Stepwise analysis of the scleral encircling learning curve for clinical fellows using surgical video review

PURPOSE: To identify which steps of the 360° scleral encircling (SE) procedure pose the greatest training challenges for retina fellows by analyzing surgical videos and evaluating changes in operative time across a two-year training period. METHODS: We retrospectively analyzed videos of SE procedures performed by vitreoretinal fellows at a single academic center (2018-2024). Only cases involving 360° SE without concurrent vitrectomy or gas tamponade were included. For each case, total operative time and the duration of six predefined steps were measured. Cases with damaged videos or performed by fellows with ≤ 5 analyzable cases were excluded. Between-fellow comparisons and learning-curve trends were assessed using analysis of variance and correlation analyses. RESULTS: Fifty-five SE cases performed by six fellows met inclusion criteria. Mean total operative time was 132.27 ± 42.92 min, with significant inter-individual differences (p = 0.0007). Among all steps, binocular indirect ophthalmoscopy showed the greatest inter-individual variability (p < 0.0001), followed by scleral suturing (p = 0.0009) and tire positioning (p = 0.006). Across training, the duration of indirect ophthalmoscopy did not show measurable reduction for any fellow. Five of six fellows demonstrated a significant decrease in total operative time correlated with training progression (p < 0.05 for each), with a marked early decrease within their first five cases, followed by a plateau. CONCLUSION: Binocular indirect ophthalmoscopy demonstrated the largest variability and the least improvement during SE training. Prioritizing targeted instruction in this technically demanding step may accelerate skill acquisition and improve overall operative efficiency for early-career ophthalmologists.