In light of the increasing use of online learning platforms in medical education, there is a critical need to assess the current state of online learning environments. Despite the global emphasis on digital education, limited studies have systematically explored how medical students perceive the effectiveness and quality of these environments, particularly in Pakistan. This study aims to fill this gap by evaluating medical students’ experiences with their institution’s online learning environments and identifying key strengths and challenges that impact learning outcomes. A mixed-method, sequential exploratory design was used, starting with a quantitative assessment followed by qualitative inquiry. Data from 253 medical students were collected via a survey, and 30 focus group interviews were conducted to provide deeper insights into the challenges students face in navigating the online learning environment. The findings revealed critical areas in need of improvement, including digital infrastructure, student engagement, and the accessibility of online resources. Qualitative data highlighted the need for more interactive and student-centred approaches to online education. By focusing on the status of online learning in medical education, this research provides valuable insights for educators and policymakers aiming to enhance the quality of digital learning environments. The study contributes to ongoing efforts to develop more effective, engaging, and responsive online learning strategies for medical students in Pakistan.
Education, Distance ; Education, Medical, Undergraduate ; Perception

In this study, we explored the neural mechanism underlying impaired stereopsis and possible functional plasticity after strabismus surgery. We enrolled 18 stereo-deficient patients with intermittent exotropia before and after surgery, along with 18 healthy controls. Functional magnetic resonance imaging data were collected when participants viewed three-dimensional stimuli. Compared with controls, preoperative patients showed hypoactivation in higher-level dorsal (visual and parietal) areas and ventral visual areas. Pre- and postoperative activation did not significantly differ in patients overall; patients with improved stereopsis showed stronger postoperative activation than preoperative activation in the right V3A and left intraparietal sulcus. Worse stereopsis and fusional control were correlated with preoperative hypoactivation, suggesting that cortical deficits along the two streams might reflect impaired stereopsis in intermittent exotropia. The correlation between improved stereopsis and activation in the right V3A after surgery indicates that functional plasticity may underlie the improvement of stereopsis. Thus, additional postoperative strategies are needed to promote functional plasticity and enhance the recovery of stereopsis.
Humans ; Exotropia/surgery* ; Depth Perception/physiology* ; Strabismus/surgery* ; Oculomotor Muscles/surgery*

PURPOSE: The purpose of this study was to evaluate whether eye dominance changes after conventional pseudophakic monovision, and to identify factors that affect changes in eye dominance. METHODS: This retrospective study included 70 patients who underwent bilateral conventional monovision cataract surgery. Patients were divided into two groups based on whether they experienced a change in the dominant eye. We compared patients' uncorrected distance visual acuity (UCDVA), uncorrected near visual acuity (UCNVA), best-corrected visual acuity (BCVA), spherical equivalent, stereopsis, and time interval between cataract surgeries. RESULTS: The mean age was 71.26 ± 10.84 (range, 25–90) years, mean interval between surgery in each eye was 118.46 ± 183.50 (range, 17–1,018) days, and mean postoperative diopter difference was 1.16 ± 0.53 (range, 0.00–2.75) diopters. After bilateral cataract surgery, 22 patients (31.43%) experienced a change in eye dominance, whereas 48 patients (68.57%) experienced no change. There were no differences in the time interval between cataract surgeries, preoperative UCDVA and UCNVA, pre- and postoperative BCVA, or stereopsis in either group. Patients who experienced a change in eye dominance showed smaller differences between preoperative and postoperative spherical equivalent, compared with patients who experienced no change in eye dominance (t-test, p < 0.05). CONCLUSIONS: Twenty-two (31.43%) patients whose nondominant eyes were targeted for near vision showed altered eye dominance after conventional monovision cataract surgery. Eye dominance shows greater plasticity in patients with smaller differences between preoperative and postoperative spherical equivalent.
Cataract ; Clinical Study ; Depth Perception ; Dominance, Ocular ; Humans ; Plastics ; Presbyopia ; Retrospective Studies ; Visual Acuity

PURPOSE: To analyze stereopsis change before and after inferior oblique weakening surgery. METHODS: We retrospectively reviewed the medical records of 31 patients who had undergone inferior oblique weakening surgery. The factors analyzed included sex, age at surgery, preoperative and postoperative visual acuity (VA), time from first detection to surgery, degree of inferior oblique overaction (IOOA), primary/secondary IOOA, exotropia/hypertropia, bilaterality, and type of surgery. RESULTS: Eighteen patients with a mean age 7.3 ± 3.1 years exhibited stereopsis of 60 arc seconds or better before surgery and 17 had stereopsis better than 60 arc seconds after surgery. Postoperatively, stereopsis improved in 13 patients and deteriorated in 9. Better preoperative VA and the absence of superior oblique underaction were associated with better preoperative stereopsis. Better preoperative VA, postoperative VA, and the presence of head tilt were associated with better postoperative stereopsis. Unilateral inferior oblique weakening surgery and accompanying hypertropia were associated with improved stereopsis, while the absence of hypertropia was associated with deteriorated stereopsis. CONCLUSIONS: In this retrospective study, 58.1% of patients tended to have bifoveal fixation. When a vertical deviation is present in the primary position due to unilateral IOOA, IO weakening surgery can be expected to improve binocular function.
Depth Perception* ; Head ; Humans ; Jupiter ; Medical Records ; Retrospective Studies ; Strabismus ; Telescopes ; Visual Acuity

PURPOSE: To evaluate the relationship between initial postoperative overcorrection and long-term surgical success in exotropia patients. METHODS: The medical records of 46 patients who underwent surgery for intermittent exotropia after the age of 18 were enrolled. Enrolled patients also had at least 2 years of postoperative follow-up. Based on the initial postoperative deviation at distance measured by prism and the alternating cover test at 1 week, patients were assigned to one of the following groups: group A included patients who demonstrated any esodeviation, while group B included patients who showed orthophoria to exodeviation of 10 prism diopters. The records were analyzed to determine the preoperative deviation with stereoacuity and postoperative deviations with stereoacuity at the follow-up examinations at the following intervals: 1 week; 1, 3, and 6 months; and 1 and 2 years. A comparison between groups for demographic data and preoperative and postoperative angles of deviation was performed using analysis of variance. RESULTS: Of the 46 patients with intermittent exotropia included in this study, 18 (39%) belonged to group A, while 28 (73%) belonged to group B. The postoperative angle of deviation for distant fixation until 2 years of follow-up showed statistically significant differences in each group (p < 0.003 in all comparisons). The amount of exodrift until 2 years in group A (from −9.7 ± 6.1 to 1.6 ± 3.7) was greater than that in group B (from 2.0 ± 2.7 to 6.8 ± 5.6). The long-term surgical success rate within 2 years of surgery was significantly better in group A than in group B (p = 0.027). The number of patients with intermittent diplopia and the duration of diplopia were greater in group A (n = 8) than in group B (n = 2). CONCLUSIONS: Long-term surgical success was achieved in 89% of patients who were initially overcorrected. Overcorrection of an average of 10 prism diopters at the first postoperative week was found to be associated with a more favorable long-term surgical outcome.
Adult* ; Depth Perception ; Diplopia ; Esotropia ; Exotropia* ; Follow-Up Studies ; Humans ; Medical Records

PURPOSE: To compare the characteristics of patients with surgically overcorrected intermittent exotropia treated with alternate patching. METHODS: The medical records of 51 patients who underwent bilateral lateral rectus muscle recession for intermittent exotropia and required alternate patching to correct postoperative overcorrection were retrospectively reviewed. Patients with postoperative esodeviation ≥18 prism diopters (PD) were started on alternate patching on postoperative day 1, whereas those with postoperative esodeviation of 10 to 17 PD were started after 2 weeks. Postoperative esodeviation <10 PD was considered as slight intentional overcorrection after exotropia surgery. Patients not responsive to alternate patching treatment were defined as those with postoperative esodeviation ≥10 PD after 3 months of treatment. Sex, family history, age, refractive error, amblyopia, stereopsis, suppression, type of exotropia, surgical method, preoperative and postoperative angle of deviation, and start time of alternate patching were compared. RESULTS: Among 51 patients, 29 patients responded to alternate patching and 22 patients did not respond. Female sex (p = 0.04), larger preoperative exodeviation at distance (p = 0.04), late onset of postoperative maximal esodeviation (p < 0.01), larger postoperative maximal esodeviation at near (p = 0.02), and late initiation of alternate patching (p = 0.01) were associated with patients in the non-responsive group. Although postoperative angle of deviation was similar for 2 weeks, the angle of postoperative esodeviation was significantly larger in the non-responsive group than in the responsive group, beginning at 1 month postoperatively. CONCLUSIONS: Female sex, large preoperative exodeviation, late initiation of alternate patching, and large esodeviation 1-month postoperative predisposed patients to be resistant to alternate patching for postoperative overcorrection.
Amblyopia ; Depth Perception ; Esotropia ; Exotropia* ; Female ; Humans ; Medical Records ; Methods ; Refractive Errors ; Retrospective Studies

PURPOSE: To determine the amount of additional surgery required for patients with consecutive esotropia, who had an esodeviation angle similar to their pre-operative exodeviation angle, following bilateral lateral rectus recession surgery for intermittent exotropia. METHODS: The medical records of 29 patients who underwent surgery for intermittent exotropia from 1998 through 2013 were reviewed. These patients had consecutive esotropia with an unchanged postoperative esodeviation angle. Thirteen patients underwent esotropia surgery with the aim of full correction (Group A), while 16 patients underwent esotropia surgery with the aim of partial correction (Group B). The postoperative ocular alignment and stereopsis of both groups were compared. RESULTS: A total of 29 patients were evaluated including 13 patients in Group A and 16 patients in Group B. At the final follow-up visit, at least 24 months post procedure, Group B had a significantly greater success rate than Group A (62.5% vs. 23.1%, p = 0.039). Over-correction rates were higher in Group A than Group B (76.9% vs. 37.5%, p = 0.039). The changes during the follow-up period (6 months to their last follow-up) showed that the over-correction rate had increased from 30.8% to 76.9% in Group A (p = 0.034) and from 12.5% to 37.5% in Group B (p = 0.046). CONCLUSIONS: Consecutive esotropia surgery with the aim of partial correction showed favorable motor and sensory outcomes in patients who had a postoperative esodeviation angle similar to that of their pre-operative exodeviation. This strategy may also be helpful in preventing long-term postoperative over-correction in patients presenting with consecutive esotropia.
Depth Perception ; Esotropia ; Exotropia ; Follow-Up Studies ; Humans ; Medical Records

Videogames offer the usual skills needed for laparoscopy namely, eye-hand coordination, depth perception, and bimanual operation. The impact of playing videogames on basic laparoscopic skills is still ambiguous with some studies showing correlation and with other studies demonstrating little or no effect.

OBJECTIVE: To determine the impact of training with Nintendo® WiiTM in the improvement of basic laparoscopic skill among laparoscopic novices by measuring the time to completion of eye-hand coordination task, two-hand manipulation task, grasping and cutting task or grasping and clipping tasks.

METHODS: An electronic systematic search was done in online databases and search engines. This review included randomized prospective studies, written in English language, and published within the last 5 years. Participants included adults 19-29 years old, medical students and surgical residents, with a low video game experience, without or minimal experience in laparoscopic surgery and laparoscopic simulator. The studies compared the performance of participants in a laparoscopic simulator (SimbionixTM LapMentorTM or ProMIS) after training with Nintendo® WiiTM and measured their completion time of several tasks.

RESULTS: Training with Nintendo® WiiTM showed improvement in time to completion of eye-hand coordination task, two-hand manipulation task, and grasping and clipping task. The study however showed equivocal results in the grasping and cutting tasks.

CONCLUSION: Training with Nintendo® WiiTM can be used as a training tool for the improvement of basic laparoscopic skills of laparoscopic novices.

Multiple-pinhole (MPH) glasses are currently sold in many countries with unproven advertisements; however, their objective and subjective effects have not been investigated. Therefore, to investigate the effects of MPH glasses excluding the single-pinhole (SPH) effect, we compared the visual functional changes, reading speed, and ocular discomfort after reading caused by MPH and SPH glasses. Healthy 36 participants with a mean age of 33.1 years underwent examinations of pupil size, visual acuity (VA), depth of focus (DOF), and near point accommodation (NPA); tests for visual field (VF), contrast sensitivity (CS), stereopsis, and reading speed; and a survey of ocular discomfort after reading. Both types of pinhole glasses enlarged pupil diameter and improved VA, DOF, and NPA. However, CS, stereopsis, and VF parameters deteriorated. In comparison with SPH glasses, MPH glasses induced smaller pupil dilation (5.3 and 5.9 mm, P < 0.001) and showed better VF parameters with preserved peripheral VF. However, no significant difference was observed for VA, DOF, NPA, stereopsis, and CS. Reading speed using pinhole glasses was significantly slower than baseline; SPH glasses showed the slowest reading speed. Both types of glasses caused significant ocular discomfort after reading compared with baseline, and symptoms were worst with MPH glasses. In conclusion, both types of pinhole glasses had positive effects due to the pinhole effect; however, they had negative effects on VF, CS, stereopsis, reading speed, and ocular discomfort. In spite of the increased luminance and preserved peripheral VF with MPHs, these glasses caused more severe ocular discomfort than SPH glasses. This clinical trial was registered at www.ClinicalTrials.gov (Identifier: NCT02572544).
Contrast Sensitivity ; Depth Perception ; Eyeglasses* ; Glass* ; Pupil ; Visual Acuity ; Visual Fields

PURPOSE: To evaluate the clinical analysis of intermittent exotropia patients who required more than three reoperations and to investigate the factors leading to situations that require more than three reoperations. METHODS: We retrospectively analyzed the results of 13 patients who underwent more than three reoperations for recurrence after the second operation, as well as for 29 patients who had successful results for operation at least 1 year after the second operation. We investigated the factors associated with surgical outcomes of the second operation using multiple logistic regression analysis, which included; onset of symptom, primary, secondary, tertiary, and fourth ages of surgery, stereopsis before and after surgery, distance and near deviation before and after surgery, and constancy of exotropia. RESULTS: There were more cases in which symptoms occurred before 1 year of age (p = 0.011) and which had constant exotropia (p = 0.023), with a large deviation at first operation (p = 0.003) after more than three operations compared to patients who only had two operations. There were less cases that achieved initial overcorrection after first operation (p = 0.003) and successful postoperative stereopsis after second operation (p = 0.043) in the three operations group than in the two operations group. Among these factors, the most important factor affecting reoperation and success after second operation was related to successful recovery of stereopsis using multiple regression analysis (odds ratio [OR] = 50.00, 95% confidence interval [CI] = 4.392–569.224, p = 0.002). CONCLUSIONS: In cases of intermittent exotropia occurring before 1 year of age, constant exotropia with a large deviation at first operation, and insufficient initial overcorrection after operation, it may be necessary for patients to receive more than three operations because of recurrence. Further, recovery of postoperative stereopsis after the second operation was the most important predictor for postoperative results.
Depth Perception ; Exotropia* ; Humans ; Logistic Models ; Recurrence ; Reoperation ; Retrospective Studies