Predictive and construct validity of virtual reality cataract surgery simulators

The impact of extended reality simulators on ophthalmic surgical training and performance: a systematic review and meta-analysis of 17,623 eyes

BACKGROUND

Extended reality (XR) simulators, including virtual reality and augmented reality, hold significant promise for enhancing surgical training by providing trainees with a controlled practice environment. This is particularly vital in microsurgery, where the steep learning curve and the challenge of mastering surgical skills are significant. Despite notable advancements in XR technology, its role in ophthalmic surgical training remains uncertain.

METHODS

In our systematic review and meta-analysis, eight electronic databases were searched, and studies were evaluated against predefined criteria. Data extraction and random-effects meta-analysis assessed the odds ratio (OR) for posterior capsular rupture (PCR), an important surgical complication.

RESULTS

A meta-analysis of 17,623 eyes that underwent cataract surgery across seven studies revealed a significant decrease in PCR post-Eyesi practice, with low heterogeneity across studies (OR = 0.71, 95% CI = 0.60-0.85, I2 = 9%). Studies that predominantly utilized XR for cataract surgery training (84%) consistently improved surgical outcomes by reducing complications such as PCR, retained lens material, and aphakia. XR training also significantly improved operating scores (p < 0.05), self-efficacy (p < 0.01), and non-dominant hand dexterity (p < 0.01). Of the 25 studies in this review, 22 (88%) found overall XR training benefits.

CONCLUSIONS

XR simulators enhance ophthalmic surgical training by reducing complications like PCR, and improving surgical performance, self-efficacy, and non-dominant hand dexterity. These findings challenge conventional training methods and advocate for integrating XR into residency curricula to optimize learning and patient outcomes.

Virtual reality simulation and real-life training programs for cataract surgery: a scoping review of the literature

BACKGROUND

Cataract surgery requires a high level of dexterity and experience to avoid serious intra- and post-operative complications. Proper surgical training and evaluation during the learning phase are crucial to promote safety in the operating room (OR). This scoping review aims to report cataract surgery training efficacy for patient safety and trainee satisfaction in the OR when using virtual reality simulators (EyeSi [Haag-Streit, Heidelberg, Germany] or HelpMeSee [HelpMeSee foundation, Jersey city, New Jersey, United States]) or supervised surgical training on actual patients programs in residents.

METHODS

An online article search in the PubMed database was performed to identify studies proposing OR performance assessment after virtual-reality simulation (EyeSi or HelpMeSee) or supervised surgical training on actual patients programs. Outcome assessment was primarily based on patient safety (i.e., intra- and post- operative complications, OR performance, operating time) and secondarily based on trainee satisfaction (i.e., subjective assessment).

RESULTS

We reviewed 18 articles, involving 1515 participants. There were 13 using the EyeSi simulator, with 10 studies conducted in high-income countries (59%). One study used the HelpMeSee simulator and was conducted in India. The four remaining studies reported supervised surgical training on actual patients, mostly conducted in low- middle- income countries. Training programs greatly differed between studies and the level of certainty was considered low. Only four studies were randomized clinical trials. There were 17 studies (94%) proposing patient safety assessments, mainly through intraoperative complication reports (67%). Significant safety improvements were found in 80% of comparative virtual reality simulation studies. All three supervised surgery studies were observational and reported a high amount of cataract surgeries performed by trainees. However, intraoperative complication rates appeared to be higher than in virtual reality simulation studies. Trainee satisfaction was rarely assessed (17%) and did not correlate with training outcomes.

CONCLUSIONS

Patient safety assessment in the OR remains a major concern when evaluating the efficacy of a training program. Virtual reality simulation appears to lead to safer outcomes compared to that of supervised surgical training on actual patients alone, which encourages its use prior to performing real cases. However, actual training programs need to be more consistent, while maintaining a balance between financial, cultural, geographical, and accessibility factors.

Validity evidence of a new virtual reality simulator for phacoemulsification training in cataract surgery

This study aims to assess validity evidence of the new phacoemulsification module of the HelpMeSee [HMS] virtual reality simulator. Conducted at the Ophthalmology Department of Strasbourg University Hospital and Gepromed Education Department, Strasbourg, France, this cross-sectional study divided 20 surgeons into two groups based on their experience over or under 300 cataract surgeries. Surgeons filled out a background survey covering their phacoemulsification experience and prior simulator use before undergoing single-session simulations on the EyeSi [EYS] and HMS simulators. Handgrip strength was measured pre- and post-simulation to evaluate grip fatigue. Afterwards, surgeons rated the perceived realism on a seven-point Likert scale. Participants were predominantly right-handed males, with expert surgeons averaging 44 years and intermediate surgeons 29 years of age. Expert surgeons had completed around 2000 phacoemulsification surgeries compared to 150 by intermediates. Primary outcome was to assess the construct validity of HMS simulator based on the difference in total and modules scores between both groups. Significant performance differences were observed between the two groups, with experts scoring higher. HMS scores were 35.8 ± 1.5 out of 46 points for experts and 27.2 ± 2.3 for intermediates (p = 0.006). For EYS, scores were 405.2 ± 20.3 out of 500 points for experts and 327.8 ± 25.2 for intermediates (p = 0.028). Experts experienced significantly less grip fatigue post-simulation on HMS compared to intermediates. This research evaluates validity evidence of HMS's phacoemulsification modules for the first time. It emphasizes the potential to broaden simulation-based training by targeting diverse populations.

Immersive teaching using virtual reality technology to improve ophthalmic surgical skills for medical postgraduate students

Medical education is primarily based on practical schooling and the accumulation of experience and skills, which is important for the growth and development of young ophthalmic surgeons. However, present learning and refresher methods are constrained by several factors. Nevertheless, virtual reality (VR) technology has considerably contributed to medical training worldwide, providing convenient and practical auxiliary value for the selection of students' sub-majors. Moreover, it offers previously inaccessible surgical step training, scenario simulations, and immersive evaluation exams. This paper outlines the current applications of VR immersive teaching methods for ophthalmic surgery interns.

Validation of collaborative cyberspace virtual reality oculometry enhanced with near real-time spatial audio

Currently, most medical image data, such as optical coherence tomography (OCT) images, are displayed in two dimensions on a computer screen. Advances in computer information technology have contributed to the growing storage of these data in electronic form. However, the data are usually processed only locally on site. To overcome such hurdles, a cyberspace virtual reality (csVR) application was validated, in which interactive OCT data were presented simultaneously to geographically distant sites (Lucerne, London, and Barcelona) where three graders independently measured the ocular csVR OCT diameters. A total of 109 objects were measured, each three times, resulting in a total of 327 csVR measurements. A minor mean absolute difference of 5.3 µm was found among the 3 measurements of an object (standard deviation 4.2 µm, coefficient of variation 0.3% with respect to the mean object size). Despite the 5 h of online work, csVR was well tolerated and safe. Digital high-resolution OCT data can be remotely and collaboratively processed in csVR. With csVR, measurements and actions enhanced with spatial audio communication can be made consistently in near real time, even if the users are situated geographically far apart. The proposed visuo-auditory framework has the potential to further boost the convenience of digital medicine toward csVR precision and collaborative medicine.

Evaluation of Two-Dimensional (2D) versus Three-Dimensional (3D) Video Tutorials in Cataract Surgery for New Trainees

Purpose  Microscopic ophthalmic surgery requires an understanding of three-dimensional (3D) spaces within the eye. Recently, there has been an increase in 3D video training tools in health care. Studies have evaluated the efficacy of 3D tutorials in general surgery, but little has been published within ophthalmology. We present a randomized study evaluating differences in surgically naïve trainees after watching either a 2D or 3D phacoemulsification tutorial. Design  This was a double-blind, randomized study. A group of third and fourth year medical students at our institution were randomized with stratified randomization based on prior surgical courses to control for differences in baseline surgical skill. The two study arms were watching 2D or 3D instructional videos on phacoemulsification (Richard Mackool). Methods  Participants received a preliminary survey and participated in an hour-long microscopic surgery session. During the session, participants performed tasks evaluating baseline microscopic spatial awareness and surgical skill. The students were then instructed to watch either a 2D or 3D video on phacoemulsification based on their randomized study arm. During the postintervention session, participants performed the biplanar incision and capsulorhexis steps of cataract surgery discussed in the video on model eyes. Students were evaluated on speed and overall capsulorhexis quality. Results  Thirty-one students qualified for the study and completed the microscopic surgery session. Students in both groups had similar baseline speed and quality of preintervention microscopic tasks ( p  > 0.05 for all tasks). Postintervention, students randomized to the 3D video performed significantly faster than the 2D group for biplanar incision (11.1 ± 5.5 s vs. 20.7 ± 10.5 s, p  = 0.001). There were no statistically significant differences found between the groups in capsulorhexis timing ( p  = 0.12) or quality score ( p  = 0.60). Conclusions  3D video surgical training tutorials may improve speed of certain steps of cataract surgery for surgically naïve ophthalmology trainees. Given the limited sample size of this study, further investigation of their effectiveness is warranted.