Virtual Reality Simulators Yield Real Benefits in Cataract Surgery

Sumit (Sam) Garg, MD


April 09, 2021

When I was a medical student, I had the opportunity to try an ophthalmic surgery simulator that allowed for the creation of a capsulorrhexis, removal of nuclear fragments, and even a core vitrectomy. It was the coolest thing.

Unfortunately, this experience was not a sign of things to come. As I moved through my training, I wasn't given a chance to work with a surgical simulator again. A few programs that I interviewed at for residency had more "practical" ways of determining my ability to perform microsurgery. Could I tie a small-gauge suture under a microscope? Stack pills with chopsticks? Ascertain my stereo vision using the Titmus fly test? I wondered whether simulators, even in their early-generation versions, would have been a superior means of testing my skills and improving my learning curve.

This question has become even more pertinent to me now, after more than a decade of training residents and fellows, as I've come to realize that surgical skill is part nature and part nurture. There are some truly gifted surgeons with excellent surgical intuition, decision-making skills, and execution, but these individuals are the exception. For most, practice is essential, with repetition of surgical maneuvers and cases helping them gain confidence and skill.

A New Review of Virtual Cataract Surgery

It was therefore with some interest that I read a recent systematic literature review from Rothchild and colleagues, who explored whether virtual reality simulation (VRS) actually improves cataract surgery outcomes. They assessed 10 studies published between 2011 and 2020, encompassing 471 residents who performed more than 30,000 cataract surgery procedures.

The authors concluded that there is reasonable evidence that VRS results in a reduction in the real-life complication rate of cataract surgery, particularly posterior capsule tear rate and curvilinear capsulorrhexis completion. One study showed a statistically significant difference in terms of posterior capsule tear rate of 1.5% (simulator group) and 3.3% (non-simulator group). Rothchild and colleagues noted, however, that VRS access alone did not confer such benefits; a structured and supervised program with numerous repetitions and active teaching also played a role.

It must also be noted that this paper has several limitations typical of systematic reviews, including selection bias, its retrospective nature, and compiling data from various studies with differing study protocols.

Practice Is Practice, Whether Simulated or Not

Various surgical simulators are currently on the market with the aim of providing such help, including Eyesi, MicrovisTouch, and PhacoVision. It may be that concerns around cost are limiting the widespread incorporation of VRS systems. While I do not know the current price of these systems, I do recall that they were not inexpensive (eg, $30,000-$40,000) when our department looked into them.

Luckily for us, there are more economical ways to practice surgery (other than the traditional pig eye), such as eye models like the Kitaro Kit and the SimulEYE, among others. For trainees, we know that practice in any way possible is essential: wet labs, eye models, VRS, and real-time surgery.

This doesn't just apply to them, though.

As Malcolm Gladwell said, "Practice isn't the thing you do once you're good. It's the thing you do that makes you good." As surgical technologies and techniques continue to evolve, finding innovative and helpful ways of practicing is important for surgeons of all skill levels.

Sumit (Sam) Garg, MD, is the vice chair of clinical ophthalmology and an associate professor in the Department of Ophthalmology at the Gavin Herbert Eye Institute, University of California, in Irvine. He specializes in corneal and cataract surgery as well as laser refractive surgery.

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