, mainly pig and cow, and synthetic materials to acquire surgical skills. Such activity was not performed prior to the pandemic. However, aiming to improve the skills of junior residents before operating on real patients, we plan to maintain the surgical simulation program. Also, the use of cataract and vitreoretinal surgery virtual simulators like the Eyesi^® Surgical, the Phacovision^®, and the HelpMeSee^® Eye Surgery Simulator would be ideal for residents' training surgical skills; however, their substantial cost is a barrier for acquiring them in developing countries like ours.^{[17],[24],[25]}

On the contrary, during the lockdown, the time spent at home increased residents' research interest and activity, improving their scientific productivity. We found a 6-fold increase in the number of scientific publications involving residents during 2020 compared to 2019, some of which were related to COVID-19 pandemic topics.^{[8],[9],[10],[11],[12],[13],[14],[15],[16]} Similar increased scientific productivity applied to attendings. We found only one publication regarding the influence of the COVID-19 pandemic condition on resident's scientific productivity.^[26] Such publication found an increase in research productivity in 40% of the residents. On the other hand, the pandemic affected senior residents' thesis terminations. In longitudinal studies, clinical follow-up of participant patients via VCA and text messages was performed to overcome somehow the lockdown barrier. In such cases, this adapted method completed this requirement on time to graduate.

The residents' national and international clinical observerships to different subspecialty academic centers were also significantly affected by the COVID-19 pandemic. Most of the scheduled clinical observerships were mutually canceled by interinstitutional collaborative arrangements. Like in other residency programs, clinical subspecialty observerships allow senior residents to spend 3 months of their last academic year visiting a different national or international academic institution with which there is an agreement. This activity helps residents decide their plans for doing a particular fellowship after graduation.

On the other hand, a substantial increase in the mentorship activity and switching from presential to an online mode resulted in the trainees' excellent mental health follow-up during the pandemic, which is very important to residents' well-being and development. The activity raised from two regularly scheduled mentorship sessions per semester to four performed for every resident to discuss four essential aspects of well-being, personal, academic, labor, and professional, exploring the level of motivation, support networks, confronted difficulties, and problems, among others.^[27] The mentorship interviews are regularly recorded in a residency drive via Google^® forms. The University Mentorship and Well-Being Department reads and evaluates the interviews to detect residents requiring mental and psychological support.

Finally, residents participated in COVID-19 teams at our hospital designated to attend the pandemic victims, acquiring other knowledge and sharing experiences with other residents such as anesthesiologists, internal medicine, and intensivists during the COVID-19 rotations.^[28]

Barriers that emerged during the COVID-19 pandemic reflect the importance of everyday improvement in teaching strategies and innovative solutions to constant academic, clinical, and surgical challenges. Migration to distance education and clinical model supported by new videoconference applications, the introduction of surgical simulation by creating a whole new center for ophthalmic microsurgical simulation played an essential role in developing surgical skills. Knowledge acquisition is rapidly changing to a distance format facilitated by technological tools propelled by the social contact restrictions, becoming a novel educational model. Furthermore, hybrid models probably represent the future of education in medical schools, residency programs, and most educational centers. The distance telemedicine model for patients' follow-up for cataract service via an online video consultation platform and electronic resources before face-to-face visits as remote preassessments can result in a viable way to return to clinical activity postpandemic.

This study was limited to a single-center surgical residency program; hence, findings may not generalize to other residency programs. Moreover, we acknowledge that evaluating the impact of these interventions (i.e., surgical simulation at the Center for Simulated Ocular Microsurgery) is complex; thus, the actual efficacy of these interventions when performing them remains uncertain.

Currently, surgical procedures are nearly the same as prepandemic time. Surgical simulation at the Center for Simulated Ocular Microsurgery increased residents' surgical skills in this area. Furthermore, keeping patients' follow-up and clinical cases discussions in a hybrid format will allow a better learning process for trainees. Another priority is to restart the residents' subspecialty observership rotations to comply with the program's objectives.Like worldwide, our residency program was affected by the pandemic sanitary measures; hence, prompt reaction and implementing innovative institutional strategies were necessary to accomplish the educational goals drawn by the program's academic curriculum. Future meticulous academic outcomes analyses will finally tell how much this pandemic affected medical training worldwide.

Acknowledgments

We want to thank Dr. J. Homar Paez-Garza, Director of Fundacion TecSalud, and the teachers and administrative staff from the residency program for permitting the implementation of the different teaching and training strategies, also all current ophthalmology residents for facilitating the data collection for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Escudero X, Guarner J, Galindo-Fraga A, Escudero-Salamanca M, Alcocer-Gamba MA, Del-Río C. The SARS-CoV-2 (COVID-19) coronavirus pandemic: Current situation and implications for Mexico. Arch Cardiol Mex 2020;90:7-14.
2.	Almazroa A. Sustainability of ophthalmology practice and training during and post the pandemic of coronavirus (COVID-19): A review. Clin Ophthalmol 2021;15:2355-65.
3.	Acter T, Uddin N, Das J, Akhter A, Choudhury TR, Kim S. Evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as coronavirus disease 2019 (COVID-19) pandemic: A global health emergency. Sci Total Environ 2020;730:138996.
4.	Dedeilia A, Sotiropoulos MG, Hanrahan JG, Janga D, Dedeilias P, Sideris M. Medical and surgical education challenges and innovations in the COVID-19 era: A systematic review. In vivo 2020;34:1603-11.
5.	Hilburg R, Patel N, Ambruso S, Biewald MA, Farouk SS. Medical education during the coronavirus disease-2019 pandemic: Learning from a distance. Adv Chronic Kidney Dis 2020;27:412-7.
6.	Kogan M, Klein SE, Hannon CP, Nolte MT. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg 2020;28:e456-64.
7.	Chick RC, Clifton GT, Peace KM, Propper BW, Hale DF, Alseidi AA, et al. Using technology to maintain the education of residents during the COVID-19 pandemic. J Surg Educ 2020;77:729-32.
8.	Ibarra-Nava I, Cardenas-de la Garza JA, Ruiz-Lozano RE, Salazar-Montalvo RG. Mexico and the COVID-19 response. Disaster Med Public Health Prep 2020;14:e17-8.
9.	Ruiz-Lozano RE, Cardenas-De La Garza JA, Ibarra-Nava I, Garza-Garza LA, Hernández-Camarena JC. The role of football as a super-spreading event in the SARS-CoV-2 pandemic. J Sports Med Phys Fitness 2020;60:1408-9.
10.	Ruiz-Lozano RE, Garza-Garza LA, Cardenas-de la Garza JA, Hernandez-Camarena JC. Slit-lamp evaluation during SARS-CoV-2 pandemic: Safety first! Graefes Arch Clin Exp Ophthalmol 2020;258:2865-6.
11.	Ruiz-Lozano RE, Rodriguez-Garcia A, Garza-Garza LA, Rodriguez-Garcia A. Evaluating glaucoma during the times of COVID-19: Simple measures may save lives! Expert Rev Ophthalmol 2020;15:263-5.
12.	Tamez-Tamez VE, Ruiz-Lozano RE. Evaluating amblyopia during the era of COVID-19. Graefes Arch Clin Exp Ophthalmol 2020;258:2857-9.
13.	Domínguez-Varela IA. High mortality among health personnel with COVID-19 in Mexico. Disaster Med Public Health Prep 2021;15:e20-1.
14.	Domínguez-Varela IA, Ancona-Lezama DA, Dalvin LA, Pérez-Ramos EE. Choroidal melanoma treatment in times of coronavirus disease 2019. Melanoma Res 2021;31:194-5.
15.	Domínguez-Varela IA, Rodríguez-Gutiérrez LA, Morales-Mancillas NR, Barrera-Sánchez M, Macías-Rodríguez Y, Valdez-García JE. COVID-19 and the eye: A review. Infect Dis (Lond) 2021;53:399-403.
16.	Ruiz-Lozano RE, Galvan-Lopez CA, Garza-Garza LA, Rodriguez-Valdes PJ. Acute angle closure glaucoma in a patient admitted at the intensive care unit for the management of COVID-19. Pan Am J Ophthalmol 2021;3:16.
17.	Mishra D, Nair AG, Gandhi RA, Gogate PJ, Mathur S, Bhushan P, et al. The impact of COVID-19 related lockdown on ophthalmology training programs in India – Outcomes of a survey. Indian J Ophthalmol 2020;68:999-1004. [PUBMED] [Full text]
18.	Sandars J, Correia R, Dankbaar M, de Jong P, Goh PS, Hege I, et al. Twelve tips for rapidly migrating to online learning during the COVID-19 pandemic. MedEdPublish, 2020; 9(1), [3068]. https://doi.org/10.15694/mep.2020.000082.1.
19.	Hiatt JM. ADKAR: A Model for Change in Business, Government, and Our Community. First Edition. Prosci Research. Loveland, CO. USA. 2006. ISBN: 978-1-930885-50-9.
20.	Tibyampansha D, Ibrahim G, Kapanda G, Tarimo C, Minja A, Kulanga A, et al. Implementation of a Learning Management System for Medical Students: A Case Study of Kilimanjaro Christian Medical University College. MedEdPublish 2017, pp.1-16. https://doi.org/10.15694/mep.2017.000050.
21.	Chatziralli I, Ventura CV, Touhami S, Reynolds R, Nassisi M, Weinberg T, et al. Transforming ophthalmic education into virtual learning during COVID-19 pandemic: A global perspective. Eye (Lond) 2021;35:1459-66.
22.	Mehrotra A, Ray K, Brockmeyer DM, Barnett ML, Bender JA. Rapidly converting to “virtual practices”: outpatient care in the era of Covid-19. NEJM catalyst innovations in care delivery, 2020;1(2):1-5. DOI: 10.1056/CAT.20.0091.
23.	Amin S, Patel R, Beilan J, Helveston EM, Shaikh S. Telemedicine for retinal care in developing nations: The ORBIS Cyber-Sight programme, 2003-2011. J Telemed Telecare 2014;20:282-7.
24.	Lee R, Raison N, Lau WY, Aydin A, Dasgupta P, Ahmed K, et al. A systematic review of simulation-based training tools for technical and non-technical skills in ophthalmology. Eye (Lond) 2020;34:1737-59.
25.	Choi KS, Soo S, Chung FL. A virtual training simulator for learning cataract surgery with phacoemulsification. Comput Biol Med 2009;39:1020-31.
26.	Silva N, Laiginhas R, Meireles A, Barbosa Breda J. Impact of the COVID-19 pandemic on ophthalmology residency training in Portugal. Acta Med Port 2020;33:640-8.
27.	Abdel-Razig S, Ahmad W, Shkoukani MA, Nusair A, Ramirez A, Siddiqi K, et al. Residency training in the time of COVID-19: A framework for academic medical centers dealing with the pandemic. Perspect Med Educ 2021;10:135-40.
28.	Klasen JM, Vithyapathy A, Zante B, Burm S. “The storm has arrived”: The impact of SARS-CoV-2 on medical students. Perspect Med Educ 2020;9:181-5.