Level 4 Guide

  1. EPA Level 4 – two EPAs out of twelve (minimum of one every six months). Level 4 requirements per SIA are summarised in Table A.
  2. EPA Level 4 Managing Operating List – for each surgically based SIA ((Oculoplastics & Orbit, Cornea & Ocular Surface Disease, Cataract Surgery, Glaucoma, Vitreoretinal Surgery, Ocular Motility and Paediatric Ophthalmology).
  3. GSAT Level 4 – one every six months until final one signed off by ES as achieving Level 4. competencies in the six non-clinical domains. Examples of evidence that can be used in the Level 4 GSAT are summarised in Table B.
  4. ESR – one every six months and final one indicating that Level 4 competencies have been achieved in all seven domains.
  5. Logbook indicating the described breadth of surgical experience (see Patient Management Level 4 syllabi) and supervision of juniors at Level 3 in the chosen SIA.
  6. Cataract complications audit where Level 4 Cataract Surgery training is undertaken.
  7. Audit of surgical outcomes for each surgically based SIA undertaken (Oculoplastics & Orbit, Cornea & Ocular Surface Disease, Cataract, Glaucoma, Vitreoretinal Surgery, Ocular Motility and Paediatric Ophthalmology).
  8. Logbook
  9. PDP
  10. MSF – one per calendar year
  11. Form R or SOAR declaration
  12. Satisfactory outcome at ARCP

Table A Curriculum requirements as listed in Level 4 EPA for each SIA
*A formative tool should be used if a trainee is not achieving the expected level. These requirements can be demonstrated by DOPS, OSATS, direct observation or observation by another team member.
Mandatory requirements in OutpatientsMandatory requirements in TheatreOther mandatory requirements
OCULOPLASTICS
CRS1 Consultation skills in oculoplastics OSATS Surgical skills – eyelid and adnexal surgeryNasal endoscopy* - either Outpatients or Theatre
Independent management of the oculoplastics clinic* OSATS Temporal artery biopsyLongitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Management of thyroid eye disease* OSATS Removal of eye (enucleation and evisceration)Longitudinal observation by consultant assessor in the theatre and simulation setting
Participation in MDT meetings* EPA L4 Managing an oculoplastics operating listReview of logbook
Ability to supervise and train trainees and other health professionals in oculoplastic Surgical management of oculoplastic adnexal and lacrimal conditions including complex entropion,Review of personal audit of surgical outcomes
Surgery to Level 3 in a clinic setting*Ectropion, ptosis, surgical excisions, and peri-ocular reconstruction*Review of record keeping and letters
Anterior orbital biopsy*CbDs
External dacryocystorhinostomy*Multi-assessor report
CORNEA & OCULAR SURFACE DISEASE
CRS1 Consultation skills in cornea and ocular surface disease OSATS Surgical skills – cornea and ocular surfaceLongitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Independent management of the cornea and ocular surface clinic* OSATS Cataract surgeryLongitudinal observation by consultant assessor in the theatre and simulation setting
Management of complex corneal, ocular surface and anterior segment disease including use of systemic immunomodulators* EPA L4 Managing a corneal and ocular surface operating listReview of logbook
Management of post refractive surgery complications e.g. ectasia, epithelial in growth* Complex cataract surgery, pre-existing corneal abnormalities, absence of capsular support, etc.*Review of personal audit of surgical outcomes
Ability to supervise and train trainees in corneal and ocular surface disease to Level 3 and other health professional in a clinic setting*Corneal grafting*Review of record keeping and letters
Ocular surface biopsy*CbDs
Pterygium surgery and amniotic membrane graft*Multi-assessor report
Conjunctival manipulation*
Collagen crosslinking*
Supervise and provide objective assessment of other surgical competency at Level 3 (e.g. WpBAs)*
CATARACT SURGERY
CRS1 Consultation skills in cataract surgery OSATS Managing range of complex cataract surgery cases and different IOL types Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Independent management of the cataract clinic* EPA L4 Managing a cataract operating listLongitudinal observation by consultant assessor in the theatre and simulation setting
Perform and interpret biometry in complex cases*Performance of anterior vitrectomy*Review of logbook
Placement of secondary IOL*Review of ‘continuous audit of complications of cataract surgery’ and evidence of ability to manage complications
Management of complication including capsule tears and iris complications*Review of ‘Outcomes 50 consecutive cataract surgery’ personal audit (to be completed within 3 years of achieving Level 4 Cataract Surgery)
Ability to supervise and train trainees in cataract surgery to Level 3 and other health professionals in a theatre setting*Review of record keeping and letters
CbDs
Multi-assessor report
GLAUCOMA
CRS1 Consultation skills in glaucoma OSATS Microsurgical skills – glaucoma surgeryMedical and surgical management of glaucoma patients including trabeculectomy or non-penetrating glaucoma surgery and cyclodestructive procedures* - either Outpatients or Theatre
Independent management of the glaucoma clinic* OSATS Cataract surgeryLongitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Ability to supervise and train trainees in glaucoma surgery to EPA L4 Managing a glaucoma operating listLongitudinal observation by consultant assessor in the theatre and simulation setting
Level 3 and other health professional in a clinic setting* Complex cataract surgery: shallow anterior chamber, poor dilation, pseudoexfoliation, previous glaucoma surgery, etc.*Review of logbook
Supervise and provide objective assessment of other surgical competency at Level 3 (e.g. WpBAs)*Review of personal audit of surgical outcomes
Review of record keeping and letters
CbDs
Multi-assessor report
UVEITIS
CRS1 Consultation skills in uveitis Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Independent management of the uveitis eye care clinic* Longitudinal observation by consultant assessor in the theatre and simulation setting
Advanced interpretation of electrophysiology and multi-modal imaging modalities: e.g. FFA/ICG/Blue light autofluorescence and EDI-OCT* Review of record keeping and letters
Prescribe steroid sparing agents and/or biologic therapies* CbDs
Liaise with physicians for systemic management of patients* Multi-assessor report
Ability to supervise and train trainees and other health professionals in uveitis to Level 3 in a clinic setting*
MEDICAL RETINA
CRS1 Consultation skills in medical retinaLongitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Independent management of the medical retina clinic*Longitudinal observation by consultant assessor in the theatre and simulation setting
Advanced interpretation of multi-modal imaging*Review of personal audit of treatment outcomes
Use of appropriate pharmacological and laser therapies*Review of record keeping and letters
Indirect laser and subthreshold laser treatment*CbDs
Photodynamic therapy*Multi-assessor report
Order appropriate genetic testing and interpret results*
Ability to supervise and train trainees in intravitreal injections and laser techniques up to Level 3 and other health professional in a clinic setting*
VITREORETINAL SURGERY
CRS1 Consultation skills in vitreoretinal surgery OSATS Cataract surgeryLongitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Independent management of vitreoretinal clinic* OSATS Microsurgical skills - vitreoretinal surgery Longitudinal observation by consultant assessor in the theatre and simulation setting
Management of endophthalmitis, vitreous haemorrhage, sub-retinal haemorrhage, uncomplicated rhegmatogenous retinal detachment, vitreo-macular traction, epiretinal membrane, macular hole* EPA L4 Managing a vitreoretinal operating listReview of record keeping and letters
Indirect laser to the retina*Complex cataract surgery, post vitrectomy, posterior polar cataract, etc.*Review of logbook
Ability to supervise and train trainees in vitreoretinal surgery to Level 3 and other health professional in a clinic setting*Management of complications of cataract surgery*Review of personal audit of surgical outcomes
Supervise and provide objective assessment of other surgical competency at Level 3 (e.g. WpBAs)*CbDs
Multi-assessor report
OCULAR MOTILITY
CRS1 Consultation skills in ocular motility OSATS Surgical skills (extraocular muscle surgery)Management of complications of strabismus surgery and re-do surgery* - either in Outpatients or Theatre
DOPS Botulinum toxin injection to extraocular muscles - either in Outpatients or Theatre
Independent management of the ocular motility clinic* Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Complex strabismus assessment and management* EPA L4 Managing an ocular motility operating listLongitudinal observation by consultant assessor in the theatre and simulation setting
Ability to supervise and train trainees and other health professionals in ocular motility disease surgery to Level 3 in a clinic setting*Review of record keeping and letters
Review of logbook
Review of personal audit of surgical outcomes
CbDs
Multi-assessor report
NEURO-OPHTHALMOLOGY
CRS1 Consultation skills in neuro-ophthalmology OSATS Temporal Artery Biopsy DOPS Botulinum toxin injection to extraocular muscles - either in Outpatients or Theatre
Independent management of the neuro-ophthalmology clinic* Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Forced duction test* Longitudinal observation by consultant assessor in the theatre and simulation setting
Use and interpretation of appropriate neuroimaging* Review of record keeping and letters
Use of and interpretation of appropriate electrodiagnostic testing* CbDs
Ability to supervise and train trainees and other health professionals in neuro-ophthalmology to Level 3 in a clinic setting*Multi-assessor report
PAEDIATRIC OPHTHALMOLOGY
CRS1 Consultation skills in paediatric ophthalmology OSATS Surgical skills – paediatricsComplex strabismus and nystagmus assessment* - either Theatre or Outpatients
Independent management of the paediatric care clinic* Management of complications of strabismus surgery and re-do surgery* - either Theatre or Outpatients
Diagnosis and treatment of ROP* DOPS Laser for retinal problems (e.g. ROP)Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Collaborative working with tertiary and special interest teams* EPA L4 Managing a paediatric operating listLongitudinal observation by consultant assessor in the theatre and simulation setting
Ability to supervise and train trainees and other health professionals in paediatric ophthalmology to Level 3 in a clinic setting*Review of logbook
Review of personal audit of surgical outcomes
Review of record keeping and letters
CbDs
Multi-assessor report
COMMUNITY OPTHALMOLOGY
Understand local eye health needs, value of services and financial pressuresLongitudinal, periodic observation by consultant assessor in the outpatient and community setting where possible (consider handling of referrals, communication with primary care, virtual clinics, teleophthalmology, etc.)
Ability to supervise and train trainees in community ophthalmology to Level 3 and other health professionals Review of record keeping and letters
Health services evaluation project/quality improvement projectCbDs
Multi-assessor report
URGENT EYE CARE
CRS1 Consultation skills in urgent eye care OSATS Ocular/adnexal traumaOSATS1 Vitreous biopsy and intravitreal injection in endophthalmitis* - either Theatre or Outpatients
Independent management of the urgent eye care clinic* Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible
Ultrasound of the vitreous cavity, retina and choroid- performance and interpretation* Longitudinal observation by consultant assessor in the theatre and simulation setting
Ability to supervise and train trainees in urgent eye care to Level 3 and other health professionals in a clinic setting*Review of record keeping and letters
Review of logbook
CbDs
Multi-assessor report

Table B Examples of evidence that can be used in the GSAT Level 4
CbDs and reflections can be used to demonstrate evidence.
Learning outcome Suggested examples of evidence and topics on which related CBDs can be used 
DOMAIN: HEALTH PROMOTION 
Develop special interest area specific guidance for health promotion. New local guidelines 
Develop or update patient information leaflet in SIA for health promotion 
Be an effective supervisor and guide in the area of health promotion. Logbook, Audit, reflective practice 
Evidence of supervision of more junior trainee in explaining health promotion strategy to patients 
Evidence of involvement in patient engagement events 
Evidence of supervision or providing training for other members of multidisciplinary team in health promotion in SIA 
DOMAIN: LEADERSHIP AND TEAMWORKING 
Critically evaluate own skills in leadership, with particular reference to the quality of patient care. Audit, reflective practice 
Examples include:  
Audit of own or departmental outcomes with reflection 
SIA audit 
Audit of own surgical outcomes; cataract for example or ptosis if doing oculoplastics 
Supervising, challenging, influencing and appraising colleagues and peers to enhance performance and to support development 
Critically appraise performance of colleagues, peers and systems and escalate concerns  
Attend and contribute to clinical governance meetings, e.g. confirmed log of meetings attended/evidence of participation in governance  
Promote service improvement through: quality, innovation, productivity and prevention (QIPP); supervision of the multidisciplinary team; effective management of incidents and complaints. QIPP, M+M, SAI’s involved in/ RCA meetings 
Undertake a quality, innovation, productivity and prevention (QIPP) project 
Supervision of the multidisciplinary team e.g., run a theatre list/ outpatient clinic 
Effective management of incidents and complaints  
Demonstrate management of a complaint with report and be involved in the investigation 
Demonstrate training in root cause analysis 
Demonstrate understanding of risk register and risk assessment 
Provide proof of supervision ability  
Simulation/clinical setting/theatre 
DOMAIN: PATIENT SAFETY AND QUALITY IMPROVEMENT 
Share improved practice with others and be able to defend changes made. Portfolio  
Part 2 FRCOphth  
Research/publication 
Critically evaluate own skills in quality improvement. Portfolio  
Part 2 FRCOphth  
QI Project/Audit; reflection piece on own work 
Promote clinical governance and quality improvement in the wider organisation / NHS.Portfolio  
Part 2 FRCOphth  
QI project, Audit 
DOMAIN: SAFEGUARDING AND HOLISTIC CARE 
Critically evaluate personal and wider organisational responses to safeguarding issues Adult and Child Safeguarding Level 3 
https://portal.e-lfh.org.uk/Component/Details/510424 
Safeguarding Children: Level 3 – Parental Risk Factors https://portal.e-lfh.org.uk/Component/Details/510430 
Safeguarding Children: Level 3 – Unexplained Injuries 
https://portal.e-lfh.org.uk/Component/Details/510436 
Safeguarding Children: Level 3 – Disability and Neglect 
https://portal.e-lfh.org.uk/Component/Details/510442 
Safeguarding Children: Level 3 – Fabricated and Induced Illness 
https://portal.e-lfh.org.uk/Component/Details/510448 
Deprivation of Liberty Safeguards (DoLS) training 
Audit/QIP in Safeguarding standards 
Reflective piece/CBD in a more complex case involving support for visual impairment/additional needs 
Supervise and support other professionals with regard to safeguarding. Teaching for colleagues 
Supervising more junior trainee or members of multidisciplinary team; arranging best interests meeting or undertaking MCA training or arranging for patient with special needs to attend clinic/procedure/theatre. 
Arranging teaching session on MCA/DOLS training etc 
Demonstrate effective specialised management techniques for those with special needs. Undertaking best interests meeting; make specific enhancements to support patient in theatre, clinic, procedure undertaken  
Audit/QIP in Safeguarding standards 
Reflective piece/CBD in a more complex case involving support for visual impairment/additional needs 
Creating or updating patient information leaflets 
DOMAIN: EDUCATION AND TRAINING 
Demonstrate readiness to act as a clinical and educational trainer. Take on supervision roles, training skills, mentoring, supervising in theatre, logbook 
Appropriate Training the Trainers course(s) to be a registered Clinical Supervisor 
PG Cert or MSc in medical education 
TTT course 
College faculty for surgical courses/examiner  
Balance service and training needs. Demonstrate ability to supervise or assist more junior trainees or other professionals in clinic but manage clinic in timely manner  
CSR 
Supervising juniors on theatre 
Be able to identify and support a trainee experiencing difficulty. Supervise, support and encourage other trainees 
Module on trainee in difficulty in Training the Trainers courses 
DOMAIN: RESEARCH AND SCHOLARSHIP 
Understand the principles of research methods, research governance, application of ethics to research and the translation of research into practice. Research/publication, evidence of submission of application for funding for research project 
Evidence of participation in the NIHR Associate Principal Investigator Scheme
Evidence of involvement in ethics submission for research project; use own or contemporary research to revise/develop local guidelines 
GCP course 
Promote innovation in ophthalmology. Publication – 1st author 
Evidence review for own research project/publication; evidence of submission for funding for research project; complete and publish peer-reviewed paper 
Evidence of participation in the NIHR Associate Principal Investigator Scheme