During the final 18 months of the programme doctors in training must achieve Level 4 competency in at least two Special Interest Areas (SIA) in the Patient Management domain and Level 4 in the other six domains, to complete their training and obtain a CCT. This is expected to happen for most doctors in training by the end of OST7; however, there is a degree of flexibility allowing some doctors to complete training in less time (the indicative minimum time will be 5 ½ years). The indicative time for Level 4 training varies according to the SIA as shown in the table below.
It is expected that most doctors in training will complete Level 4 training in the Cataract Surgery SIA. Cataract surgery training will be taken throughout as currently occurs, and it is therefore expected that many will have completed the Level 4 training in Cataract Surgery by mid-OST6. This will allow focus on the other Level 4 SIAs during the final 12-18 months of the 7-year training programme.
The indicative times for Level 4 training are listed below – ranges apply to some SIAs to make rotas manageable. These are only indicative times as completion of Levels in Curriculum 2024 is competency-based and not time or number-based.
| Special Interest Area (SIA) | Indicative time |
|---|---|
| Oculoplastics and Orbit | up to 18 months |
| Cornea and Ocular Surface Disease | up to 18 months |
| Cataract Surgery | 6-12 months, which should be integrated longitudinally across the entire training programme |
| Glaucoma | up to 18 months |
| Uveitis | 12-18 months |
| Medical Retina | 12-18 months |
| Vitreoretinal Surgery | up to 18 months |
| Ocular Motility | 12-18 months |
| Neuro-ophthalmology | 12-18 months |
| Paediatric Ophthalmology | 12-18 months |
| Urgent Eye Care | 6-12 months |
| Community Ophthalmology | 6-12 months |
An ophthalmologist working at Level 4 will demonstrate the advanced clinical management and surgical skills expected of a consultant with a special interest in this area. They will be able to manage the complexity and uncertainty of the SIA. They will be an effective teacher and trainer. Full details of the descriptors supporting each Learning Outcome can be found in the curriculum microsite.
- EPA Level 4 – Two EPAs out of twelve (minimum of one every 6 months). See Table A for the specific requirements for each EPA.
- EPA Level 4 Operating List – for each surgically based SIA (Oculoplastics, Cornea & Ocular Surface Disease, Cataract Surgery, Glaucoma, Vitreoretinal Surgery, Ocular Motility and Paediatric Ophthalmology)
- GSAT Level 4 – GSAT (one from each 6-month post) for each non-clinical domain. Examples of evidence that can be used in the Level 4 GSAT are summarised in Table B.
- Educational Supervisor Report – one for every six months and final one confirming a review of the ePortfolio indicating that Level 4 competencies have been achieved in all seven Domains.
- Logbook indicating the described breadth of surgical experience (see Patient Management Level 4 syllabi)
- Logbook indicating supervision of juniors (up to Level 3) in the chosen SIA (Oculoplastics, Cornea & Ocular Surface Disease, Cataract Surgery, Glaucoma, Vitreoretinal Surgery, Ocular Motility and Paediatric Ophthalmology) and supervision of juniors (up to Level 4) in Cataract Surgery (only where Cornea, Glaucoma and Vitreoretinal Surgery have been chosen as Level 4 SIAs)
- Cataract complications audit (from each 12-month training period where Cataract Level 4 SIA is undertaken)
- Audit of surgical outcomes for each surgically based SIA undertaken (Oculoplastics, Cornea & Ocular Surface Disease, Cataract Surgery, Glaucoma, Vitreoretinal Surgery, Ocular Motility and Paediatric Ophthalmology)
- MSF – one for each 12 month training period
- Form R, SOAR declaration or equivalent – for each 12 month training period
- Satisfactory outcome in ARCP
Please also see Level 4 training requirements in the section on ARCP and the Learning Outcomes in the curriculum microsite.
| 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 Outpatients | Mandatory requirements in Theatre | Other mandatory requirements | |
| OCULOPLASTICS | |||
| CRS1 Consultation skills in oculoplastics | OSATS Surgical skills – eyelid and adnexal surgery | Nasal endoscopy* - either Outpatients or Theatre | |
| Independent management of the oculoplastics clinic* | OSATS Temporal artery biopsy | Longitudinal, 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 list | Review 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 surface | Longitudinal, 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 surgery | Longitudinal 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 list | Review 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* | |||
| Ability to supervise and train in cataract surgery to Level 4* | |||
| 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 list | Longitudinal 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 surgery | Medical 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 surgery | Longitudinal, 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 list | Longitudinal 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 | |
| Ability to supervise and train in cataract surgery to Level 4* | 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 retina | Longitudinal, 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 surgery | Longitudinal, 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 list | Review 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 | |
| Ability to supervise and train in cataract surgery to Level 4* | 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 | |
| Independent management of the ocular motility clinic* | DOPS Botulinum toxin | 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 list | Longitudinal 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 | Longitudinal, periodic observation by consultant assessor in the outpatient and/or on call setting, where possible | |
| Independent management of the neuro-ophthalmology clinic* | Longitudinal observation by consultant assessor in the theatre and simulation setting | ||
| Forced duction test* | Review of record keeping and letters | ||
| Use and interpretation of appropriate neuroimaging* | CbDs | ||
| Use of and interpretation of appropriate electrodiagnostic testing* | Multi-assessor report | ||
| Ability to supervise and train trainees and other health professionals in neuro-ophthalmology to Level 3 in a clinic setting* | |||
| PAEDIATRIC OPHTHALMOLOGY | |||
| CRS1 Consultation skills in paediatric ophthalmology | OSATS Surgical skills – paediatrics | Complex strabismus and nystagmus assessment* - either Theatre or Outpatients | |
| Independent management of the paediatric care clinic* | DOPS Botulinum Injection | 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 list | Longitudinal 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 pressures | Longitudinal, 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 project | CbDs | ||
| Multi-assessor report | |||
| URGENT EYE CARE | |||
| CRS1 Consultation skills in urgent eye care | OSATS Ocular/adnexal trauma | OSATS1 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 under each Learning Outcome. | |
| 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 | |