Validity and usability of a virtual reality intraocular surgical simulator

Abstract: Cataract surgery is one of the most common surgical procedures in Sweden and around 90 000 operations are made each year. An aging population with increased demands on quality of life and good visual acuity, has led to an increased rate of surgery and more surgeons needs to be trained. Training of new cataract surgeons is done on scarce wet-lab training but mainly on patients. Training is costly and complications are higher for new surgeons compared to experienced ones. In the airline industry simulators are used for training. Pilots have to prove competent before flying a new airplane. No such standards exist for new cataract surgeons. Surgical simulators have been used in other surgical fields for training and reports have shown that training has improved performance on real operations. The purpose of this work was to validate Eyesi, a surgical simulator for cataract surgery training, and analyze learning curves. Furthermore we set out to investigate whether factors like stereoacuity and sex would be important for performance in the simulator. Evidence for construct validity was found for cataract specific modules capsulorhexis, hydromaneuvers and phaco divide and conquer and for manipulating modules cataract navigation training, cataract forceps training and cataract cracking and chopping training. Analysis of learning curves showed significant improvement throughout training. Evidence for concurrent validity was established for the capsulorhexis module. For the hydromaneuvers and phaco modules, the innate simulator scoring could not distinguish surgical skill but discrimination was dependent on video based human scoring. Stereoacuity was found to correlate with performance on the simulator but there were large individual variations. An individual’s sex had no influence on performance. We have shown that Eyesi can differentiate cataract surgical skill and that naïve can train in the simulator and improve. Stereoacuity has an effect on performance but there were large individual variations. Simulation-based training has the potential to move the early learning curve out of the operating room.