![](https://assets.reachrx.ai/images/10.1038%E2%98%8Ds41433-025-04206-1/_page_0_Picture_1.jpeg) # **COMMENT OPEN** ![](https://assets.reachrx.ai/images/10.1038%E2%98%8Ds41433-025-04206-1/_page_0_Picture_3.jpeg) # Modernising patient education in vitreoretinal surgery Jae Yee Ku 1.2, Rumana Hussain 2, Heinrich Heimann, Nima Ghadiri 2, Ivan Sychev, Max Griebsch, Aruni Makuloluwa, Christopher Ze Qian Go 3,4, Konstantinos Kaprinis, Tom Southern, Keeran Shou Yao Chang, Paul Y. Chua, Carl Groenewald, Fidan Jmor, Ian Pearce, Teresa Sandinha, Sandra Gray and Shi Zhuan Tan, © The Author(s) 2026 Eye; https://doi.org/10.1038/s41433-025-04206-1 #### INTRODUCTION Poor literacy is a major barrier to effective healthcare communication, with one in six people in the UK affected [1]. In Liverpool, literacy vulnerability is among the highest in the North West of England [2, 3]. At the same time, social media has shaped patient preferences, with images and videos now the preferred modes of learning and engagement. Traditional, text-heavy patient education materials risk leaving many patients behind. In vitreoretinal surgery, this gap has significant clinical consequences. Patients often struggle to understand written postoperative instructions or read small print, particularly those relating to postoperative posturing. Poor adherence can compromise surgical success and lead to poorer visual outcomes [4, 5]. To address this, we developed a new patient information leaflet (PIL) that incorporates clear illustrations and is complemented by short instructional videos. This quality improvement project aims to enhance patient understanding of posturing instructions after vitreoretinal surgery. By modernising educational resources, this initiative promotes patient-centred care in the Royal Liverpool University Hospital and was delivered using the Model for Improvement through a Plan-Do-Study-Act (PDSA) cycle described below [6, 7]. #### **STAGE 1: PLAN** A baseline questionnaire was completed by staff for day one postoperative patients to assess their understanding of postoperative care, including proper posturing. The questionnaire included three questions (Table 1), each answered on a five-point Likert scale (very certain, certain, neutral, uncertain, very uncertain). Of the 20 questionnaires collected over two weeks, most patients (85%) felt very certain or certain that posturing was required. However, only 60% reported being very certain or certain about the correct posture itself, and fewer still (45%) were confident about the duration for which posturing should be maintained (Table 1). In response to these findings, we proposed a new patient information leaflet (PIL) featuring illustrations of key postures and embedded QR codes linking to instructional videos. #### STAGE 2: DO A local team convened to develop the new PIL incorporating illustrations of key postoperative postures. To complement this, three educational videos were produced covering posturing after macular hole surgery, after retinal detachment surgery and the correct technique for instilling postoperative eye drops. These videos were launched on the trust's YouTube channel in April 2024. Staff in the theatre admission unit who care for postoperative patients received training on how to implement the new PIL. To enhance accessibility for individuals with visual impairment, the PIL has a minimum 16-point font and is printed on yellow paper, as recommended by the Royal National Institute of Blind People (RNIB) [8]. The PIL and videos could be viewed by scanning the QR codes in Fig. 1. #### **STAGE 3: STUDY** Two months after introducing the new PIL, we reassessed its impact on patients' certainty regarding posturing instructions. **Table 1.** Questionnaire of patients' certainty of their postoperative posturing instructions before and after the introduction of the new patient information leaflet (PIL). | Questions | Very certain/Certain | | Neutral | | Uncertain/Very uncertain | | |-----------------------------------------------------------|----------------------|---------------|------------|-------------|--------------------------|--------------| | | Before PIL | After PIL | Before PIL | After PIL | Before PIL | After PIL | | 1. How certain is the patient that they need to posture? | 85% (17/20) | 94.4% (17/18) | 5% (1/20) | 0% (0/18) | 10% (2/20) | 5.6% (1/18) | | 2. How certain is the patient of their posture? | 60% (12/20) | 83.3% (15/18) | 20% (4/20) | 5.6% (1/18) | 20% (4/20) | 11.1% (2/18) | | 3. How certain is the patient of their posturing duration | 45% (9/20) | 72.2% (13/18) | 10% (2/20) | 5.6% (1/18) | 45% (9/20) | 22.2% (4/18) | ^<sup>1Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, Faculty of Health & Life Sciences, University of Liverpool, William Henry Duncan Building, Liverpool, UK. ²Royal Liverpool University Hospital, Liverpool, UK. ³Faculty of Medicine, University of New South Wales, Wallace Wurth Building, Sydney, NSW, Australia. ⁴Save Sight Institute, University of Sydney, Sydney, NSW, Australia. ⁵Brisbane Grammar School, Spring Hill, QLD, Australia. ^™email: jku@liverpool.ac.uk Received: 25 October 2025 Revised: 4 December 2025 Accepted: 19 December 2025 Published online: 09 January 2026 ![](https://assets.reachrx.ai/images/10.1038%E2%98%8Ds41433-025-04206-1/_page_1_Picture_2.jpeg) **Fig. 1 Figures and QR codes shown in the patient information leafet.** Example of the face down posture illustrated in the patient information leafet (**A**) and demonstrated in the video (**B**). QR codes to obtain the patient information leafet (**C**) nd view the videos for posturing after macular hole surgery (**D**), retinal detachment surgery (**E**) and the technique for applying eye drops (**F**). The original questionnaire was repeated over two weeks (*n* =∠18). Compared with baseline, the proportion of patients who were very certain or certain increased to 94.4% for Question 1, 83.3% for Question 2, and 72.2% for Question 3 (Table [1](#page-0-0)). We obtained more specifc patient feedback in a questionnaire with the following 5 questions (*n* =∠8). Feedback (indicated in brackets) was uniformly positive. - 1. Do you feel that there is a need for this PIL? (Yes, 100%) - 2. Do you feel that the amount of information (As much as you want, 100%) - 3. Did you fnd the information in the leafet clear to understand? (Understood all the information, 100%) - 4. Do you think the size of the print is (Just right, 100%) - 5. Do you think the information on each page is (Just right, 100%) In addition, staff feedback was collected using the following 5-question (*n* =∠8) questionnaire. Responses (indicated in brackets) were strongly supportive of the new PIL. - 1. How satisfed are you overall with the PIL? (Very satisfed 87.5%, Satisfed 12.5%, Neutral 0%, Unsatisfed 0%, Very unsatisfed 0%) - 2. How easy is it to complete the PIL? (Very easy 87.5%, Easy 12.5%, Neutral 0%, Diffcult 0%, Very diffcult 0%) - 3. How much time does it take to complete the PIL (Very short 50%, Short 50%, Neutral 0%, Long 0%, Very long 0%) - 4. How certain are you that the new PIL will help patients understand their posturing instructions better? (Very certain 37.5%, Certain 50%, Neutral 12.5%, Uncertain 0%, Very uncertain 0%) - 5. Is the PIL available for you to use? (Very available 62.5%, Available 25%, Neutral 12.5%, Unavailable 0%, Very unavailable 0%) # **STAGE 4: ACT** Based on the questionnaire results and feedback, the current format of the PIL was deemed satisfactory. In addition to the planned formal review of the PIL in three years, the highly viewed patient instructional videos (over 22,000 views for the retinal detachment video; over 15,000 views for the macular hole video) available on the trust's YouTube channel will be maintained and promoted as a sustainable, internationally accessible tool. As part of this effort, the videos have been made available on the British & Eire Association of Vitreoretinal Surgeons (BEAVRS) website as a patient resource [\[9\]](#page-2-0). ## **CONCLUSION** This quality improvement project successfully achieved its aim of modernising patient education in vitreoretinal surgery. By introducing a visually enhanced PIL supported by instructional videos, we improved patients' certainty in understanding and following their postoperative instructions. Both patient and staff feedback were overwhelmingly positive, confrming the value of clear, accessible, and engaging educational resources. Interestingly, the countries that have viewed these videos the most are the USA and India, suggesting that these videos are having an impact beyond the UK. This work demonstrates that adapting patient information to contemporary learning preferences can signifcantly enhance patient-centred care, and it provides a sustainable model for future innovations in patient education. #### **DATA AVAILABILITY** The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. # **REFERENCES** - 1. National Literacy Trust. Adult literacy. 2025. 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Seno Y, Shimada Y, Mizuguchi T, Tanikawa A, Horiguchi M. Compliance with the face-down positioning after vitrectomy and gas tamponade for rhegmatogenous retinal detachments. Retina. 2015;35:1436–40. - 5. Suzuki K, Shimada Y, Seno Y, Mizuguchi T, Tanikawa A, Horiguchi M. Adherence to the face-down positioning after vitrectomy and gas tamponade: a time series analysis. BMC Res Notes. 2018;11:142. Eye 3 - 6. Taylor M, McNicholas C, Nicolay C, Darzi A, Bell D, Reed J. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf. 2014;23:290–8. - 7. Langley G, Moen R, Nolan K, Nolan T, Norman C, Provost L The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2009;2nd edn. Jossey-Bass, San Francisco. - 8. Parliament UK. Clear Print Guidelines from RNIB. 1998. [https://publications.parliament.uk/](https://publications.parliament.uk/pa/cm199798/cmselect/cmhaff/768/768ap22.htm) [pa/cm199798/cmselect/cmhaff/768/768ap22.htm](https://publications.parliament.uk/pa/cm199798/cmselect/cmhaff/768/768ap22.htm). - 9. British & Eire Association of Vitreoretinal Surgeons (BEAVRS). Patient Information. 2025. . ## **ACKNOWLEDGEMENTS** We would like to thank the staff at the theatre admission unit and St Paul's eye unit in the Royal Liverpool University Hospital for their assistance in this project. # **AUTHOR CONTRIBUTIONS** JYK, RH, HH, NG, MG, AM, CZQG, KK, PYC, CG, FJ, IP, TS, SG and SZT conceived the project. JYK, IS, NG, TS, and RH were directly involved with the production of the videos. KSYC provided the illustrations. JYK, IS, MG, AM, and CZOG contributed to data collection. All authors contributed to the production of the patient information leafet. All authors have reviewed and approved the fnal manuscript. ### **COMPETING INTERESTS** HH and NG are members of the Eye editorial board. The remaining authors declare that they have no confict of interest. ## **ADDITIONAL INFORMATION** **Correspondence** and requests for materials should be addressed to Jae Yee Ku . **Reprints and permission information** is available at [http://www.nature.com/](http://www.nature.com/reprints) [reprints](http://www.nature.com/reprints) **Publisher's note** Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affliations. **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. 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