Supplementary Material for: Technological Influence on Retina Fellows' Learning Curves: A Prospective Study of Digital vs. Analog Microscopes (The BRAVE Study) (Bridging Retina Fellows’ Advancement with Visualization Enhancements)

Purpose:
The BRAVE Study (Bridging Retina Fellows’ Advancement with Visualization Enhancements) aims to compare the learning curves of retina fellows performing epiretinal membrane (ERM) surgery trained using digital heads-up display (HUD) systems versus analog surgical operating microscopes (SOMs) in a prospective manner.
Methods:
In this prospective two-year study, four retina fellows were trained exclusively with either a digital (NGENUITY® 3D) or analog (ZEISS OPMI LUMERA 700) microscope. Each fellow performed 127 ERM surgeries (total: 508). Learning progression was rated using an 18-item Likert scale (1–5; higher scores = greater difficulty). Primary outcomes included visualization quality, surgical comfort, and instructor interaction. A linear regression model assessed learning trends.
Results:
Fellows using the digital system achieved proficiency within three months, compared to seven months for the analog group. Initial difficulty scores were significantly lower in the digital group (1.64 vs. 5.14, p<0.001). Monthly improvement rates were -0.30 (digital) vs. -0.86 (analog). Instructor interventions were higher in the analog group during the first six months (p<0.05) but equalized later. Early ergonomic and comfort advantages with digital systems also leveled over time.
Conclusions:
Digital HUD systems enhance early skill acquisition and reduce learning-related challenges in retina fellow training. Although long-term proficiency equalizes, these systems offer clear early-phase benefits, supporting their integration into surgical education.

### 研究目的
BRAVE研究（全称：Bridging Retina Fellows’ Advancement with Visualization Enhancements）旨在以前瞻性研究方式，对比使用数字化手术抬头显示（heads-up display, HUD）系统与模拟式手术显微镜（surgical operating microscopes, SOMs）培训的视网膜专科医师学员，在开展视网膜前膜（epiretinal membrane, ERM）手术时的学习曲线差异。

### 研究方法
本研究为为期两年的前瞻性队列研究，共纳入4名视网膜专科医师学员，分别仅通过数字化（NGENUITY® 3D）或模拟式（ZEISS OPMI LUMERA 700）手术显微镜接受培训。每位学员完成127例ERM手术，总手术量达508例。采用18条目李克特量表进行评分（范围1~5分，分值越高代表操作难度越大），评估学员的学习进展情况。主要结局指标包括可视化质量、手术舒适度及带教互动情况，并通过线性回归模型分析学习趋势。

### 研究结果
使用数字化系统的学员在3个月内即达到手术熟练水平，而模拟式组学员则需7个月方可达标。数字化组的初始操作难度评分显著更低（1.64 vs. 5.14，p<0.001）。两组月度评分改善率分别为-0.30（数字化组）与-0.86（模拟式组）。在前6个月，模拟式组的带教干预次数更多（p<0.05），但后续两组差异逐渐趋于一致。数字化系统早期带来的人机工效与舒适度优势，也随培训推进逐渐趋于平稳。

### 研究结论
数字化抬头显示系统可加快视网膜专科医师培训学员的早期技能掌握速度，减轻培训初期的学习相关困难。尽管长期来看两组的手术熟练程度最终趋于一致，但该系统在培训早期阶段具有明确优势，支持其在外科手术教学中的整合应用。