International Council of Ophthalmologys Ophthalmology Surgical Competency Assessment Rubrics (ICO-

OSCAR)

The International Council of Ophthalmologys Ophthalmology Surgical Competency Assessment Rubrics (ICO-

OSCAR) are designed to facilitate assessment and teaching of surgical skill.1,2 Surgical procedures are broken down to

individual steps and each step is graded on a scale of novice, beginner, advanced beginner and competent. A description

of the performance necessary to achieve each grade in each step is given. The assessor simply circles the observed

performance description at each step of the procedure. The ICO-OSCAR should be completed at the end of the case

and immediately discussed with the student to provide timely, structured, specific performance feedback. These tools

were developed by panels of international experts and are valid assessments of surgical skill. Thus far, ICO-OSCARs

have been produced for extracapsular cataract extraction, small incision cataract surgery and phacoemulsification.

Similar tools for strabismus surgery and lateral tarsal strip surgery are nearly complete. The plan is to produce a toolbox

of ICO-OSCARs for each ophthalmic subspecialty.

1. Golnik KC, Beaver H, Gauba V, Lee AG, Mayorga E, Palis G, Saleh G. Cataract Surgical Skill Assessment.
Ophthalmology 2011;118:427. E5.

2. Golnik KC, Haripriya A, Beaver H, Gauba V, Lee AG, Mayorga E, Palis G, Saleh G. The ICO-OSCAR:SICS.
Ophthalmology, in press.

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Figure 2
ICO-Ophthalmology Surgical Competency Assessment Rubric Extracapsular Cataract Extraction (ICO-OSCAR:ECCE)
Date __________ Not
Novice Beginner Advanced Beginner Competent applicable.
Resident ____________ (score = 2) (score = 3) (score = 4) (score = 5) Done by
Evaluator ___________ preceptor
(score= 0)
Draping Unable to start draping without Drapes with minimal verbal instruction. Lashes mostly covered, drape is at most Lashes completely covered and clear of
1 help. Drape needs to be redone. Incomplete lash coverage. minimally obstructing view. incision site, drape not obstructing view.

Eye position and stability Unable to stabilize eye in good Achieves acceptable eye position and Achieves good eye position and stability. Precisely and consistently stabilizes eye
2 position. stability with some difficulty. in good position.
Scleral access & Unable to successfully access Accesses sclera but with difficulty and Achieves good scleral access with mild Precisely and deftly accesses sclera.
Cauterization sclera. Cauterization insufficient hesitation. Cauterization insufficient or difficulty. Adequate cauterization. Appropriate and precise cauterization.
3 or excessive both in intensity and excessive in location or intensity.
localization.
Scleral or Corneo-scleral Inappropriate incision depth, Only one of the following is done Only two of the following are done Good incision depth, location and size.
4 Incision location, and size. correctly: incision depth, location or size. correctly: incision depth, location or size.

Unsure of when, what type and Requires minimal instruction. Knows Requires minimal instruction. Uses at Viscoelastics are administered in
how much viscoelastic to use. when to use but administers incorrect appropriate time. Administers adequate appropriate amount and at the
Viscoelastic: Appropriate Has difficulty or multiple amount or type. amount and type. Cannula tip in good appropriate time with cannula tip clear
5 Use and Safe Insertion unsuccessful attempts at position. of lens capsule and endothelium with no
accessing anterior chamber instruction.
through paracentesis.
Awkward or rough movements Either awkward or rough movements of Gentle but imprecise movements of Gentle precise movements of cystitome;
of cystitome, digging too deep or cystitome but not both; depth of attempts cystitome; depth of attempts adequate but depth and control correct for
too superficial, lens movement adequate but not optimal, some lens may not be optimal OR some lens appropriately sized capsulotomy.
6 Anterior Capsulotomy endangers zonules, poor control movement, intermittent poor control of movement OR intermittent poor control of
risks radialization. Difficulty capsulotomy. Minor difficulty everting thecapsulotomy.
initializing and keeping flap flap.
everted.
Inappropriate wound architecture Iris prolapse, leakage with local pressure. May be mild leakage, allows adequate Beveled precise parallel incision edges,
and/or size, iris is damaged Provides poor surgical access to and extraction of nucleus. Incision edges not no iris prolapse, allows easy extraction
7 Wound Enlargement during the maneuver. Incomplete visibility of capsule and bag. parallel. of nucleus.
enlargement, loss of tissue plane,
residual strands across incision.
Rough and incomplete Hydrodissection is rough or incomplete Hydrodissection and lens mobilization is Precise and controlled hydrodissection.
Nucleus Hydrodissection hydrodissection of lens-capsular but able to recognize and correct with imprecise but accomplished in one to several
8 adhesions preventing lens multiple attempts. attempts without assistance.
rotation or extraction, not
recognized by surgeon.
Attempt causes radialization of Movements coordinated but still unable to Uncoordinated and imprecise movements Nucleus removed with dexterity, well
capsulorrhexis or tear in posteriorextract nucleus. but with successful lens nucleus extraction. controlled movements and technique.
9 Nucleus Extraction
capsule; unable to hold and
extract lens nucleus.
10 Irrigation and Aspiration Great difficulty introducing the Moderate difficulty introducing aspiration Minimal difficulty introducing the aspiration Aspiration tip is introduced under the
Technique aspiration tip under the anterior tip under anterior capsule and maintaining tip under the anterior capsule, aspiration free border of the anterior capsule in
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 capsule, aspiration hole position hole up position, attempts to aspirate hole usually up, cortex will engaged for 360 irrigation mode with the aspiration hole
not controlled, cannot regulate without occluding tip, shows poor degrees, cortical peeling slow, few technical up, Aspiration is activated in just enough
aspiration flow as needed, cannot comprehension of aspiration dynamics, errors, minimal residual cortical material. flow as to occlude the tip, efficiently
With Adequate Removal peel cortical material adequately, cortical peeling is not well controlled, Some difficulty in removing sub-incisional removes all cortex, The cortical material
of Cortex engages capsule or iris with jerky and slow, capsule potentially cortex. is peeled gently towards the center of the
aspiration port. compromised. Prolonged attempts result pupil, tangentially in cases of zonular
in minimal residual cortical material. weakness. No difficulty in removing
sub-incisional cortex.
Unable to insert IOL. Insertion and manipulation of IOL is Insertion and manipulation of IOL is Insertion and manipulation of IOL is
difficult, eye handled roughly, anterior accomplished with minimal anterior performed in a deep and stable anterior
Lens Insertion, Rotation, chamber not stable, repeated attempts chamber instability, incision just adequate chamber and capsular bag, with incision
11 and Final Position of result in borderline incision for implant for implant type, the lower haptic is placed appropriate for implant type. The lower
Intraocular Lens type. Repeated hesitant attempts result in inside the capsular bag with some difficulty, haptic is smoothly placed inside the
lower haptic in the capsular bag, upper upper haptic is rotated into place. capsular bag; the upper haptic is rotated
haptic is rotated into place. or gently bent and inserted into place.
Cannot reliably load suture. Some difficulty loading and placing Able to load sutures consistently. Stitches No difficulty loading or placing sutures
Instruction is required and sutures, often in wrong tissue plane, are placed with minimal difficulty usually in consistently in correct tissue plane.
stitches are placed in an resuturing may be needed. correct tissue plane. All sutures radial and of adequate length
Wound Closure: Suture awkward, slow, non-radial Sutures not radial or appropriately spaced. Sutures mostly radial and of adequate length and space between sutures.
12 handling & Placement fashion with much difficulty, and space between sutures.
consistently in the wrong tissue
plane, has to repeat same stitch.

Unable to get tension correct,
multiple corneal striae present,
Wound Closure: Suture
13 tying & Knot rotation
incorrect number of throws,
knots often not buried.
Uneven suture tension, some corneal Sutures tied tight enough to maintain the Sutures are tied tight enough to maintain
striae, number of throws usually correct, wound closed, may have slight corneal the wound closed, but not too tight as to
most knots buried. distortion, rare knot not buried adequately. induce astigmatism. All knots buried.
No corneal striae.

Unable to remove viscoelastics Questionable whether all viscoelastics are Viscoelastics are adequately removed after Viscoelastics are thoroughly removed
Wound Closure: thoroughly. Unable to make thoroughly removed, Extra maneuvers are this step with some difficulty. The incision is after this step, the incision is checked
viscoelastic removal, incision water tight or does not required to make the incision water tight checked and is water tight or needs minimal and is water tight at the end of the
14 wound hydration, wound check wound for seal. Improper at the end of the surgery. May have adjustment at the end of the surgery. May surgery. Proper final IOP.
security final IOP. improper IOP, but recognizes possibility. have improper IOP but recognizes and treats
IOP.
Global Indices
Nearly constant eye movement Eye often not in primary position, Eye usually in primary position, mild The eye is kept in primary position
Wound Neutrality and and corneal distortion. frequent distortion folds. corneal distortion folds occur. during the surgery. No distortion folds
15 Minimizing Eye Rolling are produced. The length and location of
and Corneal Distortion incisions prevents distortion of the
cornea.
Eye Positioned Centrally Constantly requires Occasional repositioning required. Mild fluctuation in pupil position. The pupil is kept centered during the
16 Within Microscope View repositioning. surgery.
Conjunctival and Corneal Tissue handling is rough and Tissue handling borderline, minimal Tissue handling appropriate but potential for Tissue is not damaged nor at risk by
17 Tissue Handling damage occurs. damage occurs. damage exists. handling.
Instruments often in contact with Occasional accidental contact with Rare accidental contact with capsule, iris No accidental contact with capsule, iris
Intraocular Spatial
18 Awareness
capsule, iris or corneal capsule, iris and corneal endothelium. and corneal endothelium. or corneal endothelium.
endothelium.
Iris constantly at risk, handled Iris occasionally at risk. Needs help in Iris generally well protected. Slight Iris is uninjured. Iris hooks, ring, or
19 Iris Protection roughly. deciding when and how to use hooks, ring difficulty with iris hooks, ring, or other other methods are used as needed to
or other methods of iris protection. methods of iris protection. protect the iris.

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 Hesitant, frequent starts and Occasional starts and stops, inefficient Occasional inefficient and/or unnecessary Inefficient and/or unnecessary
Overall Speed and stops, not at all fluid. Case and unnecessary manipulations common, manipulations occur, case duration about 45 manipulations are avoided, case duration
20 Fluidity of Procedure duration greater than 60 minutes. case duration about 60 minutes. minutes. is appropriate for case difficulty. In
general, 30 minutes should be adequate.

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