Eyeworld

46 | EYEWORLD | WINTER 2026 ATARACT C References 1. Staropoli PC, et al. Surgical simulation training reduces intraoperative cataract surgery complications among residents. Simul Healthc. 2018;13:11–15. 2. Ferris JD, et al. 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. 3. Jacobsen MF, et al. Correlation of virtual reality performance with real-life cataract surgery performance. J Cataract Refract Surg. 2019;45:1246–1251. 4. Thomsen AS, et al. Operating room performance improves after proficiency-based virtual reality cataract surgery training. Ophthalmology. 2017;124:524– 531. Relevant disclosures Cherwek: None Pettey: None Sun: None creation is particularly well suited to simulation. "In our experience, residents seem to become comfortable with it much earlier. Nuclear disas- sembly remains more difficult to simulate well." Concerns and barriers In terms of implementation, Dr. Pettey said the major barriers to surgical simulation tools in- clude cost, access, and faculty time. The ACGME requires ophthalmology programs to provide access to hands-on surgical skills resources, which can be a wet lab, dry lab, or simulation lab. "It does not require every program to own an expensive VR simulator, so access still varies significantly," he said. Faculty time is also important. "Self-direct- ed practice is useful, but residents still need someone to make sure they are learning the right movements rather than simply repeating and reinforcing bad habits," he said. "This variability was one reason AUPO developed SCOR—the Surgical Curriculum for Ophthalmology Residents," Dr. Pettey said, noting that he and Dr. Sun were involved in its original concept and design. "The goal was to give residents more standardized training and access to advanced equipment and expert instruction, regardless of what was available at their own program." While this is a valuable tool, some concerns remain. "No simulator perfectly reproduces human tissue or the complete experience of surgery," Dr. Pettey said. For example, fidelity varies significantly by procedure and even by individual steps within a procedure. "Simulation is also much better at teaching technical movements than judgment," Dr. Pettey said. "It cannot fully reproduce tissue variability, an anxious patient, an unexpected complica- tion, or the decision-making required when a case starts going wrong." Dr. Sun also noted that VR systems can be expensive, so not all training programs have them accessible to all of their residents. "Most programs use both simulated eyes/animal eyes in a traditional wet lab environment, paired with time on a virtual simulator," she said. "Many programs require that residents meet a certain level of competency in cataract surgery steps prior to entering the operating room. For example, they need to complete a certain number of capsulorhexis on the synthetic eye, or throw a certain number of sutures in the cor- nea, which need to be evaluated and signed off on by a faculty member, or they must complete a number of modules in the virtual reality sim- ulator," she said. "After time in the OR, faculty may decide to 'assign' particular tasks in the wet lab or on the simulator to build on skills identi- fied in the operating room that day." Dr. Sun agreed that cost and time are cur- rent barriers to implementing the use of simula- tion technology, as well as a structured curricu- lum. This includes faculty who are available and are trained to teach these surgical skills as well as trained in assessment and giving feedback. One concern Dr. Cherwek noted is lack of standardization in training, and he thinks that Orbis International addresses this well. With the Orbis training protocol, students get used to doing it one way and until they demonstrate competency, there are not a lot of variables in- troduced. "I do think that standardization is still a problem in medicine, where at Institution X, they do it this way, and at Institution Y, they do it this way," he said, adding that these choices are also not always evidence based. Growing evidence in support of surgical simulation Dr. Pettey noted evidence in favor of simula- tion, adding that a prospective multicenter study found that novices improved their actual OR performance by about 32% after proficien- cy-based Eyesi training. Surgeons with fewer than 75 independent cataract cases improved by about 38%. Another study found posterior capsule tear and vitreous prolapse rates of 2.2% among simulation-trained residents versus 4.8% in the comparison group. continued from page 45 AUPO SCOR lab using synthetic eyes for simulation Source: Grace Sun, MD

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