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.