Commentary: Changing era of modern cataract surgery – The role of virtual reality-based simulators in manual small-incision cataract surgery training modules

Cataract surgery is one of the most commonly performed procedures worldwide. Considering training in cataract surgery, it has undergone a massive revolution because of constant research, innovations, and the availability of better-wet lab facilities.[¹] During the earlier days of extra-capsular cataract extraction and manual small-incision cataract surgery (MSICS), the surgeons encountered higher intra-operative and post-operative complications because of a lack of structured training curriculum, limited hands-on training, and a lack of wet lab facilities. Simulation can be defined as an imitative representation of a process or system over time. A systematic simulation requires the use of simulating models. These models represent a step-by-step portrayal of a task enabling a real-time feel without performing the actual procedure.[²] With the introduction of the innovative concept of simulators, the training prospects have undergone a major drift resulting in better surgical outcomes. The use of simulators has resulted in a shorter learning curve, increased confidence during surgery, better tissue handling, lesser complication rates, and a reduced intra-operative time. A simulator also helps a trainee to receive feedback in the form of scores generated by the simulator without putting patients at risk. A number of viable surgical training methods available include Cadaveric eyes, artificial silicone eyes, goat’s eyes, pig’s eye, and VR-based simulation.[³]

Most of the simulators available in the market are for phaco-emulsification. There are very limited VR-based simulators available for MSICS. VR-based simulators would allow training with a no-contact technique. With the recent challenges such as coronavirus disease 2019, there is an urge to develop similar simulators at low cost that can be made available worldwide to ensure resident training even in situations with low patient load or temporary halt in elective procedures.[⁴] The addition of VR-based simulation has given a recent kick to simulation-based training in cataract surgery.

Mahr and Hodge,[⁵] in their analysis of 15 participants (12 residents, three experienced surgeons), demonstrated the use of the EYESi simulator regarding anti-tremor and forceps training. The experienced surgeons had better score, task time, and instrument-in-eye time parameters and showed 76% more precision during anti-tremor task modules. In a study by Banerjee et al.[⁶] among 12 post-graduate residents, a comparison of the steps of capsulorhexis was performed using the MicrovisTouch simulator versus live surgeries. They found a significant validity of the capsulorhexis circularity with a P value of <0.05. Laurell et al.[⁷] analyzed the PhacoVision simulator and reported positive feedback from the participants. In an analysis by Selvander and Asman[⁸] on 24 participants (17 trainees and seven senior surgeons) using an EYESi simulator, the construct validity of surgical steps including the capsulorhexis, hydro-manoeuvers, phaco-emulsification, navigation, forceps, cracking, and chopping training modules was evaluated. They used the video evaluation and found that senior surgeons scored better with the simulator for the steps, including capsulorhexis, navigation, and forceps use. The difference in scores was less evident in phaco-emulsification, cracking, and chopping steps. They noted no difference in hydro-manoeuvers between senior surgeons and trainees. However, with modified Objective Structured Assessment of Surgical Skills (OSATS) and OSA of Cataract Surgical Skill (OSACSS) tools for assessment, a significant difference between the two groups was noted in steps of capsulorhexis, hydro-manoeuvers, and phaco-emulsification. In their multi-centric randomized control trial, Nair et al.[⁹] studied the effectiveness of the HelpMeeSee Eye Surgery simulator in MSICS among resident surgeons (conventional and experimental groups) with no or minimal prior experience. Masked reviewers reviewed the surgical video of the first 20 attempts, and the total number of errors was calculated. The number of total, major, and minor errors was also more in CG groups compared to the EG group. This showed that novice surgeons trained with simulators performed better than the conventional surgeons in the first 20 attempts.

In the current study,[¹⁰] the authors have established the face and content validity of the HelpMeSee Eye Surgery Simulator, a virtual reality-based cataract surgery simulator for MSICS, and the authors must be congratulated for this interesting analysis. A total of 35 expert surgeons participated in the study, which is an excellent number to validate the model. Moreover, the study was conducted at the Comprehensive Cataract Conference 2^nd World Conference on MSICS and Comprehensive Cataract Conference in Chennai, India, which further enhances the study’s validity. The study participants were provided complete information and a training module for virtual reality-based simulation. The study analyzes four critical steps of MSICS: scleral tunnel dissection with a crescent blade, paracentesis incision with a stab entry blade, visco-elastic injection through the paracentesis, and anterior chamber entry with a keratome. The complete session usually lasted 45 minutes, and a short questionnaire was used to evaluate face and content validity. The results are encouraging, with approximately 74% of respondents agreeing that the overall visual performance of the eye and the instruments was realistic in the simulator. The visco-elastic injection was the most realistic task, and 77% believed that errors and complications were near realistic simulations. Approximately 94% believed that simulation would improve hand and eye co-ordination, which can be recommended for future generations. This is a first-of-its-kind virtual reality simulation for MSICS and will enhance the pattern of training in the near future. Similar simulators can be developed to promote research and uplift the standard of training globally. Simulators for MSICS will be a boon in developing countries such as India, Pakistan, Sri Lanka, and Bangladesh, where there is a huge backlog of cataract. This real-time virtual reality-based experience will minimize intra-operative complications during MSICS in inexperienced hands. We recommend more such models to revolutionize MSICS training globally.