This is the first multi-dean study to investigate training in temporal artery biopsy for ophthalmology trainees in the UK. Ophthalmologists in the UK are required to undertake a 7-year specialist ophthalmology training program which comprises a comprehensive curriculum including a number of core learning outcomes which must be achieved by the end of the last year. [15]. A key area of this program is surgical skills, and proficiency in temporal artery biopsy is a necessary requirement, with the target year of achievement being grade 7. [16]. Key skill outcomes include consideration of the risks and benefits of the procedure as well as an understanding of the landmarks and branches of the facial nerve [16].
Currently, our results confirm that the most common approach to TAB training is “Watch one, do one, teach one”. This means that trainees receive no formal education. In other areas of ophthalmic surgery training, such as cataract surgery, implementing a structured surgical program involving the use of wet labs and simulator training has been shown to reduce surgical complications. [17]. Trainees can benefit from a structured course that includes an e-learning tutorial with modules covering the content and anatomical landmarks of the temporal region, the risks and benefits of the procedure, and a step-by-step guide to the procedure. This can be followed by a video of the procedure and a supervised wet lab experience before finally entering theater. There are many videos online demonstrating different approaches to TAB [18, 19]. UK trainees can benefit from an instructional video approved by the Royal College of Ophthalmologists and available on their website.
The use of informal teaching is likely multifactorial and may result from shared performance of the procedure across multiple specialties. A recent retrospective cohort study examining specialties performing BAT over a 10-year period in Canada found that general surgeons performed the most temporal artery biopsies, followed closely by ophthalmologists and plastic surgeons. [20]. It is unclear whether the UK experience follows this, but it is certainly the authors’ experience that in some units ophthalmologists perform very little TAB. Lotfipour et al. assessed trends in the cataract surgery training program and proposed that the choice of informal teaching may be the result of a lack of faculty time and the perception that an apprentice-type approach to training education negates the need for formal education [21]. However, in recent years there has been a move away from an informal surgical learning model, largely due to restricted training hours and the limitations of unsupervised experiential learning. [22].
From the perspective of future practice, the use of informal teaching may lead to surgical procedures being influenced by the personal preferences of teaching surgeons. This may reduce the flexibility to provide safer alternatives to a surgical technique. A safer approach to TAB would be to harvest the parietal branch of the superficial temporal artery, effectively eliminating the risk of facial nerve injury. This has already been discussed by other authors [4], yet this technique is little used by ophthalmologists. The artery can be located and marked by following the pulsation of the tragus, after removing a small amount of hair. A handheld Doppler can also be used to confirm the course of the artery if needed. Thereafter, TAB can be executed normally.
Although many trainees perform temporal artery biopsies before their senior year, with some performing more than twenty biopsies, the majority of respondents indicated that they would make their first incision in the “danger zone”. This would suggest that the teaching received by trainees does not emphasize the “danger zone” as an anatomical region that should be avoided as much as possible. Therefore, we propose to map the “danger zone” during preoperative planning of TAB and to avoid the “danger zone” when performing a temporal artery biopsy.
Our survey reveals that the majority of trainees are aware of the anatomical ‘danger zone’, but less than a fifth of respondents are aware of the Pitanguy line. The concept of Pitanguy’s line has its limitations, as the most at-risk temporal branch of the facial nerve usually has multiple branches crossing the zygomatic arch. [23, 24]. However, the preoperative markup can help the surgeon to delimit a forbidden zone (Fig. 2D) within the danger zone that should be avoided, the safety increasing all the more as the incision point is higher and lateral.
There are some limitations to this study. One of the main limitations is the generalizability of these results. Indeed, the survey was distributed to a limited number of deaneries and moreover not all trainees responded. Additionally, we received a number of incomplete surveys that were excluded from the analysis. Nonetheless, our study provides insight into how trainees learn to perform a TAB and helps spark discussion about how training can be made safer.
