Simulation training in ophthalmology: Replacement or complement?

Wet lab training on goat eye, dry lab (on synthetic materials), and surgical simulators has been utilized to enhance cataract surgery training outcomes.[1,2,3,4,5,6,7,8,9] Surgical simulation in ophthalmology involves the use of advanced technologies to replicate real-life surgical procedures in a controlled, virtual environment. These simulations are designed to help trainee surgeons improve their skills, understanding, and decision-making abilities in a low-risk setting before performing actual surgeries on patients in the operating room.

Surgical simulators help residents develop the necessary hand-eye coordination for ophthalmic surgery, ensuring patient safety.[4,5,6,7] These simulators are based on virtual reality (VR) and augmented reality (AR). There are two simulators: the EyeSi VR Magic (Haag-Streit, Heidelberg, Germany) and HelpMeSee (HMS, HelpMeSee foundation, Jersey City, New Jersey, United States) that are used commonly. The third is the MicroVisTouch (ImmersiveTouch, Inc, Chicago, USA), which is also a commercially available simulator, that has been investigated for basic steps in cataract surgery. These simulators are designed for phacoemulsification and vitreoretinal surgery training. The HMS simulators are used in countries with low-resource settings.[10,11,12] These simulators train ophthalmology medical personnel for manual small-incision cataract surgery. The EyeSi has been the most extensively assessed model in ophthalmology that uses a mannequin head and an artificial eye model connected to a computer interface and an operating microscope.

Many studies have demonstrated the effectiveness of surgical simulators in improving ophthalmological surgical skills.[4,5,6,7,8,9] EyeSi simulation was associated with reduced complications in live cataract surgery following training in most of the studies.[1,2,13,14] A systematic review evaluated the impact of supervised surgery on actual patients and VR simulators on patient safety as well as trainee satisfaction, establishing the efficacy of these methods for resident training.[15]

One of the most crucial steps in cataract surgery is capsulorhexis. Feudner et al.[7] reported superior performance in capsulorhexis, among students and residents trained on the EyeSi system after structured training. The simulator has also proven capable of distinguishing between novice and experienced surgeons, making it a valuable tool for evaluating trainee performance and progression.[8]

The advantages of VR systems include allowing multiple procedures to be performed, using less consumables, leading to lower recurring costs, and resources being shared among centers in low-resource settings as compared to wet lab training. The integration of surgical simulation can mitigate significant challenges like hand-eye coordination and improve dexterity.[16] The simulators have been tried for vitreoretinal surgery, orbital surgeries, and maxillofacial procedures[17,18,19] besides cataract surgery. Marty the Surgical Simulator (Iatrotech Inc., Del Mar, CA) was shown to have some role for teaching goniotomy.[20]

However, the finding that consultant cataract surgeons performed worse than trainees on the simulators raises important questions about the effectiveness and realism of the surgical simulation, particularly when it comes to high-level clinical expertise versus training.[21] While simulators can replicate the feel and mechanics of surgery, they may not fully account for the nuanced decision-making and dexterity developed through years of hands-on experience in live surgeries. The real-time reactions, adjusting to patient-specific problems, and unexpected complications triggered by real-life scenarios cannot be simulated in the laboratory. Human response time to these factors may be very heterogenous and in calculative. VR simulation has the potential to reduce the cost of training by reducing the need for human mentoring, but it is questionable to evaluate trainee performance only by computer-generated metrics.

Why do we need simulation in ophthalmology? We need surgeons to be well-trained, experienced, and competent with the tools for modern ocular surgery. Surgical simulation ensures proficiency in surgery and hence improves patient safety and surgical success. Simulators provide the trainees with a controlled lab environment for polishing their surgical skills. However, they should be used as a complement to, rather than a replacement for, real-world training and live operating room experience. Simulators can teach us the necessary skills for basic steps in any ophthalmic surgery, which may help us with the routine, but they may not fully replicate the dynamic and unpredictable nature of actual surgeries, such as dealing with patient-specific factors or handling complications. Discrepancies between faculty and trainees on simulators propose that the present simulator design may still have limitations. Our children are the best when winning the battlefield video games at home, but does that mean they are prepared to fight in a war?

About the author

Savleen Kaur

Dr. Savleen Kaur is an Associate Professor in the Department of Ophthalmology, PGIMER, Chandigarh. She has over 120 indexed publications and over 50 invited speaker sessions. She is a member of the WSPOS Connectivity Bureau, Research Board of AAPOS and Member Ophthalmic Genetics Study Club. She was bestowed upon with the Dr Nadehzda Pilman Award and Diploma by the Ukrainian Association Of Pediatric Ophthalmologists. She has numerous awards to her credit including the Best paper in cataract/glaucoma at AAPOS Annual Conference, New York 2023 and Third place in free paper at the 5th World Congress of Pedaitric Ophthalmology and Strabismus, Kuala Lumpur, 2024. She has a keen interest in teaching and research. Her areas of interest include Imaging in Pediatric Ophthalmology, Strabismus surgery, Pediatric Cataracts and Ocular Genetics.