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Twenty non-ophthalmologist healthcare providers in Malawi completed a course combining didactic teaching, hands-on simulation-eye practice with direct and binocular indirect ophthalmoscopy, and immediate feedback. 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BMC Medical Education (2026) 26:35 BMC Medical Education  \n[https://doi.org/10.1186/s12909-025-08213-4](https://doi.org/10.1186/s12909-025-08213-4)  \nRESEARCH Open Access  \nStructured simulation-based training with frugal ophthalmic instruments rapidly equips non-ophthalmologists to identify malarial retinopathy in simulation eyes: an audit of a training course  \nKyle J. Wilson 1,2*, Obaid Kousha3,4, Harold Nkume5, Alice M. Liomba6, Nicholas A. V. Beare 1,7 and Andrew Blaikie3,8  \nAbstract  \nBackground Malaria, particularly cerebral malaria, poses a significant health threat, especially for children in  \nsub-Saharan Africa. Identification of malarial retinopathy (MR) has diagnostic value in cerebral malaria but can be impractical due to lack of availability of trained and equipped ophthalmic specialists. Recent developments in low-cost simulation tools and ophthalmoscopes offer the potential to train non-ophthalmologists to offer fundus assessments in low-resource settings.  \nMethods Twenty non-ophthalmologist healthcare providers in Malawi attended a training program focused on identification of MR using direct and binocular indirect ophthalmoscopy. The curriculum included didactic sessions, hands-on practice with simulation eyes, and assessment of skill acquisition with immediate feedback. Pre-and posttraining confidence surveys were conducted.  \nResults Participants demonstrated significant improvement in identification of malarial retinopathy in simulation eyes after completing the training, with a mean accuracy of 83% . Clinician confidence levels increased across all domains of retinal examination covered in the course.  \nConclusions Structured simulation-based training using frugal ophthalmoscopes can equip non-ophthalmologists with skills to identify MR in simulation eyes. Future work should focus on long-term skill retention and validation in areal-world clinical setting.  \nKeywords Ophthalmology, Simulation, Malaria, Resource-limited, Low-cost  \n*Correspondence:  \nKyle J. Wilson  \n[kyle.wilson@liverpool.ac.uk](kyle.wilson@liverpool.ac.uk)  \n1Department of Eye and Vision Science, University of Liverpool, Liverpool, UK  \n2Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi  \n3Infection and Global Health Division, School of Medicine, University of St. Andrew’s, St Andrew’s, UK  \n4Department of Ophthalmology, NHS Tayside, Dundee, UK 5Department of Ophthalmology, Queen Elizabeth Central Hospital, Blantyre, Malawi  \n6Blantyre Malaria Project, Queen Elizabeth Central Hospital, Blantyre, Malawi  \n7St. Paul’s Eye Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK  \n8Department of Ophthalmology, NHS Fife, Fife, UK  \n© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creativecommons.org/licenses/by/4.0/](http://creativecommons.org/licenses/by/4.0/.)[.](http://creativecommons.org/licenses/by/4.0/.)  \nWilson et al. BMC Medical Education (2026) 26:35  \nBackground  \nMalaria remains a significant public health concern globally, being responsible for more than 600,000 deaths in 2022 [1]. Over 70% of these deaths occur in children in the African region. Within the spectrum of disease caused by malaria infection, c","cbCaikfuUvKvol76","https://ap.wps.com/l/cbCaikfuUvKvol76","pdf",1386887,"English","# Background\n## Malaria and cerebral malaria context\n## Malaria retinopathy and examination methods\n# Methods\n## Training programme design\n## Assessment and confidence surveys\n# Results\n## Accuracy improvements\n## Confidence across retinal examination domains\n# Conclusions\n## Implications for non-ophthalmologists\n## Future validation and retention work","[{\"question\":\"Why is identification of malarial retinopathy important for cerebral malaria?\",\"answer\":\"MR identification supports diagnostic value in cerebral malaria. It can be difficult in practice where trained and equipped ophthalmic specialists are not available.\"},{\"question\":\"What training activities did non-ophthalmologists complete?\",\"answer\":\"Participants attended didactic sessions, practiced with simulation eyes using direct and binocular indirect ophthalmoscopy, and received immediate feedback to support skill acquisition.\"},{\"question\":\"What were the main outcomes after the training?\",\"answer\":\"Participants showed a significant improvement in identifying malarial retinopathy in simulation eyes, with a mean accuracy of 83%, and increased confidence across covered retinal examination domains.\"}]","Structured simulation-based training with frugal ophthalmic instruments rapidly equips non-ophthalmologists to identify malarial retinopathy in simulation eyes - an audit of a training course | PDF",1790753705,18]