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Letters to the Editor

Does Video Gaming Improve Ophthalmological Surgical Proficiency?

Rothschild, Philip Samuel MBBS; Chakrabarti, Rahul MBBS, PhD

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Asia-Pacific Journal of Ophthalmology: September-October 2020 - Volume 9 - Issue 5 - p 476
doi: 10.1097/APO.0000000000000319

To the Editor:

We read with great interest the perspective article on special precautions in ophthalmic practice with regard to the COVID-19 pandemic by Lam et al.1 The authors provide an interesting assessment of the risk of COVID-19 transmission in ophthalmic practice and how it can be minimized. We wish to add further insight by discussing whether video gaming holds promise as a mechanism to maintain microsurgical skills in the context of the COVID-19 slowdown in ophthalmic surgery.

The motor skill component of ophthalmic surgery involves hand-eye-foot coordination, dexterity, and 3-dimensional spatial awareness. Traditional Halstedian approaches for teaching have shifted toward simulation that offers a platform for safe, deliberate practice. In the context of virtual reality simulation, another forum that has gained interest is that of video gaming. Video gaming is often practiced as a recreational activity, but also offers photorealistic simulation of various scenarios that require motor, visual, and cognitive coordination.2 These attributes are highly desirable particularly in microsurgical specialties such as ophthalmology. Used judiciously, video gaming holds the potential for a beneficial effect on surgical training.

A focused review of the literature was performed using Web of Science's “MEDLINE” database using the search terms “video gaming” AND “surgical skill” on April 11, 2020. We included original articles published in full-text, in English, and published from 2015 to 2020, relevant to human surgery, that specifically included video gaming as part of their study. The analysis included study aims, design, key findings, and conclusion.

Twenty-one relevant articles were found with this search strategy (please see Appendix,, with only 1 article being specific to video gaming in ophthalmology.3 The broad categories of study purpose included piloting a video game, using gaming to transition to performance on simulators, to motivate trainees, to identify surgical subspecialty selection, and as a prevocational exposure to field of surgery. Study designs included exploratory nonrandomized projects, comparative cohorts, randomized controlled trials, and case controls.

General consensus among the reviewed studies was that regular video game play seemed to enhance microsurgical performance when assessed with a surgical simulator. This held true when correlated with skills on the ophthalmological EyeSi surgical simulator.3 A core advantage of video gaming is its accessibility. Indeed, trainees and students who enjoyed video gaming before surgical training showed higher aptitude with microsurgical skills and were more likely to consider becoming surgeons. Other skills highlighted by video gaming include its cognitive component, which was shown to lead to increased voluntary usage and performance on surgical simulators.4 There is increasing evidence that video game players perform superiorly to nonvideo game players, specifically in the domains of visual tasks, and are faster and more accurate in surgical simulation. However, further evidence is needed before determining what recommendations should be given regarding video game use to maintain or support the development of surgical skills.

No evidence was found directly linking video gaming to improved microsurgical skills performance in live surgery. However, there was evidence to suggest improved performance on virtual reality simulation with gaming experience.3 Recent evidence in ophthalmology has shown evidence linking virtual reality simulation and operating room performance for cataract surgery.5

Given that accessibility to wet-lab and virtual reality simulators remain real issues, this raises the question of whether video gaming could be harnessed as a resource in some respect. In these unprecedented times, if surgeons are unable to operate, could video gaming perhaps be used to maintain some degree of fine motor skills and hand-eye-foot coordination? If so, video gaming may become a valuable, accessible adjunct to the skills laboratory. However, the evidence is not yet robust enough to support encouraging video gaming to be used in this fashion. Further evidence is needed before determining what recommendations are given regarding video game use to maintain or support the development of surgical skills.


1. Lam DSC, Wong RLM, Lai KHW, et al. COVID-19: special precautions in ophthalmic practice and FAQs on personal protection and mask selection. Asia Pac J Ophthalmol (Phila) 2020; 9:67–77.
2. Adams BJ, Margaron F, Kaplan BJ. Comparing video games and laparoscopic simulators in the development of laparoscopic skills in surgical residents. J Surg Educ 2012; 69:714–717.
3. Chung AT, Lenci LT, Wang K, et al. Effect of fine-motor-skill activities on surgical simulator performance. J Cataract Refract Surg 2017; 43:915–922.
4. El-Beheiry M, McCreery G, Schlachta CM. A serious game skills competition increases voluntary usage and proficiency of a virtual reality laparoscopic simulator during first-year surgical residents’ simulation curriculum. Surg Endosc 2017; 31:1643–1650.
5. Ferris JD, Donachie PH, Johnston RL, Barnes B, Olaitan M, Sparrow JM. Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 6. The impact of EyeSi virtual reality training on complications rates of cataract surgery performed by first and second year trainees. Br J Ophthalmol 2020; 104:324–329.

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